SAME CANOE VEGGIE RX

• Sponsoring Institution: National Institute of Food and Agriculture
• Project Status: COMPLETE
• Funding Source: OTHER GRANTS
• Reporting Frequency: Annual
• Accession No.: 1024349
• Grant No.: 2020-70030-33125
• Cumulative Award Amt.: $499,950.00
• Proposal No.: 2020-06304
• Project Start Date: Sep 1, 2020
• Project End Date: Aug 31, 2024
• Grant Year: 2020
• Program Code: [PPR]- Produce Prescription

Recipient Organization
Heritage Ranch, Inc.
PO Box 865
Honaunau,HI 96726

Performing Department
(N/A)

Non Technical Summary
Hawaii's serious food security challenge is recognized in local communities and among state and federal agencies. In spite of a year round growing season, 90% of the food consumed is imported from over 2,500 miles away, has high added transportation costs, suffers loss of freshness and nutritional value, and is vulnerable to shipping and natural disaster disruptions. The State has estimated there is at most five days of food in storage or on the shelf and food deserts have been identified in remote rural areas. These factors have led to a rising anxiety about food insecurity and sustainable solutions are needed. Not only is the per capita local farm production low, household demand for local foods has also dropped due to adoption of preferences for disease-exacerbating, highly processed, canned and packaged food diets among the low income population. It is no surprise the low income population faces rising rates of serious health challenges as a result. Obesity, diabetes, heart disease, asthma and hypertension are among the leading health crises in the state and the most at-risk populations are the most vulnerable. Our rural clinic partners estimate that over 60% of their 41,000 patients suffer from these chronic diseases.Heritage Ranch (HR) will manage the Same Canoe Veggie Rx PPR project under GusNIP support, 2020-2023. HR previously conducted a hybrid FINI SNAP/Veggie Rx program 2018-2020. Based on outcomes from that trial of Veggie Rx, HR has structured a new GusNIP PPR Veggie Rx nutrition incentive program in conjunction with 12 medical clinics in six North and West Hawaii Island districts. The new Veggie Rx program will be providing $260,000 in GusNIP produce incentives for 500 at-risk participants and will host educational programs that encourage disease prevention and improve chronic illness management.This Same Canoe NIFA food prescription incentive project focuses its emphasis on two key findings:1) Patient incentive engagement is increased through health care team support and by providing no-cost integrated online or in person nutrition education with consistent content across all clinics.2) Engaging clinic providers and their team in a unified, program-led nutrition education and incentive strategy is essential to effect measurable health and behavioral impacts correlated to an increase in consumption of fruits and vegetables.Concentrating all resources on the Veggie Rx model, with up to $600 in incentives per Veggie Rx patient (up from $320 in the previous FINI trial), the project will see increased participant involvement providing a valuable opportunity for analysis of patient outcomes and impacts. Using innovative delivery methods and customized data gathering tools enables the project to track three key distinct data sets over a longer period: changes in a) behavior, b) bio-metric, and c) purchasing patterns. Same Canoe's PPR project will demonstrate strategies and data gathering for potential replication pertinent to future GusNIP, Medicaid, and Health Insurance-funded incentive programs. The new GusNIP PPR project will:PARTICIPANTS Work in conjunction with 12 medical clinics in six rural North and West Hawaii Island districts to identify 500 patients with types of chronic illness that can potentially be improved through dietary changes when supported by the delivery of a 'food as medicine' engagement and incentive program.PANDEMIC Incorporate lessons learned from operating a Nutrition Incentive program in the COVID-19 environment, including offering produce pick-up options through a network of CSA delivery sites, in addition to farmers market and retail grocery options as those become available.PARTICIPANT ENGAGMENT Test new intervention methods that include participant online learning activities, small group learning cadres, and longitudinal patient surveys measuring change in behaviors through self-informing qualitative reporting and quantitative results (ie lab test outcomes). Actively measure changes in biometrics, purchasing, and food consumption.HEALTH CLINIC Test new methods for more effective health care provider engagement in 'food as medicine' that include nutrition education integration strategies and clinic office training for medical assistants to improve support, and leverage nutrition-based expertise from doctors and dieticians who will provide peer-to-peer teaching modules.In the unanticipated COVID-19 clinic environment, the normalizing of telehealth provides a valuable new opportunity to integrate ongoing nutrition and food purchasing education into wellness services through online or phone appointments with patients. During the recently completed FINI project, Same Canoe developed a beta test of an online learning program called 'Farm Fresh is Best' and this tool will be further developed to serve both participant and health care provider education needs. On the provider side, online learning can deliver content and engagement strategies across the care provider team to enhance their ability to work directly and effectively with health challenged patients. On the participant side, a supportive online learning community can both educate and support healthy dietary choices and increased fruit and vegetable consumption.The three top strengths Same Canoe brings to the Veggie Rx GusNIP PPR Project are:An existing network of health clinic and community partners serving high-need, low income participants is ready to move into a new stage two implementation phase.Same Canoe has a track record of safely serving participants in COVID-19 settings. 1,800 FINI SNAP/Veggie Rx participants have been served since 2015.Lessons learned from two previous FINI projects allows GusNIP funding to build on a body of prescription incentive work with national replication potential.The project's intended outcomes include improved nutrition and health, greater awareness and support of local growers and local food retailers, increased revenues for small farms, and long term adoption of fresh local food consumption as a proactive food security and healthy lifestyle choice that lowers medical costs.The 2020-2023 Veggie Rx PPR initiative will be providing $260,000 in produce incentives for 500 participants and will host educational programs that encourage disease prevention and improve chronic illness management. $104,500 will be invested in nutrition engagement, data gathering, and education programming. $90,000 will be invested in project management, with $45,450 indirect over 3 years. Total $499,950.

