CSA PARTNERSHIPS FOR HEALTH: CONNECTING LOCAL FARMERS AND HEALTH CLINICS FOR WELL-NOURISHED COMMUNITIES

• Sponsoring Institution: National Institute of Food and Agriculture
• Project Status: COMPLETE
• Funding Source: OTHER GRANTS
• Reporting Frequency: Annual
• Accession No.: 1024401
• Grant No.: 2020-70030-33122
• Cumulative Award Amt.: $492,827.00
• Proposal No.: 2020-06284
• Project Start Date: Sep 1, 2020
• Project End Date: Apr 17, 2025
• Grant Year: 2020
• Program Code: [PPR]- Produce Prescription

Recipient Organization
Friends of Zenger Farm
11741 SE Foster Rd
Portland,OR 97266

Performing Department
(N/A)

Non Technical Summary
Community Supported Agriculture (CSA) Partnerships for Health connects local farms and health clinics for well-nourished communities. Historically, health centers serving SNAP-eligible, Medicaid, and food insecure patients located in areas with concentrated poverty are enrolled in a 22-week heavily subsidized CSA prescription program by physicians and Community Health Workers. In 2020, we are piloting a project offer both 22-week CSA prescriptions as well as year-round CSA prescription programs. Patients pay a co-pay of $5 per week in cash or SNAP in exchange for $28 worth of whole fruits, vegetables, grains, and beans. Beginning in 2020, we will also pilot covering the incentive portion of the prescription CSA through Medicaid Flexible Spending.While Medicaid Flexible Spending is a huge step in the right direction, it is not a funding mechanism that can be used on a large scale. Instead, it is a limited amount of funding each year that is reserved for patients who have exhausted all other options to get their "non-medical" social needs met. However, Medicaid Flexible Spending will play an important role in utilizing insurance funding for CSA prescriptions for the first time while creating a HIPPA-compliant method of data sharing between program partners to help understand the impact of the CSA prescription program on healthcare utilization and associated costs. Proving the return on investment for healthcare providers is a necessary step to accessing truly sustainable funding for prescription produce through health insurance.Our robust partnership with some of the most promising researchers in the nation has allowed us to gather data for the last five years indicating that CSA prescriptions increase self-reported vegetable consumption by an average of ½ cup per day, increases the variety of vegetables eaten, improves food security, and improves self-reported mental, emotional, social, and physical health. From 2020-2022, our research team aims to further quantify the impact of CSA prescriptions on fruit and vegetable consumption, BMI, hemoglobin A1c, and healthcare utilization rates.Medicaid coverage for CSA Partnerships for Health could easily scale regionally and nationally, transforming the wellbeing of low-income consumers while simultaneously supporting local farmers and saving our health industry billions of dollars. This common-sense program is a win (food access for low-income consumers), win (strengthening farmers/food systems), win (saving of health industry dollars). Funding from the Gus Schumacher Nutrition Incentive Program would be used to temporarily subsidize the cost of CSA shares to low-income health clinic patients while gathering the additional data needed by insurers to cover the program as a regular benefit through Medicaid.Funding request: $492,827.50Time period: 10/31/2020 - 10/31/2023

Animal Health Component

(N/A)

Research Effort Categories

Basic

80%

Applied

(N/A)

Developmental

20%

Classification

Knowledge Area (KA)	Subject of Investigation (SOI)	Field of Science (FOS)	Percent
704	6010	1010	100%

Knowledge Area
704 - Nutrition and Hunger in the Population;

Subject Of Investigation
6010 - Individuals;

Field Of Science
1010 - Nutrition and metabolism;

