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
0%
Research Effort Categories
Basic
80%
Applied
(N/A)
Developmental
20%
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