SULLIVAN AND ORANGE COUNTY NUTRITION INCENTIVE PROGRAM

• Sponsoring Institution: National Institute of Food and Agriculture
• Project Status: ACTIVE
• Funding Source: OTHER GRANTS
• Reporting Frequency: Annual
• Accession No.: 1028886
• Grant No.: 2022-70422-37761
• Cumulative Award Amt.: $499,580.00
• Proposal No.: 2022-06173
• Project Start Date: Sep 15, 2022
• Project End Date: Sep 14, 2025
• Grant Year: 2022
• Program Code: [PPR]- Produce Prescription

Recipient Organization
CATSKILL REGIONAL MEDICAL CENTER
68 HARRIS BUSHVILLE RD
HARRIS,NY 12742

Performing Department
(N/A)

Non Technical Summary
The FreshRx Program is a Produce Prescription Program (PPR) that will make healthy fruits and vegetables more readily available to the Supplemental Nutrition Assistance Program (SNAP) and Medicaid eligible participants in the Mid-Hudson Valley community. Specifically, the program will provide a financial incentive to SNAP and Medicaid eligible participants for each Diabetes Prevention Program (DPP), "Eat Healthy, Be Active," and "Cooking Matters" workshop sessions, in an amount of up to $20 per session, redeemable at ten local farmers' markets and retailers in Sullivan and Orange Counties for fresh, eligible fruit and vegetable purchases. Garnet Health in collaboration with Cornell Cooperative Extension (CCE) Sullivan County, and other committed community partners, will implement the FreshRx Program to improve the affordability, accessibility, and approachability of local fruits and vegetables to the low-income population. The FreshRx Program is a continuation and expansion of the Sullivan Fresh RX program piloted in partnership with Garnet Health and Sullivan Renaissance in 2020. Participants visited a Garnet Health medical provider and then received a $5 coupon to be redeemed at farmers' markets. The program encouraged preventative and nutrition-based dialogue between patients and their healthcare provider, provided incentives and access to low and no cost fresh produce, and empowered patients to be proactive in choosing healthy food options to better their health. This proposal seeks to grow the program's reach by increasing the incentive amounts, participants, redemption sites across two neighboring counties, and opportunities for continued educational opportunities and resources. The goals of the FreshRx Program are to: 1) improve health outcomes in Sullivan and Orange Counties through consumption of fresh fruit and vegetables; 2) reduce individual and household food insecurity; and 3) reduce healthcare use and associated costs

Animal Health Component

(N/A)

Research Effort Categories

Basic

(N/A)

Applied

(N/A)

Developmental

(N/A)

Classification

Knowledge Area (KA)	Subject of Investigation (SOI)	Field of Science (FOS)	Percent
704	6099	1010	100%

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;

Keywords

freshrx

produce prescription

snap

Goals / Objectives
The FreshRx Program is designed to promote the accessibility and affordability of healthy, local produce while expanding the market for local food producers. This project will use an integrated approach to achieve improved health in our community and improved markets for local food producers. Through direct-to-consumer marketing of FreshRx incentives, participants will purchase eligible fresh whole or cut fruits and vegetables and be enrolled in nutrition and diabetes prevention education opportunities of their choice. This collaborative economic initiative is focused on supporting citizens participating in SNAP and Medicaid that live in Orange and Sullivan Counties, New York, that are purchasing foods from local farmers' markets and partnering retailers, of which the Community Cupboard and Catskills Food Hub are open and accessible year-round. The goals of the FreshRx Program are to:1. Improve health outcomes in Sullivan and Orange Counties through consumption of fresh fruit and vegetables:a. By December 2022, increase participation in Nutrition, Food Safety and Preparation Education Classes offered by 100% from 150 to 300 participants, over the course of the project, as measured by program registration and attendance.b. By December 2022, increase knowledge of nutrition, safe food handing, and preparation in 70% (210) of participants, over the course of the project, as measured by program feedback surveys at the end of each singular session and multi-session series.c. By December 2022, increase participation in Garnet Health's Diabetes Prevention Program (DPP) to improve health outcomes for 75% of participants. (CDC determines the benefit of the DPP program by participants recording at least a 5-7% weigh loss over one-year and 150 minutes of physical activity per week.)2. Reduce individual and household food insecurity:a. By December 2024, increase the accessibility and affordability of locally produced fruits and veggies among low-income consumers eligible for SNAP or Medicaid benefits by providing up to $320 per person per year of FreshRx incentives redeemable at site-based, door to door, and online ordering farmers' markets/retailers as measured by annual increases in FreshRx incentive redemptions of 20% year over year.3. Reduce healthcare use and associated costs:a. By December 2024, increase participation in Diabetes Prevention Programs offered by 100% (39 to 78) as measured by program registration and attendance.b. By December 2024, increase knowledge of chronic disease prevention and reduction measures in 70% (55) program participants, over the course of the project, as measured by program surveys at the end of each singular session and multi-session seriesc. December 2024, increase the knowledge and participation in the FreshRx program to sustainability after the grant period ends.

