Source: COUNTY OF LOS ANGELES submitted to NRP
A PRODUCE PRESCRIPTION PROGRAM WITH TIERED INCENTIVE AMOUNTS FOR PATIENTS WITH DIABETES AND PREDIABETES IN LOS ANGELES COUNTY
Sponsoring Institution
National Institute of Food and Agriculture
Project Status
ACTIVE
Funding Source
OTHER GRANTS
Reporting Frequency
Annual
Accession No.
1031464
Grant No.
2023-70413-41055
Cumulative Award Amt.
$483,612.00
Proposal No.
2023-06351
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
COUNTY OF LOS ANGELES
313 N FIGUEROA STREET STE 708
LOS ANGELES,CA 900122602
Performing Department
(N/A)
Non Technical Summary
The Los Angeles County Department of Public Health (DPH) will partner with Northeast Valley Health Corporation (NEVHC) and the University of California, San Francisco, Vouchers 4 Veggies - EatSF Voucher Program (V4V) to implement and expand a Produce Prescription Program (PPR) at four health center clinic sites in Los Angeles County. The activities of the proposed project support the overall goals of PPR, which are to increase fruit and vegetable consumption, improve household food security, reduce the risk of developing diet-related chronic diseases and associated complications, and improve healthcare utilization and associated costs. PPR eligibility criteria include patient enrollment in Medicaid (Medi-Cal in California), screening positive for food insecurity, and a type 2 diabetes or prediabetes diagnosis. NEVHC will train healthcare staff on the screening and referral protocols. After enrollment, these clinic settings will provide PPR participants (patients) with electronic debit cards that account for the participants' household size ($40 for 1 person, $80 for 2 people, and $110 for 3 or more people); each card will be refreshed monthly over the course of 6 months. The electronic debit cards can be redeemed for fresh produce at most large chain grocery stores in areas surrounding each clinic site. Program participants will also be referred to nutrition education classes and other food resources (e.g., SNAP, local food pantries). V4V will manage the relationship with a partnering firm that administers the incentives. DPH will use multiple strategies to evaluate key program indicators and outcomes, including using data from the GusNIP participant-level core metric survey and NEVHC's Electronic Health Records.
Animal Health Component
50%
Research Effort Categories
Basic
0%
Applied
50%
Developmental
50%
Classification

Knowledge Area (KA)Subject of Investigation (SOI)Field of Science (FOS)Percent
70460991010100%
Knowledge Area
704 - Nutrition and Hunger in the Population;

Subject Of Investigation
6099 - People and communities, general/other;

