Progress 09/15/23 to 09/14/24
Outputs
Target Audience:The Los Angeles County Department of Public Health (DPH) collaborated with LA General Medical Center (LA General) to implement the Produce Prescription Project (PPR), locally known as the Fresco y Salduable/Fresh and Healthy program, across two primary care adult clinics in Los Angeles County, California. LA General is a part of the Department of Health Services (DHS) healthcare system and is located in the central/metro region of Los Angeles County, geographically referred to as Service Planning Area 4 (SPA 4). Many households in SPA 4 are at an increased risk for experiencing food insecurity and developing diet-related chronic diseases. Among Los Angeles County households who live 300% below the Federal Poverty Level, 31.8% of SPA 4 households experience food insecurity, compared to 26.8% of Los Angeles County households experiencing food insecurity overall based on 2018 data. Nearly, 12.1% of SPA 4 adults have been diagnosed with type 2 diabetes - higher than overall Los Angeles County rate for adults (11.3%). To enhance outreach and PPR enrollment, DPH collaborated with The Wellness Center (TWC), a flagship program of the non-profit public benefit corporation, LA General Medical Center Foundation, Inc. TWC serves as a resource hub for LA General patients and the surrounding community and coordinates services for 35,000 unique clients annually. TWC analyzed data from their participant database to identify patients who meet the following PPR criteria: low-income (enrolled in Medicaid), screened positive for food insecurity, and diagnosed with type 2 diabetes. TWC Wellness Navigators then contacted eligible patients by phone in their preferred language (English or Spanish) to gauge their interest in participating in the Fresco y Saludable Fresh and Healthy program. Interested patients were scheduled for in-person appointments with TWC to finalize their enrollment. Additionally, TWC conducted outreach efforts to LA General's nursing staff, social workers, and physicians to inform them about PPR participant eligibility. LA General staff referred potential participants through the electronic health record system, and Wellness Navigators followed up with these referrals to confirm eligibility and arrange enrollment appointments. LA General also frequently hosts health fairs, and they specifically invite patients who have missed appointments or postponed their medical services, such as overdue annual physical examinations. TWC Wellness Navigators attend these health fairs and receive a list of potentially eligible patients from LA General staff. During the health fair, TWC Wellness Navigators verify patients program eligibility and enroll participants onsite. Based on preliminary data obtained from 122 participants from the baseline core metrics survey, the average age of PPR participants is 58 years old (range age 32 - 79). 75%identify as female. By race/ethnicity, 91% are Hispanic, Latino/a, or Spanish origin, 5% Black or African American, 2.5% Asian, and 1.6% Other/Multiple race. By education, 64% have less than a high school education, 19% have a high school diploma, and 17.5% have some college education or more. Changes/Problems:DPH did not experience any major problems that significantly impacted program expenditures. DPH's partner V4V signed a contract with a new technology firm to administer the produce prescription benefits through a new electronic debit card, known as the Fresco Fresh card. V4V tested the Fresco Fresh cards at participating Albertsons, Kroger, and Walmart grocery stores to ensure the cards were compatible with the stores' point-of-sales (POS) system and able to purchase/redeem fresh fruits and vegetables only. Card testing caused a slight delay in launching the Fresco y Saludable Fresh and Healthy program at LA General. During this period, TWC Wellness Navigators contacted eligible LA General patients and placed them on a waiting list until the Fresco/Fresh card completed program testing. DPH does not anticipate any programmatic delays in the next reporting period and expects to meet the deliverables of the grant within the grant term. What opportunities for training and professional development has the project provided?DPH collaborated with Elevation Health Partners, a consulting firm that provides strategic and operational support to organizations in the healthcare sector, to host the training, "Addressing Patient Needs through Empathetic Inquiry" in July 2024 with TWC Wellness Navigators. The training reviewed empathic inquiry, motivational interviewing, and cultural humility within the clinical setting. Attendees practiced active listening and how empathic approaches builds trust with patients. The training will support program implementation of Fresco Freshby building staff capacity for Wellness Navigators to apply trauma-informed approaches when screening patients for food insecurity, one of the eligibility criteria for Fresco Fresh, and enrolling participants into the program. Utilizing empathy concepts will create safe and nonjudgmental environments for participants, potentially leading to increased participate engagement and higher produce prescription redemption rates. 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?Participant enrollment at LA General is aimed to be completed by September 2024, with the goal of enrolling 175 participants. Fresco y Saludable Fresh and Healthy will be launched at a new site, Hubert H. Humphrey Comprehensive Health (HHH) Center - Adult Primary Care clinic by fall 2024. TWC Wellness Navigators will aim to enroll a total of 350 participants across LA General and HHH by March 2025. TWC will collaborate with HHH social work team to develop the clinic workflow, participant outreach plans, and data collection and documentation protocols. DPH will collaborate with TWC in developing Fresco Freshmaterials, handouts, and enrollment guides targeted for HHH patients and clinic staff. Vouchers 4 Veggies (V4V) will continue working with the payment technology firm to administer the electronic benefits to LA General and HHH participants through the Fresco/Fresh card. V4V will manage the card redemption data, and this will be reviewed monthly by DPH. Participant-level core metric surveys will be reviewed quarterly by DPH to ensure data is complete. DPH will work with TWC Wellness Navigators to resolve any data issues (e.g., duplicate IDs, missing data, etc.). TWC will review participants biomarkers (BPand hemoglobin A1c) at pre and post to ensure that the data is documented in the patients' electronic health record. DPH will work with TWC to continue to extract deidentified participant level biomarker and healthcare utilization data.
