Source: SCHA FOUNDATION INC submitted to NRP
IMPROVING DIABETES IN SC THROUGH A STATEWIDE PRODUCE BOX PRESCRIPTION MODEL SUMMARY
Sponsoring Institution
National Institute of Food and Agriculture
Project Status
COMPLETE
Funding Source
Reporting Frequency
Annual
Accession No.
1028892
Grant No.
2022-70422-37765
Cumulative Award Amt.
$500,000.00
Proposal No.
2022-06165
Multistate No.
(N/A)
Project Start Date
Sep 15, 2022
Project End Date
Sep 14, 2025
Grant Year
2022
Program Code
[PPR]- Produce Prescription
Recipient Organization
SCHA FOUNDATION INC
1000 CENTER POINT RD
COLUMBIA,SC 292105802
Performing Department
(N/A)
Non Technical Summary
The primary purpose of this grant is to demonstrate and evaluate the impact of the FoodShare Veggie Rx model on the improvement of dietary health through increased consumption of fruits and vegetables and the reduction of individual and household food insecurity. The Veggie Rx Clinical-Integration Model seeks to build a strong bridge between medical providers and a statewide food access network; FoodShare SC. Patients with a diagnosis of prediabetes or diabetes who reside in one of four target counties in SC will be offered an opportunity to participate in this project. A referral will be sent to the local county FoodShare hub who will provide the fresh food box to the patient twice per month. Patients will receive produce boxes at no cost for six months. Clinical labs will be taken at months one and six. A coordinator at each FoodShare hub will be responsible for communicating with patients and providers.As part of the SC Hospital Association (SCHA), the SCHA Foundation is well poised to lead this project based on expertise in leading statewide programs such as AccessHealth SC and Healthy People, Healthy Carolinas (see program descriptions in Project Narrative to show link with health care providers). The FoodShare member network will provide fresh food boxes for the initial project and will also be available to patients after the six-month intervention is complete. At project end, the SC team expects full implementation, as well as a documented and scalable model for delivering a produce prescription program.
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
70350103020100%
Knowledge Area
703 - Nutrition Education and Behavior;

Subject Of Investigation
5010 - Food;