Keywords

csa

chronic disease

community health center

produce prescription

public health

veggie rx

Goals / Objectives
1) Improve health of low-income patients by providing subsidized CSA shares at their home health clinicComparison of pre- and post-evaluation data show a 30% increase in skin carotenoid levels, a measure of fruit and vegetable intake.Comparison of pre- and post-evaluation data show a 1-point decrease in hemoglobin A1c and a 2.5% reduction in BMI.Comparison of pre- and post-evaluation data show significant improvement in overall health among 90% of participants.Post-intervention interviews reveal self-reported improvements in overall health for at least 90% (810) of participants2) Improve food security for low-income patients90% of patients (810) report an increase in food security based on administration of the USDA's Household Food Security Survey Model (this percentage increase is realistic based on previous survey data)3) Provide additional revenue stream for small, local mixed vegetable farmsPre- and post-surveys indicate a 35% increase in revenue for local farmers based on participating in the CSA prescription program4) Prove "return on investment" for health insurersBy November of 2020, a pilot of 30 CSA prescriptions have been completed through Medicaid Flexible Spending for CareOregon and OHSU patients.By November of 2020, data sharing agreements are finalized with CareOregon and OHSU to track changes in healthcare use and cost as a result of program participation.5) Expand nationwide coverage of produce prescriptions through training and data sharingIn May of 2023, 1000 households in the Portland metro area are enrolled in CSA prescription programs through Medicaid Flexible Spending and through regular Medicaid plan coverageBy November of 2023, 100 community health centers and insurers are trained on how to provide produce prescriptions via Medicaid Flexible Spending and other insurance coverageBy November of 2023, a "how to" guide to insurance coverage for prescription produce programs is made available online at no cost to organizations nationwide, offer free online trainings to interested organizations.

Project Methods
Since 2015, we have carried out both process and outcome evaluations for CSA Partnerships for Health. During our first season, we conducted a mixed-methods study[i] which found that CSA Partnerships for Health had a positive impact on patients, including increased access to fresh and/or organic vegetables and improved diet quality. In focus groups, patients also expressed their appreciation for the instrumental (e.g., text message reminders), informational (e.g., skill sheets), and emotional social support they received during the program. We have used these findings to shape our program.Consistent with findings from other cost-offset or subsidized CSA programs, patients participating in CSA Partnerships for Health have reported statistically significant increases in overall vegetable intake, orange vegetable intake, variety of vegetables consumed, eating habits, food security, ability to afford to eat healthy meals, and statistically significant improvements in overall health status and emotional health.[ii] During the 2019 season, we conducted a pilot study to explore the effect of CSA prescriptions on BMI and hemoglobin A1c among patients with obesity and/or diabetes and food insecurity. [iii] Although not statistically significant, we found a reduction in weight among participants (n=22) who lost, on average, 2.14 pounds during the intervention period. Too few participants had hemoglobin A1c data available at both baseline and follow-up to conduct meaningful analyses.Over the past five years, we have leveraged the research infrastructure at Portland State University, Oregon Health & Science University, and Kaiser Permanente Center for Health Research to support our work and have built our capacity to evaluate CSA Partnerships for Health using a community-based participatory research approach and mixed-methods. We are requesting funds in this proposal to conduct process and outcome evaluations of a year-round CSA prescription program. The purpose of our outcome evaluation is to use a mixed-methods approach to assess the impact of a year-round CSA prescription on fruit and vegetable consumption, food security, overall health, BMI, and hemoglobin A1c. This information will at least partially be used to determine reduction in healthcare costs while reduction in healthcare use will be calculated through a data sharing agreement with CareOregon. We will use interviews (English and Spanish) to gather information about patient experiences participating in the year-round CSA. Interview questions will focus on the benefits and challenges of participating in the program. We will use the six-item short form food security survey module[iv] to measure household food security status.To date, we have used a 2-item screener to estimate fruit and vegetable consumption. However, the screener (and other self-reported measures of fruit and vegetable intake) is based on subjective estimates and is prone to substantial error. Pressure-mediated reflection spectroscopy (SMRS) is a useful way to objectively assess fruit and vegetable intake because of its ability to measure carotenoids, an antioxidant found in green, yellow, orange, and red fruits and vegetables, in the skin. Because of its portability, SMRS can easily be used during the CSA pickup. We will use a Pressure-mediated Reflection Spectrometer (Veggie Meter)[v], which can measure skin carotenoids in seconds and is non-invasive, to assess fruit and vegetable consumption. We will also extract weight, BMI, hemoglobin A1c from patients' electronic medical records.[i] Izumi BT, Higgins CE, Baron A, Ness SJ, Allan B, Barth ET, Smith TM, Pranian K, Frank B. (2018). Feasibility of Using a Community-Supported Agriculture Program to Increase Access to and Intake of Vegetables among Federally Qualified Health Center Patients. Journal of Nutrition Education and Behavior, 50(3):289-296.e1.[ii] Izumi BT, Martin A, Garvin T, Higgins Tejera C, Ness S, Pranian K, Lubowicki L. (In Press). CSA Partnerships for Health: outcome evaluation results from a subsidized community-supported agriculture program to connect safety-net clinic patients with farms to improve dietary behaviors, food security, and overall health. Translational Behavioral Medicine.[iii] Izumi BT, Fitzpatrick SL. (2020). CSA Partnerships for Health: 2019 Season Evaluation Report. Kaiser Permanente Center for Health Research.[iv] https://www.ers.usda.gov/media/8282/short2012.pdf[v] Ermakov I, et al. (2016). Skin Carotenoids as Biomarker for Vegetable and Fruit Intake: Validation of the Reflection Spectroscopy-Based "Veggie Meter." The Faseb Journal, 30(1), 409.3 - 409.3. https://www.fasebj.org/doi/abs/10.1096/fasebj.30.1_supplement.409.3

