Progress 09/15/23 to 09/14/24
Outputs
Target Audience:The direct program recipients included a Southern Colorado Family Medicine and Mercy Primary Care patient population (adult Medicaid Members and/or SNAP recipients with a chronic condition or risk of developing one). Broader audiences included community partners (Pueblo Food Project, Nourish Colorado, La Plata Food Equity Coalition), firm partners (Southern Colorado Farmers Market, Save-a-Lot Foods, Durango Natural Foods Co-op, Durango Farmers Market and Northwest New Mexico Growers Market Alliance, and other food vendors), clinical partners (Southern Colorado Family Medicine and Mercy Primary Care staff), CommonSpirit Health leadership, technology partners (Snap2Save), Colorado fruit and vegetable growers and industry supporters, and the general public. Changes/Problems:Note that many of the changes and problems described here apply both to this award and to our original GusNIP award (award no. 2021-70030-35797). Challenges identifying and establishing the transportation vendors through existing organizational relationships proved more challenging than anticipated. The vendor account is now established for La Plata county and awaiting IRB approval to execute, but this is still in progress for Pueblo County. There is approximately a 3:1 ratio for La Plata county vs. Pueblo county enrollment rates. This puts Pueblo at almost the same rate of enrollment by total patient panel for both practices. Pueblo is the higher need patient population (higher percentages of uninsured and Medicaid caseloads), so we originally anticipated higher enrollment rates. However the social challenges patients are experiencing may also be contributing to challenges with patient enrollment in the associated research study which requires patients to present to the clinic to complete a consent process. This suggests PPR programs in higher needs communities may require adaptation to provide additional enrollment support (more staff hours, more remote or offsite enrollment opportunities, more transportation support, greater research incentives, etc), and/or enrollment targets may need to be adjusted for communities with higher needs to appropriately forecast enrollment rates and budgets. ? Unfortunately we have experienced additional staffing turnover and changes. A Community Health Supervisor role (funded by other sources at present) overseeing all community health advocates on this project became vacant on June 6, 2024. Though the project director remains, that individual was also restructured into a national role (previously regional) which will no longer include supervision of the team. We are exploring an opportunity to integrate the project team into our ambulatory business operations reporting structure to support further service alignment and electronic health record integrations. The new Community health analyst role (funded on award no. 2021-70030-35797) became vacant again June 29, 2024. Given the short time remaining on the performance period of this grant, we are identifying alternative solutions for completing evaluations through both existing internal resources and external opportunities prior to considering rehiring the role since recruiting and onboarding for these specialized skills originally took an extended period of time. What opportunities for training and professional development has the project provided?Training: The program supervisor conducted a site visit with our Pueblo enrollment site, providing education and mentorship around the enrollment process while also learning more about the challenges of serving this unique patient population.Community Health Advocates enrolling patients in the Fresh to Flourish program are enrolling in a Community Health Worker fundamentals course through Metro State University this month which will support their services for patients as well as their ability to reimburse for health equity services in the future (cost of course enrollment funded through other means).The community health advocate for La Plata County did training events at three hospital staff events, two group community partner meetings, and two individual community parter organizations. Professional Development: The project director attended and presented at the National Rural Grocery Summit in June 2024, bringing one food business partner and our Double Up Food Bucks partner, Nourish Colorado. How have the results been disseminated to communities of interest?Our program has been promoted broadly and featured in several articles and reports. 1.CommonSpirit Health Mountain Region. Feeding Our Communities Through the Fresh to Flourish Produce Prescription Program. February, 2024. https://www.mountain.commonspirit.org/story/feeding-our-communities-through-fresh-flourish-produce-prescription-program 2. Wasserstrom, C. Exploring The Intersections Of Health, Heritage + Harmony Through Fresh Foods. Spoke + Blossom Magazine. June, 2024. Accessed from https://www.spokeandblossom.com/stories/2024/7/26/exploring-the-intersections-of-health-heritage-harmony-through-fresh-foods. What do you plan to do during the next reporting period to accomplish the goals?In the next reporting period, we will implement transportation vouchers for those participants expressing needs for transportation to redeem their produce vouchers. We will also solicit a vendor for production of our individualized vouchers with unique Voucher ID numbers and scannable IDN tracking (using either a barcode, QR code or a combination of the two). In the next two quarters, we will plan and conduct clinical staff process evaluations (to include such methods as surveys, key informant interviews and focus groups). We also intend to solicit proposals for a technology solution to improve tracking of individual voucher uptake. We will also submit proposals for several national conferences taking place between spring and fall 2025. And will further develop press releases and media stories to share program information more publicly. In the third quarter we will complete analysis of our clinical staff process evaluations and begin our participant-level quantitative outcome analysis. We will continue development on our implementation toolkit and dissemination of our programmatic findings and resources while we begin our final analyses.