Field Of Science
3020 - Education;
Goals / Objectives
At the center of the FoodShare SC Veggie Rx-Clinical Integration model is a consistent product of high-quality produce accessible to SNAP families with limited income, provided by regional FoodShare SC hubs. These boxes are packed and distributed by a nonprofit located in the participant's local community using a hub and spoke model that both increases reach for transportation-limited community members and builds on existing local trust. The goal of this project is to improve food security and health of SNAP recipients with Prediabetes or Type 2 Diabetes by bridging the gap between health care and local food systems.
Project Methods
Outcomes and process evaluation will be conducted on the FoodShare SC Veggie RX program in accordance with requirements and guidance provided by the GusNIP NTAE Center. In direct alignment with the stated purposes of GusNIP Produce Prescription Projects, the first three objectives include does the FoodShare SC Veggie RX program: 1) improve dietary health through increased consumption of fruits and vegetables, 2) reduce individual and household food insecurity, and 3) reduce healthcare use and associated costs among participants? To answer these questions, we will administer the Produce Prescription Program Participant--Level Baseline Survey over the phone and enter the data into Qualtrics prior to a patient receiving their first FoodShare SC Veggie RX box and the Post Survey after 6 months with a sample of participating patients. Questions will be added to the surveys to collect a self-report of health care utilization. The project is scoped for approximately 1,600 patients. We will work with the Center to identify the sample size. We will provide deidentified matched patient data to the Center for analysis. For the added questions, we will share the deidentified data with the Center and analyze those responses to identify any changes in health care utilization and then apply nationally recognized calculations to estimate health care cost savings, including based on any reductions in related Emergency Department visits or an increase in appropriate care. Since the inclusion criteria of this project is patients with type 2 diabetes, we will also test HbA1c at baseline and 6 months post program enrollment as a fourth evaluation objective. When a provider refers a patient to FoodShare SC, they will enter BMI, BP, and lipid profile data into the portal. We will extract the data and match it with the pre- and post-survey data for each patient to also send deidentified to the Center. With a sample of patients (number based on guidance from the Center) who enroll during the first year of the project, we will conduct the Post Survey and collect biometrics data again at 12 months, with an incentive for another box.The next evaluation questions pertain to redemption rates of FoodShare SC Veggie RX boxes and long-term usage. These include: 1) What is the redemption rate of FoodShare SC Veggie RX prescriptions among participating patients? 2) Do redemption rates of FoodShare SC Veggie RX prescriptions differ among patients who are prescribed 6 months of free FoodShare SC Veggie RX boxes versus patients who are prescribed and referred to FoodShare to purchase their own boxes? and 3) Do patients who receive 6 months of free FoodShare SC Veggie RX boxes start purchasing boxes on their own after the 6 months are completed? When a patient enrolls in the program and is referred to the FoodShare SC hub in their geographic location, the hub tracks if they come to pick up their boxes in the FoodShare SC One Box software program. FoodShare SC One Box is a secure, password-protected system used to track customer orders. Patients will be denoted as participants of the Veggie RX program in the system and we will be able to pull reports to track how many weeks participants picked up boxes and if they start purchasing boxes on their own after the prescriptions ran out. Once the maximum number of patients have been enrolled in the program based on available funding, providers will continue to refer patients to FoodShare SC via the portal and encourage them to purchase boxes on their own. We will be able to determine and compare redemption rates between patients who receive a referral that includes free boxes versus those who do not. In addition to patient-based data collection, we will collect data for the Farm Direct and Clinic Core Metrics to share with the Center.We will also conduct a process evaluation to document the process, challenges, and successes of implementation and operations. Data will be collected with the 5 primary project stakeholder groups, (patients, health care partners, FoodShare SC organizations, and Unite Us developers). The participatory approach, journey mapping, will be used with a sample of patients to gain detailed input on the entirety of the produce prescription process. For the remaining stakeholder groups, quarterly group videoconferencing calls will be hosted by the SCHAF. These calls will allow sharing about their process, successes, and challenges. Real-time results of the patient journey maps will also be shared so that improvement opportunities can be implemented. There will be standard guiding questions and the sessions will be recorded and analyzed.This evaluation presents both opportunities and potential challenges. This evaluation design has been piloted as a part of partnerships between FoodShare SC hubs and health clinics in two separate counties. Through the pilot, slight changes to the referral system, processes, and the technology systems were made based on feedback from involved stakeholders including asking all survey questions over the phone, which will be incorporated into this evaluation plan.Challenges might still surface. Based on the sample size the Center recommends, we might not have the staff capacity to conduct all necessary phone surveys. If that occurs, we will recruit a graduate student. The evaluator has routinely served as a practicum advisor/intern supervisor for the past 13 years and has successfully recruited and trained students for data collection. Program retention among patients might also be a challenge, making it difficult to have a large enough sample to determine program outcomes. To help overcome this challenge, we are utilizing lessons learned from the pilot. After a participant does not pick up a box the first time, they will receive a call from FoodShareSC to troubleshoot (e.g., help figure out transportation). After missing two pick-ups, another patient will have the opportunity to enroll.The evaluator for this project, who will also serve as a co-project director, has 10 years of experience designing and conducting evaluations and research studies using both over the phone and in-person quantitative and qualitative methods. Studies include: a 6-month longitudinal study to understand if the FoodShare SC model is associated with changes in household food security and produce consumption among customers; a digit-dial survey with 2,000 SNAP participants to identify their experiences and environments to inform tailored SNAP-Ed programming; and a focus group study to understand transportation challenges and solutions.In addition to these methods, SCHA and BCBSSC have extensive experience capturing Emergency Department and Inpatient utilization in partnership with healthcare organizations and with the state's Revenue and Fiscal Affairs Office. Several project team members have previously or are currently working on other efforts that incorporate healthcare utilization and Medicaid data into their evaluation efforts. We will be able to learn from these existing structures and processes to leverage those data points into our GusNIP evaluation. As this project develops program infrastructure, data experts with experience in this facet of the work will be consulted to incorporate strategies to explore the relationship between program participants and clinical data.