Animal Health Component

50%

Research Effort Categories

Basic

50%

Applied

50%

Developmental

(N/A)

Classification

Knowledge Area (KA)	Subject of Investigation (SOI)	Field of Science (FOS)	Percent
703	6010	3020	100%

Knowledge Area
703 - Nutrition Education and Behavior;

Subject Of Investigation
6010 - Individuals;

Field Of Science
3020 - Education;

Keywords

hawaii

incentive

prescription

produce

veggie rx

Goals / Objectives
Heritage Ranch (HR) will manage the Same Canoe Veggie Rx PPR project under GusNIP support, 2020-2023. HR previously conducted a hybrid FINI SNAP/Veggie Rx program 2018-2020. Based on outcomes from that trial of Veggie Rx, HR has structured a new GusNIP PPR Veggie Rx nutrition incentive program in conjunction with 12 medical clinics in six North and West Hawaii Island districts. The new Veggie Rx program will be providing $260,000 in GusNIP produce incentives for 500 at-risk participants and will host educational programs that encourage disease prevention and improve chronic illness management.?The Same Canoe project goals are to:Provide qualifying households with Veggie Rx services to increase their fresh, local fruit and vegetable access and consumption along with providing educational and experiential market, farm and clinic nutrition and culinary tie-ins.Develop effective methods for engaging and qualifying Veggie Rx participants and for redeeming incentives via coupons, gift cards, or script.Develop curriculum materials and programs to serve participants and clinic partners.Reach historically underserved households at risk of serious health conditions, including vulnerable children and seniors.Develop and test methods for reducing cultural, historic or behavioral barriers to consuming fresh foods.Increase sales of fresh local fruits and vegetables, grains, seeds and nuts.Measure and quantify bio-metric and qualitative data to analyze potential correlations between changes in diet, health, behavior and wellness.Provide peer-to-peer tools that inform and motivate clinical adoption of more integrated 'food as medicine' education and treatment options for patients.ObjectivesWork with point of sale partners to develop efficient systems for produce access/incentive redemption.Work with clinics/community-based centers for outreach, enrollment and nutrition education.Work with sister organizations in the community to host informational presentations at churches, schools, community, and senior centers to reach multi-cultural participants.Pre-qualify participants through clinics. During pre-qualification, information on redemption locations and methods is provided and a short intake survey completed.Conduct assessments on engagement and pre-qualification / preparedness of participants, and assessments on the actual volume by location as well as differing methods of redemption. Measure outcomes quantitatively and collect qualitative feedback.Collect and analyze qualitative and quantitative data including interim and final surveys, blind aggregated lab results, and patient interviews, as components of an internal evaluation.