Impacts
What was accomplished under these goals?
Project Goal #1: Improve healthy eating behaviors among people with lower incomes. Intended Outcome: By September 2025, 80% of PPR participants will increase the frequency of daily consumption of fruits and vegetables from baseline (enrollment) to 6 months after enrollment. Substantial evidence indicates consuming a diet high in fruits and vegetables is associated with reducing the risk of developing chronic-related diet diseases. Due to their limited access and affordability, and lack of transporation,low-income households face significant barriers to consuming these recommendeddaily fruit and vegetable intake. DPH partnered with V4V to provide eligible participants with an electronic debit card, known as the Fresco/Fresh card, worth $40 per month for six months that can only be used to purchase fresh fruits and vegetables at participating Albertsons, Kroger, and Walmart grocery stores. Participants in this program receive one card per household. Participants are eligible for the program if they meet the following criteria: 1) enrolled in Medicaid, 2) screened positive for food insecurity, and 3) diagnosed with prediabetes or type 2 diabetes. To assess improvements in healthy eating behaviors, DPH collaborated with TWC to administer a validated, 10-item Dietary Screening Questionnaire (DSQ) to all Fresco y Saludable Fresh and Healthy program participants during enrollment (at the beginning of the program) and at 6 months (at program completion). The 10-item questionnaire is part of the core metrics survey and participants must complete this survey in order to receive the Fresco/Fresh card. DPH provided trainings to TWC Wellness Navigators on program participant eligibility, reporting requirements, and administering the core metrics survey via the online platform, Qualtrics. Surveys were administered to participants in-person based on their preferred language at the TWC office. From March 2024 to July 2024, TWC Wellness Navigators enrolled 93 participants into the Fresco y Saludable Fresh and Healthy program. out of 9,000 eligible patients and distributed $7,920 in benefits. Participants have purchased $6,479.48 worth of fresh fruits and vegetables at participating grocery stores, yielding 82% redemption rate. TWC supported healthy eating behaviors by offering 38 nutrition education activities to Fresco y Saludable Fresh and Healthy participants, such as cooking classes. Data, including the 10-item DSQ, has been collected from 122 participants at baseline and data analysis is pending. DPH will continue providing technical assistance to TWC to ensure that core metric survey data are complete. DPH will help reviewthe surveys in Qualtrics every 3 months. Project Goal #2: Increase household food security among people with lower incomes. Intended Outcome: By September 2025, 25% of PPR participants will improve their household food security as assessed using the Six-Item Short Form of the Food Security Survey Moduleincluded in the core metric survey from baseline to six months after enrollment. Due to limited financial resources and other socioeconomic factors, low-income populations are at risk for being food insecure, defined as the lack of consistent access to enough food for an active, healthy lifestyle. Through the partnership with V4V, eligible Fresco y Saludable Fresh and Healthy program participants received $40 every month for six months to purchase fresh fruits and vegetables at participating large-chain grocery stores through an electronic debit card or Fresco/Fresh card. Additionally, TWC routinely refers program participants to other local food resources such as food pantries, Supplemental Nutrition Assistance Program (SNAP), and LA General's bimonthly free food distributions. To measure improvements in household food security status, DPH partnered with TWC to administer a validated, 6-item food insecurity screener to all Fresco Freshprogram participants during enrollmentand at 6 months. The 6-item food insecurity screener is part of the core metrics survey and participants must complete this survey in order to receive the Fresco card. DPH trained TWC Wellness Navigators on program participant eligibility, reporting requirements, and administering the core metrics survey via the online platform, Qualtrics. Surveys were administered to participants in-person at the TWC offices based on their language preference. Data has been collected of 122 participants and data analysis is pending. DPH will continue to provide technical assistance to TWC to ensure that core metric survey data are complete. DPH will help reviewthe surveys in Qualtrics every 3 months. Project Goal #3: Reduce the risk of developing diet-related chronic disease and associated complications by improving blood pressure and blood glucose control among patients with diabetes and prediabetes. Intended Outcome: By September 2025, PPR will establish a program infrastructure to identify program eligible patients and to monitor participants for blood pressure and HbA1c improvements. Research shows that healthy eating patterns, including consuming more fruits and vegetables can lower the risk of developing hypertension (HTN). HTN in people with type 2 diabetes doubles the risk of cardiovascular disease. Lowering blood pressure (BP) among patients with this conditionis associated with decreased mortality, improved