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

Outputs
Target Audience:The target audience reached during this reporting period included adult patients with prediabetes or diabetes living in Union, Spartanburg, Georgetown, or Williamsburg counties. These patients are typically being served by an AccessHealth network, regional community-based networks of coordinated care working to support the needs of uninsured and underinsured patients. Patients are typically referred from AccessHealth network care coordination staff or directly from a clinical organization that participates in the network, including hospitals, primary care, specialty clinics, free clinics and federally qualified health centers. Changes/Problems:Transportation continues to be a barrier to participation for patients and a major implementation hurdle for FoodShare hubs. We have seen some successes among partners that have been able to leverage existing staff and volunteer infrastructure and even care coordination touchpoints and home visits to deliver boxes when transportation is a barrier, but these examples are not currently sustainable or able to be scaled. GusNIP eligibility criteria continues to be another challenge. South Carolina is one of the ten states that have not expanded Medicaid under the Affordable Care Act, therefore we have scores of individuals who meet the diagnoses criteria and who are experiencing nutrition insecurity but are not eligible under the Medicaid enrollment criterion. Further, SNAP participation and eligibility also leaves a gap between individuals who could or should be participating in VeggieRx under GusNIP, but can't with existing eligibility rules. For example, South Carolina is the only state in the nation that still has a full lifetime ban on SNAP eligibility for individuals with a drug felony conviction. We have scores of individuals and families experiencing nutrition insecurity but fall into the "SNAP gap" because their income may fall just outside of the gross income limit. Stigma also continues to be a barrier to SNAP participation. Both Medicaid and SNAP eligibility and/or participation criteria can also leave out a significant proportion of Latino South Carolinians, who are underrepresented in both programs and have additional hurdles and barriers to participating in federal healthcare and nutrition programs, exacerbating existing health and social inequities. Finally, as we've seen an increase in the number of patients completing the program, we're not seeing a significant number of former program participants continue on as FoodShare customers. We are working with our hub partners to identify opportunities to provide education and navigation support related to SNAP, Healthy Bucks, and FoodShare. This will also include engaging with participants to better understand their preferences and barriers in continuing as a FoodShare customer beyond VeggieRx. What opportunities for training and professional development has the project provided?Ongoing technical assistance (TA) and onsite quality improvement site visits continue with partners in Spartanburg, Union, and Georgetown counties. These visits have allowed forcontinued training and professional development around how to best have conversations with patients about nutrition insecurity, establishing roles and responsibilities for different members of the care team, integrating the program into Medicaid quality assurance programming, screening for SNAP eligibility, and how to best streamline and integrate referrals into clinical and FoodShare hub workflows. We also have facilitated partnership development activities to grow our clinical partner networks. How have the results been disseminated to communities of interest?We have begun sharing updated data directly with sites each month to inform quality improvement opportunities and implementation barriers to prioritize. We've also begun processes to collect patient and partner stories to share across our network and inform the development of potential case studies around core project successes. What do you plan to do during the next reporting period to accomplish the goals?We continue to prioritize consistent and rigorous quality improvement processes to maximize referral efficiencies between healthcare organizations and their FoodShare hub partners. We have maximized opportunities to reach more partners within each AccessHealth network and now are emphasizing streamlining referrals and strengthening processes across these partnerships.

Impacts
What was accomplished under these goals? Partnerships between healthcare organizations and the local FoodShare hub within all four participating communities continue to grow and each community is actively making referrals. We have worked with sites to grow and diversify their network of clinical partners making referrals and have worked with different programs within their systems to increase enrollment among Medicaid-covered patients. Sites have made 1,034 total referrals resulting in 727 participants. See Community Summaries Below: Healthcare Partner: Tidelands Health - Tidelands Community Care Network FoodShare Hub: Carolina Human Reinvestment Tidelands has experienced starts and stops with referrals based on both staffing and IT changes in electronic medical records. Technical assistance (TA) has included developing streamlined workflows and leveraging intersections with the network's support of SCDHHS' Medicaid Quality Assurance Program (QAP) to reach patients covered by Medicaid. Healthcare Partners: Spartanburg Regional Health System, AccessHealth Spartanburg FoodShare Hub: Ruth's Gleanings Spartanburg has a wide network across different departments within Spartanburg Regional Health System (SRHS) with trained staff who are equipped to submit referrals. AccessHealth is a key driver of referrals, and we've grown a network of other clinical partners - a local federally qualified health center (ReGenesis) and free clinic (St. Luke's) - to refer through the network. SRHS has also maximized referral opportunities across outpatient clinics within their system. Healthcare Partners: Spartanburg Regional Health System - Union Medical Center, AccessHealth Spartanburg, Regenesis FoodShare Hub: RobinHood Group Union still struggles with consistent referrals based on staff capacity. They have added new staff and the AccessHealth network still maintains referral capacity when available. We are continuing to onboard a local FQHC (ReGenesis) as a network referral partner. Healthcare Partners: HopeHealth FoodShare Hub: CMD Pantry Williamsburg has been booming since the shift to HopeHealth as a clinical partner. Referrals are received from clinic sites across Williamsburg County, with a majority coming from their central site in Kingstree. Technical assistance includes working through opportunities to integrate more supports for nutrition education.