Field Of Science
1010 - Nutrition and metabolism;
Goals / Objectives
The Los Angeles County Department of Public Health (DPH) will partner with Northeast Valley Health Corporation (NEVHC) and the University of California, San Francisco, Vouchers 4 Veggies - EatSF Voucher Program (V4V) to implement and expand a Produce Prescription Program (PPR) at four health center clinic sites in Los Angeles County. The activities of the proposed project support the overall goals of PPR, which are to increase fruit and vegetable consumption, improve household food security, reduce the risk of developing diet-related chronic diseases and associated complications, and improve healthcare utilization and associated costs. The objectives to support the above associated goals are to be achieved by September 2026: 1) Eighty percentof PPR participants will increase the frequency of daily consumption of fruits and vegetables from baseline (enrollment) to 6 months after enrollment, 2)Twenty percentof PPR participants will improve their household food security as assessed using the Six-Item Short Form of the Food Security Survey Module (6-item food insecurity screener) included in the core metric survey from baseline (enrollment) to six months after enrollment, 3) Sixty percentof PPR participants will improve their HbA1c concentrations and diastolic/systolic blood pressure values and 4) the project teamwill develop a program infrastructure using EHR data to track healthcare utilization and preventable healthcare costs among patients with diabetes and prediabetes.PPR eligibility criteria include patient enrollment in Medicaid (Medi-Cal in California), screening positive for food insecurity, and a type 2 diabetes or prediabetes diagnosis. NEVHC will train healthcare staff on the screening and referral protocols. After enrollment, these clinic settings will provide PPR participants (patients) with electronic debit cards that account for the participants' household size ($40 for 1 person, $80 for 2 people, and $110 for 3 or more people); each card will be refreshed monthly over the course of 6 months. The electronic debit cards can be redeemed for fresh produce at most large chain grocery stores in areas surrounding each clinic site. Program participants will also be referred to nutrition education classes and other food resources (e.g., SNAP, local food pantries). V4V will manage the relationship with a partnering firm that administers the incentives. DPH will use multiple strategies to evaluate key program indicators and outcomes, including using data from the GusNIP participant-level core metric survey and NEVHC's Electronic Health Records.
Project Methods
The primary goal of thisPPR is to evaluate and demonstrate the impact of the program on the improvement of dietary health as measured by patients' (program participants') increased consumption of fruits and vegetables, reduction of individual and household food insecurity, improvements on clinical metrics, and reduction of unnecessary healthcare utilization and associated costs (or increase in cost-efficient utilization patterns). To assess the impact of PPR, a multipronged evaluation will be implemented, comprising of both process and outcome evaluation. The program will enroll and collect data from 350 participants which will ensure adequate and complete pre- and post-data for evaluation purposes. Preliminary EHR HbA1c and blood pressure measurement data from NEVHC's current PPR program was used to conduct a power calculation for this project's sample size. This PPR evaluation requires a sample size of 108 pairs (pre/post) to achieve a power of 80%, and a level of significance of 5% to detect a mean difference of 0.47 in HbA1c level at pre- versus post.Process Evaluation:The PPR will include collection of both qualitative and quantitative program data to inform program implementation. DPH will conduct key informant interviews with a sample of patients who have completed the PPR at each NEVHC clinic site to understand program impact, the implications of the program ending, and ways that the program can best meet the needs of their local community. Interviews will also seek information on the facilitators and barriers experienced by participants when they enrolled into the PPR as well as potential challenges associated with using the electronic debit card at grocery stores. Other process measures to be collected include a satisfaction survey conducted shortly after enrollment to assess if participants understand how and where to redeem their incentives, identify customer service contact information, and provide any general feedback on the program enrollment process. Additionally, NEVHC clinic staff will track program participation and enrollment over the course of the project. At the incentive distribution level, DPH staff will collaborate with Vouchers4Veggiesto identify the total amount of incentives participants redeem each month.Outcome Evaluation: The PPR willutilize multiple strategies to rigorously track key program indicators and outcomes. Participant-level survey data will be used to assess whether PPR was associated with changes in fruit and vegetable consumption and food security status. Changes in fruit and vegetable consumption will be evaluated using the 10- item fruit and vegetable module, which will be included in the core NTAE patient survey administered on Qualtrics. The Six-Item Short Form of the Food Security Survey Module will assess food security changes. The survey will be administered in English and Spanish at enrollment and six months later when the participant has completed the program. To assess complementary supports made at the clinic, information on participants involvement in nutrition education, diabetes education classes, and free produce distribution events made available at the clinics will be documented. To assess the goal of reducing the risk of developing diet-related chronic diseases by improving blood pressure and blood glucose control among patients with diabetes and prediabetes, blood pressure readings and HbA1c levels of PPR participants will be monitored via the EHR; they will be compared at the start and within three months of completing the program. To assess whether PPR helped to reduce health care usage and associated costs, DPH will analyze participants' healthcare utilization metrics within three months of/after enrolling into the PPR, during their participation in the program, and three months after completing the program. To extract data for this project, NEVHC will help facilitate EHR data access at the patient-level from each of the health centers. An additional stipend in the form of a grocery gift card will be provided for participants who complete the entirety of the evaluation requirements: i.e., post-survey, blood pressure measurement, and HbA1c laboratory collection. To understand the impact of tiered incentive amounts on program and health-related outcomes, analyses will account for the three incentive amounts by household size. Additionally, DPH will assess the impact of PPR participation on potential healthcare (Medicaid) cost savings as a result of having improved the control of or prevented the development of diabetes. All quantitative and qualitative data will be stored and managed in HIPAA-compliant, password-protected databases on DPH's network drive. All quantitative data will be de-identified with an identification number and tracked and analyzed using statistical software programs such as SAS and/or Stata. All qualitative interview data will be transcribed, de-identified, and analyzed using Atlas.ti.