Project Methods
Project evaluation will include a self-assessment of Garnet Health's success in implementing and operating the project. Partners plan to conduct a "network" self-assessment using a tool from the National Rural Health Resource Center. The self-assessment will be an iterative process with opportunities for evaluation incorporated into the development of the final assessment report. Network partners will collectively evaluate input from each partners' self-assessment and collectively identify and integrate suggestions for network changes or development. These steps will be documented through meeting agendas, meeting minutes, and in reporting prepared by the Project Director. The activities will be evaluated against the stated activities and measurable outcomes described in the work plan. There will be an emphasis on full participation of all network partners, opportunities for feedback from all partners and efforts toward consensus building among partners. Whenever possible, the network will use quantitative data methods. Self-assessment efforts will help the partners to evaluate throughout if the project is achieving the outcomes and progress desired, consider causal factors, and to realign efforts if necessary. There will be quarterly project monitoring and data sharing by the Project Director. The Project Director will hold primary responsibility for assuring that project progress is maintained and tracked, in accordance with the work plan. The self-assessment will follow guidelines developed by the NTAE centers to ensure an appropriate level of comparability of methods, outcomes, and measures. There will be quarterly scheduled meetings with representation from all community partners that will assess progress on the identified programmatic, administrative, and financial objectives and associated activities/strategies as set forth in the work plan. Meetings of the network partners will also include time for partners to give feedback and express any concerns regarding project progress and solicit input from partners on ways to improve the implementation process and to strengthen network development. The Project Director will prepare a quarterly report on the status of the work plan relative to designated timetables and will report on expected outcomes and project expenditures to date. Additional informal check-in between project partners will be scheduled as needs or challenges arise. By the end of the project period, the following outcomes will all be measures of successful project implementation and operation: • A collaborative vision among partners; • A network communication strategy established; • Determine what federal, state, regional, and local resources can be leveraged; • The network partners' capacity is strengthened; and • The network partners will evaluate and assess the effectiveness of the implementation process and the success of the network in reaching project goals. The partners are committed to ensuring that progress towards completing the goals and objectives are continuously assessed and tracked throughout the grant period and that these assessments are used to inform the network's quality improvement strategy and sustainability beyond federal funding. This project affords community partners numerous opportunities to build relationships of trust and collaboration as they work together to progress through the proposed goals, objectives, and activities. Outcome Evaluation Components of the evaluation may include key informant interviews, surveys, and/or focus groups with selected Medicaid and SNAP users and representatives from each of the implementation sites following the implementation period. The goal of the evaluation will be to assess the opportunities and barriers for accessing the FreshRx Program and to identify lessons learned to be used to improve the program for future iterations. The evaluation data collected as a part of this produce prescription program will allow Garnet Health, CCE Sullivan, and other project partners to assess the process, goals, and intended outcomes for the project as outlined in Section C above. All outcome data will be provided for USDA's Research Performance Progress Report and in collaboration with USDA's Nutrition Incentive Program Training, Technical Assistance, Evaluation, and Information Centers