Publications


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

    Outputs
    Target Audience:The target audience reached during this reporting period include adult patients with prediabetes or diabetes living in Union, Spartanburg, Georgetown, or Williamsburg counties. These patients are typically being served by an AccessHealth network, regional community-based networks of coordinated care working to support the needs of uninsured and underinsured patients. Patients are typically referred from AccessHealth network care coordination staff or directly from a clinical organization that participates in the network, including hospitals, primary care, specialty clinics, andfederally qualified health centers. Changes/Problems:Transportation continues to be a barrier to participation for patients and a major implementation hurdle for FoodShare hubs. We have seen some successes among partners that have been able to leverage existing staff and volunteer infrastructure and even care coordination touchpoints and home visits to deliver boxes when transportation is a barrier, but these examples are not currently sustainable or able to be scaled. GusNIP eligibility criteria continues to be another challenge. South Carolina is one of the ten states that have not expanded Medicaid under the Affordable Care Act, therefore we have scores of individuals who meet the diagnoses criteria and who are experiencing nutrition insecurity but are not eligible under the Medicaid enrollment criterion. Further, SNAP participation and eligibility also leaves a gap between individuals who could or should be participating in VeggieRx under GusNIP, but can't with existing eligibility rules. For example, South Carolina is the only state in the nation that still has a full lifetime ban on SNAP eligibility for individuals with a drug felony conviction. We have scores of individuals and families experiencing nutrition insecurity but fall into the "SNAP gap" because their income may fall just outside of the gross income limit. Stigma also continues to be a barrier to SNAP participation. Both Medicaid and SNAP eligibility and/or participation criteria can also leave out a significant proportion of Latino South Carolinians, who are underrepresented in both programs and have additional hurdles and barriers to participating in federal healthcare and nutrition programs, exacerbating existing health and social inequities. What opportunities for training and professional development has the project provided?Onsite training has been provided to our new healthcare partner in Williamsburg County, and onsite quality improvement site visits have been conducted with partners in Spartanburg, Union, and Georgetown counties. These visits have allowed for continued training and professional development around how to best have conversations with patients about nutrition insecurity, establishing roles and responsibilities for different members of the care team, and how to best streamline and integrate referrals into clinical and FoodShare hub workflows. How have the results been disseminated to communities of interest?Site visits have been a helpful tool to keep community partners updated on progress. We are currently finalizing a project dashboard that will allow each community to review and comment on their progress in a consistent manner. This, coupled with upcoming opportunities for impact stories and case studies, will strengthen community partners' opportunities to provide insight to their strengths and barriers, as well as use data and findings from the project to connect with participants and local stakeholders on project impact. What do you plan to do during the next reporting period to accomplish the goals?We are placing a continued priority on consistent and rigorous quality improvement processes to maximize referral efficiencies between healthcare organizations and their FoodShare hub partners. We will also be identifying opportunities to reach more partners within each AccessHealth network - building referral bridges and opportunities for direct care provider staff within each healthcare organization and not just care coordination network staff.

    Impacts
    What was accomplished under these goals? Partnerships between healthcare organizations and the local FoodShare hub within all four participating communities are now fully operational and each community is actively making referrals and have begun implementation of the VeggieRx model. This has resulted in 241 referrals to date, 135 active current enrollees, and 13 participants that have completed the program thus far.

    Publications