Impacts
What was accomplished under these goals?
Goal 1: Objective 1.A.These outcomes will be reported with the data analysis conducted in our final reporting period. In the interim we will note factors unique to the enhancement which may influence these outcomes in the expanded geographies. We continue to collaborate with Nourish Colorado for updates on SNAP-Ed offerings in the La Plata county area to which we intend to direct our patient participants. Nourish Colorado developed a website (https://nourishcolorado.org/cooking-matters-for-participants/) which launched in spring of 2024, and hosts the available SNAP-ed offerings of virtual and in-person classes through local community partners as well as local contact info and registration information. The participant-level website feature was added more recently and functionality is still being actively improved. Offerings are updated regularly. In June of 2024, virtual offerings were added. Though these offerings started in the second half of the reporting period this year, these were not coordinated or communicated to our patients and thus patients received only the minimal nutrition education offerings provided during their program enrollment this year. It is important to note that La Plata County participants also have had access to Diabetes Self Management Education and National Diabetes Prevention Program through the Mercy Family Medicine Clinic. We are tracking patients that are concurrently participating in these programs. As of 9/14/2024, there are 236 total patient enrollments as of 9/14/2024. Of those, 175 patients enrolled in La Plata county through Mercy Primary care (35 patients prior to 9/15/2023) and are unique to this award residing in three counties (La Plata, Montezuma, and San Juan County NM). vs. 61 enrolled in Pueblo County who are represented in both this award and the original USDA NIFA GusNIP grant for this project, Pueblo Produce Prescription pilot (award no. 2021-70030-35797). Of the 175 enrolled in La Plata County, all but seven were Medicaid recipients (96%).Those seven were SNAP recipients, but not Medicaid recipients. Of those participants who answered a baseline survey question about whether or not they received SNAP benefits (n=160) 104 said yes (65%). Of participants who answered baseline survey questions about their food security (n=175) 72% (n=126) were food insecure and 41% indicated that adults in the household were skipping or cutting the size of meals because there wasn't enough money to buy food (n=72). 9/01/2023-8/31/2024 $46,500 of incentives were issued and $27,991.55 were redeemed as of 9/30/2024 yielding a redemption rate of 60%. This is a substantial increase from our early redemption rate of 37%. We hope to see continued improvements in these trends with the recent expansion of redemption locations in San Juan County, NM (three farmers market sites) and with the additional support of transportation vouchers. Goal 2: Objective 2.A. A transportation vendor has been established in La Plata County. Usage tracking and invoicing systems have been established and the vouchers can begin being deployed once a protocol and materials for these vouchers are approved by our IRB. Objective 2.B. We have maintained the two firms added last year in La Plata County, CO and added another firm in San Juan County, NM where approximately 30% of our Mercy Family Medicine (La Plata County, CO) patient participants reside. We are also in the contracting phase of onboarding a new retail firm location in Pueblo County, CO (the second year-round retail location in Pueblo) which is closer to our Southern Colorado Family Medicine clinic location. Altogether seven food firms were redeeming vouchers this year across three counties. Those not included in this narrative are included in reporting for our original USDA GusNIP award 2021-70030-35797). Northwest New Mexico Growers Market Alliance is operating three locations (Aztec, Bloomfield and Farmington), where they also accept SNAP and Double Up Food Bucks nutrition incentives and offer local produce. Through September 2024, they received $470 of vouchers and $339 of single scripts were redeemed with vendors. Durango Farmers Market (seasonal, direct to consumer) reported receiving $1620 of incentives exchanged for $1 scrip and $1068 of these were redeemed with vendors. Since no redemptions were made in the 2024 season, we mutually agreed with partners at Fort Lewis College Farmstand (seasonal, direct to consumer) not to continue this site in the 2024 growing season. Durango Natural Foods Co-op (year-round brick-and-mortar grocery retailer). This location is just three blocks (a 7-minute walk) from the primary La Plata County clinic location (Durango, Horse Gulch) where a majority of La Plata patients are receiving their initial vouchers at the time of enrollment. They have redeemed a total of $27,137.55 of Fresh to Flourish vouchers as of 8/31/2023, with an average monthly redemption value of $2261.46 and median of $2201 (range: $1020.44-$3278.19). At the conclusion of this project, we will