Progress 09/01/20 to 04/17/25

Outputs
Target Audience:The target audience for CSA Partnerships for Health is Federally Qualified Health Center (FQHC) patients in the Portland, Oregon metropolitan area. FQHCs provide primary and preventative care to individuals regardless of their ability to pay. Most patients receiving services at their health clinic receive SNAP benefits or are enrolled in Oregon Health Plan and identify as food insecure. Self-reported data from program participants during this time period indicates that our patient population has the following characteristics: • 51% speak a language other than English most often at home • 57% identified as being of Hispanic, Latinx, or Spanish origin • 15% identified as Black or African American • 78% receive Medicaid • 80% report experiencing food insecurity • 85% have a yearly household income of less than $25,000 Changes/Problems: Nothing Reported What opportunities for training and professional development has the project provided?As stated above, we provided training to Community Health Workers and Farmers. In addition, we've participated in the Oregon Food Systems Network. We also in 2024 became part of a cohort associated with becoming a Health-Related Social Needs (HRSNs) provider, which Zenger Farm is in the process of becoming in 2025 for Trillium, HealthShare, and continuing our work with CareOregon. ? How have the results been disseminated to communities of interest?Annually, we share the results of CSA Partnerships for Health with our constituents through Zenger Farm's annual report, which is shared through our website, social media, and newsletter. What do you plan to do during the next reporting period to accomplish the goals? Nothing Reported

Impacts
What was accomplished under these goals? Improve health of low-income patients by providing subsidized CSA shares at their home clinic. We were able to conduct pre and post evaluations with participating clients. Also, we shifted to a delivery model through a partnership with Doordash that increased the retention of participants. Our summer 2023 results were the following: 97% of survey respondents rated the quality of the produce as very good or good. 89% of survey respondents were familiar and or very familiar with the produce in their share. 31.7% of survey respondents shared that they used the vegetable guide. 67% would find cooking classes helpful and 62% reported that they have used a recipe from the newsletter. Additional resources requested include translated material, a recipe book, and/or videos (even though we provided them with a recipe book, the vegetable guide). 70% have access to online platform(s)- Facebook, Email, and Google being the most prevalent with 91% reporting that they WOULD use one or more of these platforms to access resources from the program. In addition, 28% reported they did NOT know who to contact if they had questions and/or problems with their share. Improve food security for low-income patients. Throughout the project, we provided 21,970 weekly produce shares to 1,093 clients across Multnomah County for 22 weeks during the spring, summer, and fall. Provide additional revenue stream for small, local mixed vegetable farms. CSA Partnership for Health distributed $760,840 to small local mixed vegetable farms during the grant period. Prove "return on investment" for health insurers. Throughout the project, we've seen a gradual increase in buy-in from insurers. In 2023-2025 90% to 70% of CSA shares provided to clients were subsidized by Medicaid, demonstrating insurers' commitment to the efficacy of the program. At the state level in Oregon, we've seen a substantial interest in supporting fresh produce and nutrition education to low-income individuals at various transition points, such as being on the brink of being unhoused (like the patients we reach at the eight FQHC we serve). Expand nationwide coverage of produce prescriptions through training and data sharing. We've shared best practices for prescription programs that specifically want to partner with directly with regional farms. We've partnered with CareOregon to provide trainings to community health workers at health centers on how to submit flex fund requests for reimbursement. We wrote a workshop series for current farmers who would like to partner with prescription produce programs, and how to grow crops in winter to provide year-around produce