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

Outputs
Target Audience:The Los Angeles County Department of Public Health (DPH) partnered with Northeast Valley Health Corporation (NEVHC) to implement the Produce Prescription Project (PPR), locally known as Fresco y Saludable/Fresh and Healthy, across three health clinics in Los Angeles County, California. NEVHC is a Federally Qualified Health Center located in the northwest region of Los Angeles County, geographically referred to as Service Planning Area 2 (SPA 2) San Fernando Valley. Residents in cities and communities in SPA 2 face significant economic hardship and have limited access to healthy food. Nearly one-fourth (24.4%) of SPA 2 households who live less than 300% of the federal poverty level experience food insecurity based on 2018 data. Approximately, 60% of SPA 2 adults face diet-related chronic diseases, such as type 2 diabetes (10.1%), hypertension (24.2%), and high cholesterol (24.7%). Efforts to reach the target population include extrapolating data from NEVHC's electronic health record (EHR) to identify patients who are low-income (defined as enrolled in Medicaid), screened positive for food insecurity, and diagnosed with type 2 diabetes or prediabetes. Patient's household size is also extracted as the amount of produce prescription benefits participants receive is determined by household size. Patients who met eligibility criterion received phone calls in their preferred language (English or Spanish) from NEVHC Health Educators asking if they are interested in participating in Fresco y Saludable Fresh and Healthy. Interested participants were scheduled for an in-person appointment at the clinic with NEVHC Family Medicine Care Coordinators to complete the enrollment process. Based on preliminary data obtained from the baseline core metrics survey, the average age is 51 (range 29- 70). 85% of participants identify as female. By race/ethnicity, 94% are Hispanic, Latino/a, or Spanish origin, 5% are White, and 1.5% are Other Race/Multiple Race. By education, 42% have less than a high school degree, 42% have a high school diploma, and 12% have some college education or more. Changes/Problems:DPH did not experience any major problems that significantly impacted program expenditures. DPH's partner V4V signed a contract with a new technology firm to administer the produce prescription benefits through a new electronic debit card, known as the Fresco/Fresh card. V4V tested the Fresco/Fresh cards at participating Albertsons, Kroger, and Walmart grocery stores to ensure the card was compatible with the stores' point-of-sales (POS) and functionality to limit e purchases to fresh fruits and vegetables only. Card testing caused a slight delay in launching Fresco y Saludable Fresh and Healthy at NEVHC. During this period, NEVHC Health Educators contacted eligible patients and placed them on a waiting list until the Fresco y Saludable Fresh and Healthy card completed program testing. DPH does not anticipate any programmatic delays in the next reporting period and expects to meet the deliverables of the grant within the grant term. What opportunities for training and professional development has the project provided? Nothing Reported 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?Fresco y Saludable Fresh and Healthy will continue being implemented at three NEVHC health centers with the goal of enrolling 175 participants across three different household sizes (1 person, 2 people, and 3 or more people per household). Participant-level core metric surveys will be reviewed quarterly by DPH to ensure data is complete. DPH will continue working with NEVHC to resolve any data issues (e.g., duplicate IDs, missing data, etc). NEVHC will review participants biomarkers (BPand hemoglobin A1c) at pre and post to ensure that the data is documented in the patients' electronic health record. DPH will collaborate with NEVHC to begin to develop a system to extract deidentified participant level biomarker and healthcare utilization data. DPH plans on conducting key informant interviews with program participants to receive feedback on the program enrollment process, utilizing benefits at the grocery store, and overall experience in the program. The goal is to publish and disseminate findings to participants and ensure the program is being delivered using concepts of fidelity, equity and dignity. Vouchers 4 Veggies (V4V) will continue working with the payment technology firm to administer the electronic benefits to NEVHC participants. V4V will manage the card redemption data, and this will be reviewed monthly by DPH.