Project Methods
The new GusNIP PPR project targets and methods include:PARTICIPANTS Work in conjunction with 12 medical clinics in six rural North and West Hawaii Island districts to identify 500 patients with types of chronic illness that can potentially be improved through dietary changes when supported by the delivery of a 'food as medicine' engagement and incentive program.PANDEMIC Incorporate lessons learned from operating a Nutrition Incentive program in the COVID-19 environment, including offering produce pick-up options through a network of CSA delivery sites, in addition to farmers market and retail grocery options as those become available.PARTICIPANT ENGAGMENT Test new intervention methods that include participant online learning activities, small group learning cadres, and longitudinal patient surveys measuring change in behaviors through self-informing qualitative reporting and quantitative results (ie lab test outcomes). Actively measure changes in biometrics, purchasing, and food consumption.HEALTH CLINIC Test new methods for more effective health care provider engagement in 'food as medicine' that include nutrition education integration strategies and clinic office training for medical assistants to improve support, and leverage nutrition-based expertise from doctors and dieticians who will provide peer-to-peer teaching modules.

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

Outputs
Target Audience:The audience are patients in the north eastern area of the Island of Hawaii and include an ethnic diversity of Native Hawaiian, white, Pacific Islander, and Asian and Portugese descendents. Changes/Problems:During this period the PPR operations for enrollment decreased as the participants reached their maxiumum produce allocations and the additional CRR enrollments took priority. What opportunities for training and professional development has the project provided?Team members learned to use the Qualtrics system and to conduct evaluation surveys. 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? Nothing Reported

Impacts
What was accomplished under these goals? The project worked with CSA and retail corner store partners to maintain a consistent produce distribution network. Produce was provided to 497 enrolled patients with 8,753 bi-monthly boxes distributed over life of project to date. During the 23-24 time period, our primary focus shifted to patients enrolled through the Hamakua Kohala Health clinics and northern end of island. Both intake and final surveys for the NIH evaluation were conducted using phone call interviews.

Publications

Progress 09/01/20 to 08/31/24

Outputs
Target Audience:The audience are patients on the Island of Hawaii and include an ethnic diversity of Native Hawaiian, white, Pacific Islander, and Asian and Portugese descendents. This PPR project focused primarily on clinics and participants in the North and Western area of the island. Diabetes, obesity, hypertension, and heart attacks are significant health challenges in these areas, Patients were enrolled through partnering clinics and selected based on limited income indicators, chronic health challenges that can be postively impacted by changes in diet, and a doctor-patient agreement to address diet as a healthy lifestyle component. Given great distances in remote rural areas between patients and providers, and infrequency of clinic contact, we also developed enrollment intiaitives through human service and community center partners in order to reach and expand our intended client base. Changes/Problems:The impacts of COVID required changing enrollment and distribution strategies. The project initially maintained the planned distribution sites for locally grown produce, but had to shift locations for pick-ups as the CSA providers had to change locations and this required adding food distribution contractors to adequately serve the enrolled participants. Enrollment saw a boost in participants in the early period of the project, reaching more individuals than anticipated, but the long term engagement waned as CSA food pick-ups fell due to buyer shopping patterns as COVID subsided. While the project did distribute more than the intended quantities of produce overall, a challenge was an increase in drop outs in more urban areas that then required re-filling the available patient spaces. In comparison, rural participants, with fewer shopping options,remained in the program in greater numbers through its full 10-12 month term. Another challenge identifies is the lack of collaboration between SNAP and WIC offices, making it difficult to serve participants directly. It appears that NIFA and the NIH are developing ways for clinics to contributehealth indivcator data to further demonstrate impacts of increased fresh produce access. We appreciate and commend this development as have watched the FINI / Gus NIP program evolve and develop improved implementation and research strategies since 2015. In previous years, the health indicator data we collected had no reporting tool to be contributed to. What opportunities for training and professional development has the project provided?Team members learned to use Qualtrics via Nutrition Incentive Hub evaluation tools and adapt them to meet this project's needs. Team members learned to conduct intake and final evaluation surveys. Project Director attended online professional development webinars with the Nutrition Incentive Hub and other GusNIP partners. Lead team memberattended an at-risk population conference. 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? Nothing Reported