clinical outcomes, and decreased healthcare costs. Fresco y Saludable Fresh and Healthy program eligibility criteria includes patients with prediabetes and type 2 diabetes. DPH and TWC established a standardized program infrastructure across LA General to identify eligible patients and monitor clinical health outcomes due to program participation. The clinic workflow specifies that participants must have their BPand glycated hemoglobin (HbA1c) measured and documented in the EHRand verified by TWC Wellness Navigators prior to receiving Fresco Fresh benefits. A BPmeasurement must be taken the day of enrollment into the program (baseline) and HbA1c must be collected three months prior to the participant's enrollment date. Both BPand HbA1c will be reassessed at six months, when the participants benefit expires/program ends. TWC Wellness Navigators will be responsible for scheduling a six-month follow up appointment with participants to ensure data collection compliance. DPH will continue collaborating with TWC Wellness Navigators to coordinate the collection, extraction, and analysis of patient-level data to evaluate the impact of nutrition incentives and diet-related chronic disease risk factors. Project Goal #4: Improve healthcare utilization and reduce associated costs. Intended Outcome: By September 2025, PPR will develop a program infrastructure using EHR data to track healthcare utilization and preventable healthcare costs among patients with diabetes and prediabetes.? Providing financial incentives to purchase fruits and vegetables improves dietary consumption and may be highly cost effective or even cost saving for healthcare systems and payers. Medical expenditures associated with diabetes are substantial. Electronic health record (EHR) data will include total number of any LA General primary care visit prior, during, and after participation in Fresco y Saludable Fresh and Healthy (past 12 months). Supplemental metrics may include visits with ancillary services (Registered Dietitian Nutritionist, Health Educator) and total number of times participants did not show for a medical visit with theirprimary care provider. TWC Wellness Navigators will help facilitate extraction and deidentification ofutilization data from the EHR--those that will be made available to DPH. At baseline, early data shows that participants have an HbA1c of 8.4, a systolic BPof 125.2, and a diastolic BPof 69.7. To date, no follow-up data has been collected/extracted because no participants have completed the six-month program.
Publications
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Progress 09/15/22 to 09/14/23
Outputs
Target Audience:The Los Angeles County Department of Public Health (DPH) is partneringwith the Los Angeles County Department of Health Services (DHS) to implement the Produce Prescription Program(PPR) at two DHS sites in Los Angeles County - LA General Medical Center (LA General) and Hubert H. Humphrey Comprehensive Health Center (HHH). Los Angeles County is divided into eight geographic regions called Service Planning Areas (SPAs). LA General is in the Metro region of Los Angeles County or SPA 4, and HHH is located in South Los Angeles or SPA 6. The PPR, locally referred to as Fresco y Saludable/Fresh and Healthy, will target both SPA 4 and SPA 6 communities given the high rates of food insecure households and adults who are at risk for developing diet-related chronic conditions. Among Los Angeles County households who live 300% below the Federal Poverty Level, 31.8% of SPA 4 households and 35.1% of SPA 6 households experience food insecurity, as compared to 26.8% of Los Angeles County households experiencing food insecurity overall. Nearly, 12.1% of SPA 4 adults and 14.7% of SPA 6 adults have been diagnosed with diabetes - these rates are higher compared to Los Angeles County adults overall (11.3%). Recent clinic records indicate that 37.8% of LA General patients and 23.8% of HHH patients have type 2 diabetes. At both LA General and HHH, approximately 65% of patients are enrolled in Medicaid. Strategies to reach both of the clinics' target populations (the target audience) currently include partnering with the LA General Medical Center Foundation (Foundation)--a non-profit public benefit foundationestablished to support LA General--to assist in the identification and recruitment ofeligible patients. The Foundation enjoysa strong rapport with LA General's clinic staff and patient population and has experience supporting program implementation at DHS clinics. The Foundation's Wellness Navigators will extrapolate data from LA General's and HHH's electronic health record to identify patients who are low-income (defined as enrolled in Medicaid [Medi-Cal in California]), screened positive for food insecurity, and diagnosed with type 2 diabetes or prediabetes. Patients who met these criteria will receive text messages and phone calls in their preferred language (English or Spanish) from Wellness Navigators asking if they are interested in participating in the Fresco y Saludable program. Patients who are interested in joining the program will be placed on a waitlist and scheduled for an in-person enrollment appointment in November 2023. Changes/Problems:No major changes to the program approach and methods occurred during this reporting period. DPH experienced a delay in program implementation due to establishing a Memorandum of