compare available data from vendors on SNAP and EBT sales to understand changes in sales over time after implementing the Fresh to Flourish PPR program. Goal 3: Objective 3.A Data collection and management systems developed in REDCap are operational as of early 2024. We had planned to deploy a system to automatically record issuance and redemption of individual vouchers using a QR code scanning system in this second program year. However, multiple organizational barriers to deploying an internal technology solution that integrates with REDCap have required us to source a contract externally. An RFP process is in development and will hopefully be executed by early 2025. In the meantime, we are able to manually track individual voucher issuance and redemptions through 10/31/2024 in our Pueblo County locations. Unfortunately our new Community Health Analyst role became vacant again in June, 2024. However, we will resume our development of implementation tools and the associated case study in quarter one of the next reporting period. Outcome. iii. The program had one national presentation and one state presentation in this program year. Church J, Bird L, Muskett O, Duncan J. Rural Grocery Development & Nutrition Incentives in the Four Corners. National Rural Grocers Summit. Montgomery, AL. June 2024 Prenni J, Church J, Neff J. Growing for Human Health: The Science and Application of Produce Prescriptions. Colorado Fruit and Vegetable Growers Association Annual Conference. Westminster, CO. Feb. 2024
Publications
- Type:
Conference Papers and Presentations
Status:
Published
Year Published:
2024
Citation:
Church J, Bird L, Muskett O, Duncan J. Rural Grocery Development & Nutrition Incentives in the Four Corners. National Rural Grocers Summit. Montgomery, AL. June 2024
- Type:
Other
Status:
Published
Year Published:
2024
Citation:
Wasserstrom, C. Exploring The Intersections Of Health, Heritage + Harmony Through Fresh Foods. Spoke + Blossom Magazine. June, 2024. Accessed from https://www.spokeandblossom.com/stories/2024/7/26/exploring-the-intersections-of-health-heritage-harmony-through-fresh-foods.
- Type:
Conference Papers and Presentations
Status:
Published
Year Published:
2024
Citation:
Prenni J, Church J, Neff J. Growing for Human Health: The Science and Application of Produce Prescriptions. Keynote at Colorado Fruit and Vegetable Growers Association Annual Conference. Westminster, CO. Feb. 2024
- Type:
Websites
Status:
Published
Year Published:
2024
Citation:
CommonSpirit Health Mountain Region. Feeding Our Communities Through the Fresh to Flourish Produce Prescription Program. February, 2024. https://www.mountain.commonspirit.org/story/feeding-our-communities-through-fresh-flourish-produce-prescription-program
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Progress 09/15/22 to 09/14/23
Outputs
Target Audience:The patient population (adult Medicaid Members and/or SNAP recipients with a chronic condition or risk of developing one) is being engaged through outreach by our Community Health Advocate integrated into Mercy Family Medicine and referrals from their primary care providers or other staff within the clinic. Changes/Problems:Note that many of the changes and problems described here apply both to this award and to our original GusNIP award (award no. 2021-70030-35797). We were unable to secure a non-seasonal redemption firm partner for this intervention prior to the end of the growing season in October 2022. The initial firm partners were two small seasonal farmstands who ceased their seasonal operations in early October 2022. Though we had an active year-round firm partnership agreement in draft phase, we still had to pause participant enrollments and notify participants of a lapse in service for their voucher redemptions until that agreement could be finalized and ready for use. Simultaneously, the project team was experiencing challenges integrating staff 1) into the clinic physically (due to space limitations) and 2) into existing clinical workflows due to unrelated staffing challenges. This led clinic administration to require a pause in activity through January 2023. During the service lapse, we created protocol adaptations in our study protocols to account for potential service lapses in the future. Following this pause, the project team pivoted to focus on further supporting our ongoing program implementation resource development such as REDCap electronic data capture and management system and consider clinical workflow improvements. A complete program staff turnover occurred in December of 2022. At that time, we anticipated a 6-month pause in implementation to restaff and reorient new program staff and that was achieved by 6/30/2023. Major contributing factors to the turnover included 1) a slow startup period due to hiring and clinical program integration 2) prolonged research protocol and evaluation systems development and 3) operational changes within the health system. These elements were challenging for continued staff engagement vs. their desire to provide direct service and see participant