Publications

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

Outputs
Target Audience:?The target audience for CSA Partnerships for Health is Federally Qualified Health Center (FQHC) patients in the Portland, Oregon metropolitan area. FQHCs provide primary and preventative care to individuals regardless of their ability to pay. Most patients receiving services at their health clinic receive SNAP benefits or are enrolled in Oregon Health Plan and identify as food insecure. Self-reported data from program participants during this time period indicates that our patient population has the following characteristics: • 51% speak a language other than English most often at home • 57% identified as being of Hispanic, Latinx, or Spanish origin • 15% identified as Black or African American • 78% receive Medicaid • 80% report experiencing food insecurity • 85% have a yearly household income of less than $25,000 Changes/Problems: Nothing Reported What opportunities for training and professional development has the project provided?Rob Cato attended the national conference for PPR and CRR which provided a great opportunity to connect with other organizations doing similar work as well as present our learnings throughout the project. 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?We will continue conducting scientific evaluation to measure improved health outcomes among program participants, as well as increases in food security. We will also conduct internal program evaluations to elicit feedback for program improvement.

Impacts
What was accomplished under these goals? During this reporting period, over 70% of CSA shares provided to clients were subsidized by Medicaid, demonstrating insurers' commitment to the efficacy of the program. CSA Partnerships for Health distributed $217,200 to local, small mixed vegetable farms over the main summer season, and $79,640 over winter, totalling $296,840 in revenue for CSA farmers. In order to supplement CSA shares, we made a series of bulk produce purchases, distributing roughly $5,000 to small local market farms.

Publications

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

Outputs
Target Audience:The target audience for CSA Partnerships for Health is Federally Qualified Health Center (FQHC) patients in the Portland, Oregon metropolitan area. FQHCs provide primary and preventative care to individuals regardless of their ability to pay. Most patients receiving services at their health clinic receive SNAP benefits or are enrolled in Oregon Health Plan and identify as food insecure. Self-reported data from program participants during this time period indicates that our patient population has the following characteristics: • 51% speak a language other than English most often at home • 43% identified as being of Hispanic, Latino, or Spanish origin • 23% identified as Black or African American • 58% receive Medicaid • 79% report experiencing food insecurity. Changes/Problems: Nothing Reported 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?We will continue conducting scientific evaluation to measure improved health outcomes among program participants, as well as increases in food security. We are developing a professional training series for health care providers and community-based organizations on how to provide produce prescriptions via Medicaid Flexible Spending and other insurance coverage.

Impacts
What was accomplished under these goals? We provided an addition $12,200 this year to regional farmers over the previous year, resulting in over $266,000 in revenue directly distributed to regional farmers. 88 percent of program participants are now covered by their health insurance providers at full program cost, demonstrating a "return on investment" by health insurers.

Publications

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

Outputs
Target Audience:The target audience for CSA Partnerships for Health is Federally Qualified Health Center (FQHC) patients in the Portland, Oregon metropolitan area. FQHCs provide primary and preventative care to individualsregardless of their ability to pay. Most patients receiving services at their health clinic receive SNAP benefits or are enrolled in Oregon Health Plan and identify as food insecure. Self-reported data from program participants during this time period indicates that our patient population has the following characteristics: • 51% speak a language other than English most often at home • 43% identified as being of Hispanic, Latino, or Spanish origin • 23% identified as Black or African American • 58% receive Medicaid • 79% report experiencing food insecurity Changes/Problems: Nothing Reported What opportunities for training and professional development has the project provided? Nothing Reported How have the results been disseminated to communities of interest?Our partnership with Portland State University published a peer-review journal article on the effectiveness of using rideshare programs (Uber, Lyft, etc) to reduce barriers to participation in prescription produce programs: https://preprint.press.jhu.edu/pchp/sites/default/files/PCHP What do you plan to do during the next reporting period to accomplish the goals?We are partnering with Doordash to provide a delivery option to remove transportation barriers. We are intending to partner with even more regional farmers for sharesthrough direct financial compensation. Working with CareOregon, we are streamlining data sharing processes between the two organizations. Additionally, we will hold training and professional development opportunities for community health centers, medical providers, and farmers on how to maximize the benefits of prescription produce programs.