Impacts
What was accomplished under these goals? Project Goal #1: Improve healthy eating behaviors among people with lower incomes. Intended Outcome: By September 2026, 80% of PPR participants will increase the frequency of daily consumption of fruits and vegetables from baseline (enrollment) to 6 months after enrollment. Substantial evidence indicates consuming a diet high in fruits and vegetables is associated with reducing the risk of developing chronic-related diet diseases. Due to limited access and affordabilityand lack of transportation, low-income households face significant barriers to consuming these recommended daily fruit and vegetable intake. DPH partnered with V4V to provide eligible participants with an electronic debit card or Fresco Fresh card that can only be used to purchase fresh fruits and vegetables at participating Albertsons, Kroger, and Walmart grocery stores over six months. Fresco y Salduable Fresh and Healthy participants received one card per household and incentive benefits are allocated based on household size - $40 a month for 1 person, $80 a month for 2 people, and $110 a month for 3 or more people. Participants are eligible for the program if they meet the following criteria: 1) enrolled in Medicaid, 2) screened positive for food insecurity, and 3) diagnosed with prediabetes or type 2 diabetes. To assess improvements in healthy eating behaviors, DPH collaborated with NEVHC Family Medicine Care Coordinators to administer a validated, 10-item Dietary Screening Questionnaire (DSQ) to all Fresco Freshparticipants during enrollment (at the beginning of the program) and at 6 months (at program completion). The 10-item questionnaire is part of the core metrics survey and participants must complete this survey in order to receive the Fresco card. DPH and V4V trained NEVHC staff on program participant eligibility, reporting requirements, and administering the core metrics survey via the online platform, Qualtrics. Surveys were administered to participants in-person in their preferred language at NEVHC health centers. From April 2024 to July 2024, NEVHC Family Medicine Care Coordinators enrolled 48 participants into Fresco Freshout of 3,170 eligible participants and issued $5,730 in benefits. Participants have purchased $4,506.38 worth of fresh fruits and vegetables at participating grocery stores, yielding 79% redemption rate. NEVHC supports healthy eating behaviors by offering over 60 nutrition education activities to Fresco Fresh participants, ranging from Supplemental Nutrition Assistance Program Education (SNAP-Ed) nutrition education classes to one-on-one consultations with a Registered Dietitian Nutritionist (RDN). Data from the core metric survey has been collected from 65 participants and data analysis is pending. DPH will continue to provide technical assistance to NEVHC to ensure that core metric survey data are complete. DPH will help reviewthe surveys in Qualtrics every 3 months. Project Goal #2: Increase household food security among people with lower incomes. Intended Outcome: By September 2026, 25% of PPR participants will improve their household food security as assessed using the Six-Item Short Form of the Food Security Survey Moduleincluded in the core metric survey from baseline (enrollment) to six months after enrollment. Due to limited financial resources and other socioeconomic factors, low-income populations are at risk for being food insecure, defined as lack of consistent access to enough food for an active, healthy lifestyle. Through the partnership with V4V, eligible Fresco Freshparticipants received benefits every month for six months based on household size (i.e., $40 a month for 1 person, $80 a month for 2 people, and $110 a month for >3people). Participants can only use their benefits to purchase fresh fruits and vegetables at participating grocery stores. Additionally, NEVHC routinely refers program participants to other local food resources such as food pantries, the Supplemental Nutrition Assistance Program (SNAP), andclinic sites where free produce and food are distributedonce a month. To measure improvements in household food security status, DPH partnered with NEVHC to administer a validated, 6-item food insecurity screener to all Fresco Freshparticipants during enrollment (at the beginning of the program) and at 6 months (program completion). The 6-item food insecurity screener is part of the core metrics survey and participants must complete this survey in order to receive the Fresco Fresh card. DPH provided trainings to NEVHC staff on program participant eligibility, reporting requirements, and administering the core metrics survey via the online platform, Qualtrics. Surveys were administered to participants in-person based on their language preference at NEVHC health centers. Data from the core metrics survey have been collected from 65 participants and data analysis is pending. DPH will continue to provide technical assistance to NEVHC to ensure that the core metrics survey data are complete. DPH is helping toreviewthe data in Qualtrics every three months. Project Goal #3: Reduce the risk of developing diet-related chronic disease and associated complications by improving blood glucose control and blood pressure among patients with diabetes and prediabetes. Intended Outcome: By September 2026, 60% of PPR participants will improve their HBA1c concentrations and diastolic/systolic blood pressure values. Research shows that healthy eating patterns, including consuming more fruits and vegetables can lower the risk of developing hypertension (HTN). HTN in people with type 2 diabetes doubles the risk of cardiovascular disease. Lowering blood pressure (BP) among patients with this conditionis associated with decreased mortality, improved clinical outcomes, and decreased health care costs. Fresco Freshtargets patients with prediabetes and type 2 diabetes as part of the eligibility criteria. DPH and NEVHC established a clinic workflow specifying that participants must have their BPand glycated hemoglobin (HbA1c) measured and documented in the electronic health record and verified by NEVHC Health Educators prior to receiving Fresco Freshbenefits. A BPmeasurement must be taken the day of enrollment into the program (baseline) and HbA1c must be collected three months prior to the participant's enrollment date. Both BPand HbA1c will be reassessed at six months, when the participants benefit expires. NEVHC Health Educators are responsible for scheduling a six-month follow up appointment with participants to ensure data collection compliance. DPH received Institutional Review Board (IRB) approval (as exempt) from the County of Los Angeles Department of Public Health to conduct this research project. DPH will request de-identified BPand HabA1c data from NEVHC quarterly to ensure data collection is accurate and complete. Project Goal #4: Improve healthcare utilization and reduce associated costs. Intended Outcome: By September 2026, PPR will develop a program infrastructure using EHR data to track healthcare utilization and preventable healthcare costs among patients with diabetes and prediabetes. Providing financial incentives to purchase fruits and vegetables improves dietary consumption and may be highly cost effective or even cost saving for healthcare systems and payers. Medical expenditures associated with diabetes are substantial. Proposed electronic health record (EHR) data to be collected will include total number of any NEVHC primary care visit prior, during, and after participation in Fresco Fresh(past 12 months). Additional supplemental metrics may include visits with ancillary services (RDN, Health Educator, Behavioral Health) and total number of times patients did not show for a medical visit with the patient's primary care provider. NEVHC will facilitate extraction of utilization data from the EHR and deidentify thesedata prior to making themavailable to DPH. DPH will request thesedata from NEVHC quarterly.

Publications