impacts. Role clarity and delineation was another challenge. Initial staffing structures (two project coordinators, and two community health advocates across multiple funding sources) were originally limited by budgets and multiple grant timelines to create more specific role delineations. Thanks to the addition of this enhancement award, the complete turnover did allow for a redesign of the staffing model prior to filling vacancies. As of June 2023, we are fully restaffed with one dedicated full-time Community Health Supervisor (currently funded under a grant from CommonSpirit Health), overseeing two part time clinic-embedded Community Health Advocates and day-to-day program operations (one currently funded by CommonSpirit and the other by this grant as originally planned) and one part-time Community Health Analyst (funded by award no. 2021-70030-35797) responsible for driving data collection, management, analysis and reporting processes. This role will implement individualized VIDN tracking plans as well. Additionally, a disaffiliation of our organization (Dba Centura Health) into its two separate sponsoring organizations, CommonSpirit Health and Advent Health previously operating under the joint venture management structure of Centura Health occurred on July 31,2023. This contributed to some losses in non-clinical operational efficiency across the health system. There were no administrative impacts to this grant as the grant is held entirely within our legal entity of Catholic Health Initiatives Colorado (which has always been affiliated with CommonSpirit Health). Cooking Matters (Colorado's State SNAP-Ed provider) also ended their SNAP-Ed contract. The new contractor will be our existing partner, Nourish Colorado, but this will cause some disruption and limitations in nutrition education services. Finally, with the establishment of an internal Community Health Analyst possessing adequate skills and resources to conduct our evaluations internally, we moved to terminate our external evaluation subaward effective 9/11/2023. Pending budget reallocations related to this change will be reported as required. What opportunities for training and professional development has the project provided?Training: The project supervisor and community health advocates have presented program training at several clinical staff meetings (4 in Durango) as well community coalition meetings (2 in Durango). Professional Development: The project supervisor and community health advocate were able to attend and present at the June 2023 Nutrition Incentive Hub National Convening in Washington DC. The project director presented at the 2023 Society of Nutrition Education and Behavior International Conference in Washington DC. How have the results been disseminated to communities of interest?Our program has been promoted broadly and featured in several articles and reports. CommonSpirit Health. 2022 Philanthropy report: Health Justice $5.1 million. November 2022. https://gettoknowphilanthropy.info/#financial-impact:~:text=%245.2%20million,Department%20of%20Agriculture Mercy Hospital. A ripple that causes a wave in food access for the Four Corners. Health & Care. Spring 2023. https://centura.widen.net/s/bglt2fpbg7/231113_newsletter_mrmc_healthcare_spring2023_final What do you plan to do during the next reporting period to accomplish the goals?In the next reporting period, we are planning to expand firm locations to New Mexico as more than 15% of enrolled patient participants are living in San Juan County, NM (Aztec, Bloomfield, Farmington, Flora Vista and Kirtland) and are citing transportation and redemption locations as a barriers to utilizing the program. We are also working to implement program enhancements such as transportation vouchers. Enrollments are currently projected to increase month on month. At year end, we will also reassess our referral and enrollment rates to determine if increasing the amount and/or duration of intervention per patient participant may be warranted to deliver the most impact to those we are able to reach in the remaining grant period in spite of timeline delays. Our Community Health Analyst will be trained and certified for Epic electronic health record (EHR) data extraction to facilitate our health outcomes and utilization analysis. This is a newly developed role within the organization that is housed in our IT department under the data engineering team, but allocated entirely to the Fresh to Flourish project. This role will be responsible for driving data collection, management, and extraction. The planned innovations for QR-code enhanced VIDN tracking will be driven by this role as well. We will track and present the process of this role and scope development as it will be relevant to our technology case study. Our data collection and management system built in REDCap will be launched in the coming months and includes efficiency improvements such as a fully automated participant self-administered enrollment and follow up surveys, and improved systems for monitoring voucher issuance and redemption.