Impacts
What was accomplished under these goals? New communities and vendors were brought on board to expand the network of services, building on previous year's accomplishments. Project management and tracking tools were tested and improved, including HIPAA compliant document storage. Relationship building and new training with clinics took place to strengthen project stakeholder engagement. Materials for recruiting, enrollment and clinical staff education were updated and distributed. The internal intake and survey instruments operated online and via printed form. Online ordering continued to streamline vendor services. As of 8/31/2024, 497 have been enrolled through 12 clinic and community sites. 8,753boxes of Hawaii grown CSA produce were distributed. 1 farmers market, 3 farm direct CSA and 1 brick and mortar firm are participating as providers. Project host pick up sites have operated in: Waimea, Honoka'a, Hawi (2 northern), Kona (4) for a total of 8 locations. CRR expanton funding was implemented separately for expansion into specific communities hard hit by COVID, including Native Hawaiian and Pacific Islanders. New relationships with clinical and produce providers in those areas was initiated and a system to differentiate and track PPR and PPR CRR was set up. Worked with the Evaluation team to develop protocols for survey instruments. Conducted intake and final surveys.

Publications

Progress 09/01/22 to 08/31/23

Outputs
Target Audience:Patients are enrolled through partnering clinics and are selected based on limited income indicators, chronic health challenges that can be postively impacted by changes in diet, and a doctor-patient agreement to address diet as a healthy lifestyle component. Given great distances in remote rural areas between patients and providers, and infrequency of clinic contact, we also developed enrollment intiaitives through human service and community center partners in order to reach and expand our intended client base. Changes/Problems:Redesigning the service areas and reporting process to differentiate PPR from CRR was more challenging than anticiapted but resolved by splitting groups based on geography What opportunities for training and professional development has the project provided?Team members are learning to use NIH evaluation tools and adapt them to meet this project's needs. Project Director is attending online professional development webinars with the Nutrition Incentive Hub and other GusNIP partners. 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? Nothing Reported

Impacts
What was accomplished under these goals? New communities and vendors were brought on board. Project management and tracking tools continue to be tested and improved, including HIPAA compliant document storage. Relationship building and new training with clinics took place to strengthen project stakeholder engagement. Materials for recruiting, enrollment and clinical staff education were updated and distributed. The internal intake and survey instruments operated online and via printed form. Online ordering continued to streamline vendor services. As of 12/31/2022, 497 have been enrolled ( minus 40 drop outs) through 11 clinic and community sites. 7,276 boxes of Hawaii grown CSA produce were distributed. 1 farmers market, 3 farm direct CSA and 1 brick and mortar firm are participating as providers. Project host pick up sites have operated in: Waimea, Honoka'a, Hawi (2 northern), Kona (2) for a total of 6 locations. CRR expanton funding was implemented separately for expansion into specific communities hard hit by COVID, including Native Hawaiian and Pacific Islanders. New relationships with clinical and produce providers in those areas was initiated and a system to differentiate and track PPR and PPR CRR was set up. Worked with the Evaluation team to develop protocols for survey instruments and efforts. Received the IRB waiver in Jan 22. Have participated inannual Directors Meeting and in PPR cohort sessions.

Publications

Progress 09/01/21 to 08/31/22

Outputs
Target Audience:Patients are enrolled through partnering clinics and are selected based on limited income indicators, chronic health challenges that can be postively impacted by changes in diet, and a doctor-patient agreement to address diet as a healthy lifestyle component. Given great distances in remote rural areas between patients and providers, and infrequency of clinic contact, we also developed enrollment intiaitives through human service and community center partners in order to reach and expand our intended client base. Changes/Problems:A challengein this period were going through the IRB Waiver process. This delayed ability to start the required intake and post participation surveys but this has been resolved and is operating. Changes in staff at the Nutrition Hub also required several restarts in processes. Redesigning the service areas and reporting process to differentiate PPR from CRR was more challenging than anticiapted but resolved by splitting groups based on geography. What opportunities for training and professional development has the project provided?Team members are learning to use a new online enrollment tools and adapt them to meet this project's needs. Project Director is attending online professional development webinars with the Nutrition Incentive Hub and other GusNIP partners. Project manager attended the 5th Annual Conference on Native American Nutrition in Minnesota. 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? Nothing Reported