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

Outputs
Target Audience:The project will serve Sullivan and Orange Counties in the Mid-Hudson Valley Region of New York State (NYS). Sullivan County is a rural community in the northwestern part of the Mid-Hudson Region about 75 miles of New York City in the Catskills Mountains. Orange County is located approximately 40 miles north of New York City. Orange County is 839 square miles of a diverse mix of rural, farmland, suburban, and urban areas. Nearly 18 % of the County's population residein three cities: Middletown, Newburgh, and Port Jervis. Sullivan County has the second worst health and economic indicators in NYS for morbidity, and poverty, faring better thanBronx county;coupled with 17.5% poverty rate with 35.7% families with children aged 18 or under living in poverty. Half of Sullivan County's children are eligible for free or reduced lunch. Obesity and chronic diseases indicators are a full 5-10% points higher than New York and U. S. averages. One in ten county residents receiveSupplemental Nutrition Assistance Program (SNAP) benefits. Changes/Problems:Several issues and changes have emerged during the program year, primarily concerning the Fresh Rx program. Key changes and problems identified include: 1. Incentive redemption issues: While incentives were distributed, redemption rates were lower than expected. Farmers faced difficulties using the Health Ways app for cash redemption, prompting project staff to seek technical support from the app developer. Discussions are ongoing about potentially switching to paper vouchers. 2. Limited redemption locations: A lack of pre-approved farmers markets in Orange County for incentive redemption has hindered access. 3. Partnership Changes: The Catskills food hub, initially designated as a seasonal source for fruit and vegetable distribution, has shifted its focus to farm-to-school efforts due to leadership and organizational changes. This has created a gap in off-season incentive redemption sites. However, the project director is establishing connections with local grocery stores to facilitate food box assemblies for participants during the off-season, particularly for those with transportation challenges. 4. Class size and venue constraints: The CCE class in Orange County attracted more participants than expected, exceeding the capacity of the available classroom space. A cutoff for participants will be implemented, with pre-registration encouraged for better planning. 5. Language barriers: A significant number of Spanish-speaking participants attended the first Orange County class, but the educator was unprepared to teach simultaneously in both languages. Pre-registration will help identify language preferences, and translation services will be provided as needed. 6. Referral Challenges: There have been few referrals from local social services, SNAP staff, or health care providers, partly due to limited capacity (0.80FTE nutrition educators) impacting partnership development and recruitment. 7. Geographic challenges: the rural nature of Sullivan County complicates regular attendance and incentive redemption, despite efforts like mobile market stops. 8. Target population focus: Project staff plan to prioritze outreach and programming for high-risk communities in Orange and Sullivan counties, including homeless shelters, soup kitchens, food pantries, federally qualified health centers, community centers, and senior housing. Overall, the program is actively seeking solutions to address these challenges while enhancing its outreach and support for underserved populations. What opportunities for training and professional development has the project provided?Garnet Health staff attended Temple University, Prevent T2 Lifestyle Coach training. Staff included Jessie Moore, DrPh, MPH, CHESand Emily Rynd, RN; Leslie Miccio, RN completed her CLC through the Association of Diabetes Care and Education Specialists. Cornell Cooperative Extension's Nutrition Educator, Joy Leon, attended the following trainings:- 6-month course in Public Health Essentials;CITI Certification; ServSafe Certification; CPR training; National Nutrition Certificate Program from Ohio State University; attendance at the Making Healthful Decisions Conference; 2 LinkedIn Learning Classes (Strategies to Learn and Upskill More Effectively and Moving Your Class Online Quickly and Efficiently); and regular participation in continuing education opportunities outside of scheduled work hours to improve Spanish-language skills, public speaking and communication skills, and physical activity teaching skills. Cornell Cooperative Extension's Market and Food Systems Program Manager, Alan Carroll, attended the SNAP processing annual training and the Farmers Market Management Pro Certification training. How have the results been disseminated to communities of interest?We understand the significance of sharing our program's results with the community and consider it a priority. However, we have not yet disseminated the findings as we are still in the early stages of building new community relationships, promoting our programming, and addressing ongoing challenges. We are currently analyzing the collected data to ensure that our results are accurate, comprehensive, and meaningful. It's essential that the information we share is both genuine and beneficial to the community. What do you plan to do during the next reporting period to accomplish the goals?As we finalize Year 2 of the project, we are on target withaccomplishing the established goals.