Impacts
What was accomplished under these goals?
Goal 1: Extend geographic diversity. Objective 1.A Addthree rural primary careclinic sites in La Plata County(associated with Mercy Hospital) serving approximately 800 additional patients, direct farm-to-consumer and brick and mortar redemption locations. Outcome 1.i. The same outcomes evaluated in our current award's evaluation plans (existing Pueblo Produce Prescription Program USDA GusNIP award no. 2021-70030-35797) will apply to these additional sites and participants (La Plata County), noting the unique, rural population, redemption firms and a healthcare workforce previously and currently exposed to an effective food security competency intervention.These outcomes will be reported with the data analysis conducted in our final reporting period. In the interim we will note factors unique to the enhancement which may influence these outcomes in the expanded geographies. Due to a change in State-contracted SNAP-Ed provider from Cooking Matters Colorado to Nourish Colorado, participants received only the minimum nutrition education level (enrollment nutrition education) until September 2023. A virtual Nutrition Education event offered by Pueblo County's Cooking Matters Coordinator was available these participants on 9/12/2023 covering the topic of "How to make the most with your fruits and veggies: Learn new ideas for saving time and money while shopping for and preparing meals and snacks that you enjoy." We are in continued partnership with both Nourish Colorado and their contracted community Nutrition Education providers and will continue to coordinate both virtual and in-person nutrition education offerings. Outcome 1.ii. Number of counties, participants, clinic sites, and communities served are expanded Mercy Family Medicine's practice began enrolling patients on (7/26/2023). This addition represents three new clinic sites in La Plata County (two in Durango and one in Bayfield). As of 9/14/2023 35 patients were enrolled, residing in 3 counties (La Plata, Montezuma, and San Juan County NM). Preliminary issuance data shows approximately $5500 of prescription incentives were issued and $2018.36 of prescription incentives were redeemed, representing an early redemption rate of 37% and an increasing trajectory. Among participants, we will track the following outcomes pre- and post- intervention: - Individual and household food security and fruit and vegetable consumption - Utilization of food access resources among those with food insecurity - Routine visit compliance - Clinical and biometric health indicators A system to record issuance and redemption of individual vouchers is in development and should be deployed in the next reporting period to explore dose-response relationships. Goal 2: Enhance participant experience. Objective 2.A. Address transportation barriers to redemption. We are still in the early phases of identifying and activating contracting and payment pathways for transportation vouchers and expect this enhancement will be live in both La Plata county and Pueblo County by Spring of 2023. Objective 2.B. Expand firm locations and types. Outcome 2.i. Number of firm types are expanded &?Outcome 2.ii. Number and geographic spread of firm locations are expanded A total of four new voucher-redemption locations in La Plata County have been incorporated (one of them is no longer operating in the 2023 growing season). The three remaining this growing season also accept SNAP and Double Up Food Bucks nutrition incentives and offer local Colorado produce: Good Food Collective Farmstand (Sept 2022 only, co-located at clinic enrollment site) redeemed $240 of incentive. Anecdotally, most of these were redeemed on the same day as patients' enrollment or receipt of their first vouchers. Durango Farmers Market (seasonal, direct to consumer) is reporting issuing incentives (vouchers are redeemed at the market info booth for scrip to spend with market vendors), but they did not yet report redemptions as of 9/14/2023. Our community health advocate has received patient reports, however, that they are visiting the market, bringing their neighbors, and using their vouchers. "My neighbor told me you gave her some vouchers for produce, can I get some of those, too?" This patient arrived at the clinic within the hour, brining yet another