Impacts
What was accomplished under these goals? Project design was tested and improved. New communities and vendors were brought on board. Additional team members were hired. Project management and tracking tools continue to be tested and imrpoved, including HIPAA compliant document storage. Relationship buildingand new training with clinics took place to strengthen project stakeholder engagement. Materials for recruiting, enrollment and clinical staff education were updated and distributed. The internal intake and survey instrumentsoperated online and via printed form. Online ordering continued to streamline vendor services.Of the 500 intended participants, 303 have beenthrough 11 clinic and community sites. 2,808 boxes of Hawaii grown CSA produce were distributed. 1 farmers market, 2farm direct CSA and 1 brick and mortar firm are participating as providers. Project host pick up sites operated in: Waimea, Honoka'a, Hawi (2 northern), Kona (2) for a total of 6 locations. CRR expanton funding wasawardedfor expansion into specific communities hardhit by COVID, including Native Hawaiian and Pacific Islanders. New relationships with clinical and produce providers in those areas was initiated and a system to differentiate and track PPR and PPR CRR was set up. Worked with the Evaluation team to develop protocols for survey instruments and efforts. Received the IRB waiver. Participated in the annual Directors Meeting and in PPR cohort sessions.

Publications

Progress 09/01/20 to 08/31/21

Outputs
Target Audience:The project launched with enrollments startingJune 2021 and produce incentives began iJuly 2021. This initial group of participants were largely drawn from the West Hawaii Community Health Centers (WHCHC) and the Hamakua Kohala Health Centers (HKH). Patients are enrolled through the clinics and are selected based on lmited income indicators, chornic health challenges that can be postively impacted by changes in diet, and a doctor-patient sgreement to address diet as a healthy lifestyle component. As of Aug 31st, 185 were enrolled. Outreach to Mango Medical and Island Heart Care also began with 32 of the enrollments coming from non WHCHC or HKH locations. Changes/Problems:The impacts of COVID have required the project to initially focus on safe drive-by or pick-up options for participants and this has been an opportunity to shift from paper vouchers to online (or phone in) produce ordering. We have not yet found a way to re-engage with the larger brick and mortar sites we have worked with previously using paper vouchers and are researching electrornic voucher solutions with the goal of addingadditional retail locations in 2022. The change in the program that we are finding very positive is switching to the Barn 2 Door (B2D) online ordering system that enables participants to direct order a prepacked box of produce that is easy to pick up and limits potential COVID exposures. On the administrative side, this ordering system is a great improvement from the quick-pivot inhouse efforts to launch CSA services in our previous FINI project, which came to a close a few months after COVID began. For participants not able to order online themselves, they can call in their order and a team memberenters it into the online system. This is a huge time and effort saving solution for our team, and using the B2D interface allows us to hand off a pack list to the farmers with out taking any of their order administration time dealing with individual buyers. They in turn pass that cost savings on to the project, yielding more produce per box for our participants. What opportunities for training and professional development has the project provided?Team members are learning to use a new online enrollment tool and adapt it to meet this project's needs. Project Director is attending online professional development webinars with the Nutrition Incentive Hub and other GusNIP partners. 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?Continue to expand enrollment, learn from clinical partners how best to refine processes, research additional produce access locations, find pathways to deliver culturally appropriate foods, keep communication open with clinical partners and community stakeholders, assess when to expand to additional clinic enrollment sites.

Impacts
What was accomplished under these goals? Project design constructed and team members hired. Project management and tracking tools created and tested. Relationships and initial training with clinics took place to strengthen project stakeholder engagement. Materials for recruiting, enrollment and clinical staff education wereproduced and distributed. The intake survey instruments were designed and operated online and via printed form. Tablets were purchased and delivered to the clinics to ease enrollment through the Care Coordinators. Of the 500 intended participants, 185 were enrolled in this period through 10 clinic sites. 221 boxes of Hawaiigrown CSA produce were distributed. 1 farmers market, 1 farm direct CSA and 1 brick and mortar firm began participating as providers. Co-hosted a culinary education program using culturally appropriate Polynesian ingredients. Project hostpick up sites were established in: Waimea, Honoka'a, Hawi (3 northern), Kona (2), and South Kona (2) for a totalof 7 locations. CRR expanton funding was applied for (and awarded) for expansion into specificcommunities hardest hit by COVID, including Native Hawaiian and Pacific Islanders. New relationships with clinical and produce providers in those areas was initiated and a system to differentiate and track PPR and PPR CRR was set up. Worked with the Evaluation team to develop protocols for survey instruments and efforts. Enrolled in the annual Directors Meeting for Sept 1st.

Publications