Understanding agreement with their new partner, LA General Medical Center Foundation (Foundation), and processing a new Institutional Review Board (IRB) with the University of Southern California, Los Angeles (USC); the latter activity was required for any organization evaluating or studying LA General Hospital patients because many of the clinics and health services at the medical center are staffed by USC personnel/clinicians. This administrative delay resulted in no participants being enrolled into Fresco y Saludable during this first part of the project. However, DPH and the Foundation have created a plan to emphasisprogram enrollment for the next reporting period by properly training Foundation Wellness Navigators to enroll at least 25 participants per month. Given this plan, DPH is confident that it will overcome these initial delays and foresees no further disruptions in therate of expenditures for the remainder of the grant. 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?Fresco y Saludable will be implemented intwo clinics at LA General (Primary Care West and Primary Care East) and one clinic at HHH (Adult Primary Care), beginning in November 2023with a target number of enrolling 350 participants across all sites. Trainings will be provided to the Foundation's Wellness Navigators who are responsible for screening and enrolling eligible adults with type 2 diabetics and prediabetes into Fresco y Saludable at all three clinic sites. DPH will continuously offer trainings and technical assistance to these clinics and to Foundation's Program Coordinator(s) to support program operations and fidelity. The University of California, San Francisco, Vouchers 4 Veggies (V4V) will finalize their contract with the payment technology firm and complete all incentive/benefit card testing. V4V and DPH will collaborate to develop materials, handouts, and enrollment guides for both participants and clinic staff on PPR eligibility requirements and guidelines. V4V will train Wellness Navigators on how to activate the card (produce prescription benefits) for participants and how to properly track and document active card users. V4V will manage the card redemption data, and this will be reviewed monthly by DPH. Participant-level core metric surveys will be reviewed quarterly by DPH to ensure the data is complete. DPH will work with the Foundation to resolve any data issues (e.g., duplicate IDs, missing information, etc). The Foundation leadership will review participants biomarkers (blood pressure and hemoglobin A1c) at pre and post-program participationto ensure that the data is documented in the patients' electronic health record. DPH will work with the Foundation todevelop a system to extract deidentified participant level biomarker and healthcare utilization data from the clinics' databases.
Impacts
What was accomplished under these goals?
Project Goal #1,Intended Outcome:By September 2025, 80% of PPR participants will increase the frequency of daily consumption of fruits and vegetables from baseline (enrollment) to 6 months after enrollment. DPH is partnering with University of California, San Francisco, Vouchers 4 Veggies - EatSF Voucher Program (V4V) to provide eligible participants with an electronic debit card worth $40 per month for six months which can only be used to purchase fresh fruits and vegetables at participating Albertsons, Kroger, and Walmart grocery stores. Locally known as Fresco y Saludable/Fresh and Healthy, participants in this program receive one card per household. Participants are eligible for the program if they meet the following criteria: (i) enrolled in Medicaid (Medi-Cal in California), (ii) screened positive for food insecurity, and (iii) diagnosed with type 2 diabetes or prediabetes. V4V is currently establishing an agreement with the payment technology firm to administer the incentive debit card. To assess improvements in healthy eating behaviors, DPH will collaborate with the LA General Medical Center Foundation (Foundation) to administer a validated, 10-item fruit and vegetable intake survey to all Fresco y Saludable participants during enrollment (at the beginning of the program) and at 6 months (at program completion). Participants must complete the survey in order to receive their produce prescription benefits. The online platform, Qualtrics, will be used to administer the survey in both English and Spanish. The Foundation's Wellness Navigators will be trained on best practices--e.g., empathetic inquiry, cultural humility, appropriate facial expressions--to reduce response bias when administrating surveys to participants. The goal is to complete these trainings by November 2023. Project Goal #2, Intended Outcome:By September 2025, 25% of PPR participants will improve their household food security as assessed using the Six-Item Short Form of the Food Security Survey Module (6-item food insecurity screener) included in the core metric survey from baseline (enrollment) to six months after enrollment. Due to limited financial resources and other socioeconomic factors, low-income populations are at risk of being food insecure, defined as the lack of consistent access to enough food for an active, healthy lifestyle. Through V4V, eligible Fresco y Saludable participants will receive $40 via an electronic debit card every month for six months to purchase fresh fruits and vegetables at participating chain