neighbor from the subsidized housing complex where they all live. During enrollment, they made plans to go to the local Farmer's Market together Fort Lewis College Farmstand (seasonal, direct to consumer) did not report any redemptions. Their number of SNAP transactions was also low and we will explore whether and how to continue this site next season. Durango Natural Foods Co-op (year-round brick-and-mortar grocery retailer). This location is just three blocks (a 7-minute walk) from the primary La Plata County clinic location (Durango, Horse Gulch) where a majority of La Plata patients are receiving their initial vouchers at the time of enrollment. They have redeemed a total of $681.92 of Fresh to Flourish vouchers as of 8/31/2023. Their number of transactions more than tripled from July to August (from five to 17 transactions) and the total value nearly doubled ($267.71 to $414.21). We will compare last year's available data from both vendors on SNAP and EBT sales with these two firms to understand changes in sales after beginning to accept our Fresh to Flourish produce prescription vouchers. Goal 3: Expand scaling capacity and clinical implementation technical assistance. We will explore innovations to improve program efficiency and will broadly disseminate findings and resources. Objective 3.A Pilot a scannable social needs paper voucher issuance system which utilizes QR codes, iPad scanners, and REDcap mobile app data entry to enhance administrative efficiency. Following program staff turnover, we were able to create and hire a new role in the organization for this project. Our Community Health Analyst was hired in June 2023 (funded by this enhancement's original award 2021-70030-35797) and provides skilled expertise internally. As of September, this individual is refining the REDCap database and integrating into our Data Engineering team. Outcome 3.i. A technology case study and implementation tools The new Community Health Analyst role is operationalizing a REDCap-integrated paper voucher issuance and tracking system, as well as driving data collection, extraction and management related to the project. We anticipate tools developed with the support of this unique role will bring innovation and greater efficiency to not only this project, but the broader field of social needs health incentive evaluation. We are archiving the process required to develop the technology and instruments for the purposes of this case study. Outcome 3.ii. Number of Centura health primary care clinics demonstrating expansion readiness. Once implementation tools are ready for public viewing, we will share them with internal primary care site administrators to disseminate information about the study, learnings and opportunity for expansion. These sessions will also help to identify sites expressing readiness to expand the program and necessary additional resources to support the expansion. Outcome3.iii. State and national level presentations and publications prepared to disseminate knowledge The program had two national presentations. Church JT, Mulholland AM. Implementation Protocols for Health System-Based Produce Prescriptions. National Nutrition Incentive Hub Convening. June 2023, Washington DC. Church JT. Design of Implementation Protocols for a Health System-based Produce Prescription Program: A Process Evaluation. J Nutrition Ed and Behavior. 2023; 55(7S): 67.. https://doi.org/10.1016/j.jneb.2023.05.148).
Publications
- Type:
Other
Status:
Published
Year Published:
2022
Citation:
1.CommonSpirit Health. 2022 Philanthropy report: Health Justice $5.1 million. November 2022. https://gettoknowphilanthropy.info/#financial-impact:~:text=%245.2%20million,Department%20of%20Agriculture
- Type:
Conference Papers and Presentations
Status:
Published
Year Published:
2023
Citation:
Church JT. Design of Implementation Protocols for a Health System-based Produce Prescription Program: A Process Evaluation. J Nutrition Ed and Behavior. 2023; 55(7S): 67.. https://doi.org/10.1016/j.jneb.2023.05.148).
- Type:
Conference Papers and Presentations
Status:
Published
Year Published:
2023
Citation:
Church JT, Mulholland AM. Implementation Protocols for Health System-Based Produce Prescriptions. National Nutrition Incentive Hub Convening. June 2023, Washington DC.
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