Impacts
What was accomplished under these goals? 1. Improve health of low-income patients by providing subsidized CSA shares at their home health clinic We were able to conduct pre and post evaluations with participating clients. We have submitted data to the Gretchen Swanson Center for Nutrition for data analysis, and are imminently waiting for the analysis to arrive. Through CareOregon, we secured pre-approval for all Ride to Care trips to produce pick-up weekly, for those clients with disabilities who already utilizeRide to Carefor primary care clinic visits; this is a new agreement in place for 2022. 2. Improve food security for low-income patients We have provided 6,600 weekly produce shares to 300 households across Multnomah County, for at least 22 weeks during the spring/summer/fall season. 3) Provide additional revenue stream for small, local mixed vegetable farms We partnered with 8 small farms this season, providing over $198,000 in direct payments to farmers. 4) Prove "return on investment" for health insurers We secured an oral agreement with CareOregon to reimburse CSA shares for flex fund-eligible Medicaid clients up to 160 shares in 2022. Additionally, Trillium Community Health Plan, a regional health insurance provider, has issued the first flex fund payment ever for a prescription produce share in CSA Partnerships for Health; they have agreed to approve future flex fund requests on a "case-by-case" basis. 5) Expand nationwide coverage of produce prescriptions through training and data sharing We are currently writing an executive summary of findings since the start of COVID to illustrate best practices for prescription programs that specifically want to partner directly with regional farms. We will partner with CareOregon to provide trainings to community health workers at health centers on how to submit flex fund requests for reimbursement. We are writing a workshop series for current farmers who would like to partner with prescription produce programs, and how to grow crops in winter to provide year-round produce.

Publications

• Type: Journal Articles Status: Accepted Year Published: 2022 Citation: https://preprint.press.jhu.edu/pchp/sites/default/files/PCHP-WIP_Izumi.pdf

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

Outputs
Target Audience:The target audience for CSA Partnerships for Healthis Federally Qualified Health Center (FQHC) patients in the Portland, Oregon metropolitan area. FQHCs provide primary and preventative care to individuals regardless of their ability to pay. Most patients receiving services at their health clinic receive SNAP benefits or are enrolled in Oregon Health Plan and identify as food insecure. Self-reported data from program participants during this time period indicates that our patient population has the following characteristics: 51% speak a language other than English most often at home 43% identified as being of Hispanic, Latino, or Spanish origin 23% identifiedas Black or African American 58% receive Medicaid 79% report experiencing food insecuirty Changes/Problems:Major changes that have impacted the program have been the COVID-19 pandemic,which has limited our ability to be in person and collect data. We plan to implement in-person data collection during the 2022 summer season and therefore, adjusted our timeline accordingly. Additionally, we have had personal change, which has required the onboarding of the new Project Director (Nicky Ulrich). These challenges have not changed the mission and goals of the program, but have created challenges and edits to the timeline. 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?During the next reporting period, we will have pre and post-survey data to report back on that will reveal how this program impacts food insecurity, self-reported improvements of health,and revenue increase for partner farms. Additionally, we will continue to increase our use of Medicaid Flex Funding, when eligible. Finally, we will formalize agreements fordata sharing and expand nationwide coverage of produce prescriptions through training.

Impacts
What was accomplished under these goals? Accomplishments included in this reporting period are below: - Prove "return on investment" for health insurers By August 2021, 193 CSA prescriptions have been completed through Medicaid Flexible spending for CareOregon, Kaiser, and OHSU patients. Due to the COVID-19 pandemic, we have not achieved the data-sharing agreement goal at this point. We are in conversations with CareORegon and OHSU about how to best track changes in healthcare use and cost as a result of program particiaption and will include those outcomes in future reporting.

Publications