grocery stores. V4V is currently establishing an agreement with a new payment technology firm to administer these produce incentive debit cards. Participants can use a website or an app to check on their card balance and to find participating grocery stores near them. The new technology company plans to offer a customer service call-in number in case participants have questions or difficulty using the card. V4V will meet with the participating grocery store managers near LA General and HHH in September 2023 to briefly review the program goals. To ensure that they work and are compatible with the store's point-of-sales system, V4V intends to test the cards at grocery stores located within a 3-mile radius of LA General and HHH, where Fresco y Saludable will be implemented. Testing of the cards will include using it at both self-checkout and cashier and purchasing non-allowable items (e.g., fruit juice, frozen vegetables). To measure improvements in household food security status, DPH will partner with the Foundation's Wellness Navigators to administer a validated, 6-item food insecurity screener to all PPR participants during enrollment (at the beginning of the program) and 6 months after (at program completion). The Wellness Navigators will be responsible for documenting survey responses into the online system, Qualtrics. Participants must complete the survey in order to receive their produce prescription benefits. Similar to Project Goal # 1, the Wellness Navigators will be trained on best practices to reduce response bias when administrating surveys to participants; trainings to be completed by November 2023. Project Goal #3, Intended Outcome:By September 2025, PPR will establish a program infrastructure to identify program eligible patients and to monitor participants for blood pressure and HbA1c improvements. Evaluation efforts will be able to use data generated by this infrastructure to assess and quantify health outcomes related to PPR participation. Research shows that healthy eating patterns, including consuming more fruits and vegetables can lower the risk of developing hypertension (HTN). HTN in people with type 2 diabetes doubles the risk of cardiovascular disease. Lowering blood pressure among patients with type 2 diabetes is associated with decreased mortality, improved clinical outcomes, and decreased health care costs. Fresco y Saludable targets type 2 diabetes and prediabetes patients--i.e., DPH and the Foundation will establish a standardized program infrastructure across LA General and HHH to identify eligible patients and monitor for clinical health outcomes that are expected to improve as a result of participating in the PPR. The clinic workflow specifies that participants must have their blood pressure and glycated hemoglobin (HbA1c) measured and documented in the electronic health record and verified by Wellness Navigators prior to receiving produce incentive benefits (debit cards). A blood pressure measurement must be taken the day of enrollment into the program (baseline) and HbA1c must be collected within three months of the participant's enrollment date. Both blood pressure and HbA1c will be reassessed at six months, when the participants incentive benefit expires. The Wellness Navigators are responsible for scheduling a six-month follow up appointment with participants to ensure data collection compliance. DPH has received Institutional Review Board (IRB) approval (exempt from full review) from both the County of Los Angeles Department of Public Health/Department of Health Services IRB and the IRB at the University of Southern California, Los Angeles (USC) to proceed with this project. Approvals were received in July 2023. For the duration of the PPR, DPH will collaborate with LA General and HHH to coordinate the collection, extraction, and analysis of patient-level data to evaluate Fresco y Saludable's impact.A meeting has been scheduled for September 2023 to discuss and finalize the clinic's workflow process for this program. Project Goal #4, Intended Outcome:By September 2025, PPR will develop a program infrastructure using HER data to track healthcare utilization and preventable healthcare costs among patients with diabetes and prediabetes. Providing financial incentives to purchase fruits and vegetables improves dietary consumption and may be highly cost-effective or even cost saving for healthcare systems and payers. Medical expenditures associated with diabetes are substantial. Electronic health record (EHR) data to be reviewed will include the total number of any LA General and HHH primary care visit prior, during, and after participation in the Fresco y Saludable PPR (i.e., for the past 12 months). Additional supplemental metrics to be examined may include visits with ancillary services (Registered Dietitian Nutritionist, Health Educator, Behavioral Health) and the total number of times patients did not show for a medical visit with the patient's primary care provider. The clinics will help facilitate extraction of health services utilization data from the HER; these deidentified EHR data will be made available to DPH. DPH has scheduled a meeting with LA General, HHH, and the Foundation in September 2023 to discuss the roles and responsibilities of clinic staff in extracting these data and in developing a system to monitor them.
Publications
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