Impacts
What was accomplished under these goals? Goal 1: Improve health outcomes through fresh fruit and vegetable consumption 1. Increase education participation: Successfully expanded participation in food safety and preparation education classes from 23 to 66individuals, enhancing knowledge and skills for healthier food preparation. 2. Diabetes Prevention Program Engagement: Achieved a significant increase in participants for the diabetes prevention program, growing from 11to 25individuals, contribuiting to better health management in the community. Goal 2: Reduce individual and household food insecurity 1. Fresh Rx program participation: Increased the number of individuals participating in the Fresh Rx program from 23 in 2022/2023 grant year to 66in the 2023/2024 year, improving access to affordable fresh produce for low-income consumers eligibile for SNAP or Medicaid. 2. Incentive distribution insight: Despite the increased participation, no individuals or household reached the maximum incentive distribution of $320, highlighting a need for enhanced integration of the Fresh Rx program with the Diabetes Prevention Program to maximize benefits. Goal 3: Reduce health care use and associated costs 1. Increased participation in the Diabetes Prevention Program : Achieved a 44% increase in enrollment in the Diabetes Prevention Program in Year 2, effectively empowering more individuals to adopt healthier lifestyles and reduce their risk of chronic diseases. 2. Expanded Fresh Rx Program participation: Boosted participation in the Fresh Rx program by 34.8% in Year 2, facilitating greater access to fresh produce for community members and promoting healthier eating habits. 3. Enhanced Community Awareness: Launched targeted outreach initiatives that raised awareness about the benefits of fresh fruits and vegetables, contributing to increased program participation and improved health literacy among participants. 4. Cost Saving: Equipped participants with tools and resources to manage their health proactively, contributing to reduced healthcare utilization and associated costs. These accomplishments indicate progress in improving health outcomes and addressing food insecurity, while also identifying areas for further development to optimize program effectiveness.

Publications

Progress 09/15/22 to 09/14/23

Outputs
Target Audience:The project will serve Sullivan and Orange Counties in the Mid-Hudson Valley Region of New York State (NYS). Sullivan County is a rural community in the northwestern part of the Mid-Hudson Region about 75 miles northwest of New York City in the Catskill Mountains. Orange County is located approximately 40 miles north of New York City. Orange County is 839 square miles of a diverse mix of rural, farmland, suburban, and urban areas. Nearly 18% of the County's total population resides in its three cities of Middletown, Newburgh, and Port Jervis. Sullivan County has the second worst health and economic indicators in NYS for morbidity, mortality, and poverty, faring better only the Bronx county. Coupled with a 17.5% poverty rate with 35.7% of families with children aged 18 or under living in poverty, half of Sullivan County's children are eligible for free or reduced lunch. Obesity and chronic diseases indicators are a full 5-10% points higher than New York and U.S. Averages. One in ten Sullivan County residents receives Supplemental Nutrition Assistance Program (SNAP) benefits. Changes/Problems:This first year has been a challenge due to staffing changes, clarity on population to beserved andgetting a better understanding of the reporting requirements with multiple portals. We have experienced issues with contracts and delays in the work plan as well. Major changes included project staff only. What opportunities for training and professional development has the project provided?Staff has been trained on CITI certifications and as CDC Certifiedlifestyle coaches 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?In order to meet our goals defined in the work plan we have engaged the physician relations department of the health system to further promote the program in doctors' offices and clinics. We are exploring ways to address the language barriers that have been identified in the last year as well as the transportation barrier.

Impacts
What was accomplished under these goals? The FreshRX program got a late start this year with staffing an operational delays. Please see the below edits to the work plan as the program cycle years identified above are not aligned with the cycle we are currently in. 1. Improve health outcomes in Sullivan and Orange Counties through consumption of fresh fruit and vegetables: a. By December 2024, increase participation in Nutrition, Food Safety and Preparation Education Classes offered by 100% from 150 to 300 participants, over the course of the project, as measured by program registration and attendance. b. By December 2024, increase knowledge of nutrition, safe food handing, and preparation in 70% (210) of participants, over the course of the project, as measured by program feedback surveys at the end of each singular session and multi-session series. c. By December 2024, increase participation in Garnet Health's Diabetes Prevention Program (DPP) to improve health outcomes for 75% of participants. (CDC determines the benefit of the DPP program by participants recording at least a 5-7% weigh loss over one-year and 150 minutes of physical activity per week.) 2. Reduce individual and household food insecurity: a. By December 2026, increase the accessibility and affordability of locally produced fruits and veggies among low-income consumers eligible for SNAP or Medicaid benefits by providing up to $320 per person per year of FreshRx incentives redeemable at site-based, door to door, and online ordering farmers' markets/retailers as measured by annual increases in FreshRx incentive redemptions of 20% year over year. 3. Reduce healthcare use and associated costs: a. By December 2026, increase participation in Diabetes Prevention Programs offered by 100% (39 to 78) as measured by program registration and attendance. b. By December 2026, increase knowledge of chronic disease prevention and reduction measures in 70% (55) program participants, over the course of the project, as measured by program surveys at the end of each singular session and multi-session series c. December 2026, increase the knowledge and participation in the FreshRx program to sustainability after the grant period ends.

Publications