CORNELL COOPERATIVE EXTENSION OF SUFFOLK COUNTY PARTNERSHIP WITH HEALTHCARE PROVIDERS TO FACILITATE FRESH FRUIT AND VEGETABLES VOUCHERS TO UNDERSERVED POPULATIONS.

• Sponsoring Institution: National Institute of Food and Agriculture
• Project Status: COMPLETE
• Funding Source: OTHER GRANTS
• Reporting Frequency: Annual
• Accession No.: 1029409
• Grant No.: 2022-70424-38544
• Cumulative Award Amt.: $420,886.00
• Proposal No.: 2022-07025
• Project Start Date: Sep 15, 2022
• Project End Date: Feb 14, 2025
• Grant Year: 2022
• Program Code: [PPR]- Produce Prescription

Recipient Organization
CORNELL COOPERATIVE EXTENSION ASSOCIATION OF SUFFOLK COUNTY
423 GRIFFING AVE STE 100
RIVERHEAD,NY 119013071

Performing Department
(N/A)

Non Technical Summary
Chronic diseases, such as diabetes can be controlled by simple lifestyle changes. By increasing healthier food consumption and decreasing foods with a high glycemic index, people with risk factors associated with diabetes, as well as diabetic and prediabetic conditions can live longer and healthier lives. Many people do not know how to do this and by referring to a nutritionist immediately upon diagnosis, patients can start to incorporate healthier eating habits.There is no doubt that people that live in high needs areas, and have limited resources are presented with the challenges of good nutrition education as well as affordable access to healthier foods. This program is designed to target both problems.First, if a person is identified by their healthcare worker as having risk factors, and or diabetic, they are referred to our nutrition education workshops. Our nutritionists work in small groups to provideinterventions to improve their health. VEry often, increasing fruit and vegetable consumption is one of those interventions, but having the resources to change this into a habit can be challenging for people living in high needs areas. In addition, having fresh produce can be quite costly and being able to make this change may be too expensive.Our program will not only provide the education and ways to find resources to help with the expenses of managing their health, but we provide vouchers to local food outlets, including locally grown farmers markets and food stores. The voucher is used specifically for produce.Part of our educational workshops include healthy ways to prepare and preserve fresh fruits and vegetables. Tools are given to provide sustainable habit changing activities.By creating healthy changes, the participants in turn should see improvement in their health, which should in the long term, decrease sick days, and healthcare associated costs, including medicine.

Animal Health Component

60%

Research Effort Categories

Basic

30%

Applied

60%

Developmental

10%

Classification

Knowledge Area (KA)	Subject of Investigation (SOI)	Field of Science (FOS)	Percent
703	5010	1010	100%

Knowledge Area
703 - Nutrition Education and Behavior;

Subject Of Investigation
5010 - Food;

Field Of Science
1010 - Nutrition and metabolism;

Keywords

ny

nutrition education gusnip suffolk county

nutrition incentive

voucher

Goals / Objectives
Goal 1: Improve affordable food access and food security among PPR participants.By September 2023, 1200 SNAP eligible participants who are at risk or currently have diabetes will be given $20 produce vouchers redeemable at accessible partner sites and Thera Farms after each nutrition education session.By September 2023, 80% of the 1200 SNAP eligible participants will understand the accessibility to fresh produce in farmers markets, convenience stores food stores and other outlets.By September 2023, 80% of the 1200 participants will understand the use of Double Up Bucks, SNAP benefits and alternative access to fresh produce.Goal 2: Increase consumption of fruits and vegetables among PPR participants.By September 2023, of the PPR food insecure participants not meeting the 2021 USDGA at enrollment, 60% will report intent to increase consumption of fruits and vegetables for themselves and/or their household.?Goal 3: Increase knowledge of nutrition and the value of?consuming fresh fruits and vegetables among PPR participants.By September 2023, 90% of participants will increase?knowledge of?the health benefits of fresh fruits and vegetables?in family meals and snacks. Participants will complete pre-& post-surveys tracking individual knowledge of the effect of fruits and vegetables on health. A positive change in knowledge in post-surveys will be marked as "improved."By September 2023, of the PPR food insecure participants, 80% will improve knowledge on the nutritional value?of increased consumption of fruits and vegetables for themselves and their family.Goal 4: Increase knowledge and skills?on?preparation?and storage of fresh produce among PPR participants.By September 2023, 75% of participants will improve?food?preparation?and storage skills of?fresh produce in meals through hands-on food?demonstrations. Participants will complete pre-& post-surveys tracking individual knowledge and skills of food preparation and food storage.Goal 5: Improved health metrics associated with diabetes.By September 2023, 75% of participants that utilize the vouchers for increased produce purchasing will have improved medical metric, which will be determined in collaboration with NTAEBy September 2023, 75% of participants will understand the correlation between increased fruits and vegetables and healthy lifestyle which leads to a decrease in healthcare costs.Goal 6: To create a long-lasting, welcoming community that is inclusive and thrives on partnerships.By September 2023, 85% of PPR SNAP eligible participants, community stakeholders, healthcare partners, nutrition and outreach staff understand the value of incorporating fresh fruits and vegetables into their daily meals. They will all be engaged and actively working together to find ways to sustain the PPR program.

Project Methods
Project Readiness will be in 3 Phases of planning over the period of September -October 2022. Since the nutritionists are already working within the healthcare centers, this program would slide into the existing programming. We have the advantage of utilizing protocols from other organizations that have implemented similar programs. We also will be utilizing existing staff, that will just shift their responsibilities to accommodate this program.Phase One (September 2022) will include notification of partners and stakeholders, press releases, training of staff and volunteers, as well as notification of healthcare partners of required training schedules. Discussions with NTAE to determine medical metric that is most beneficial and appropriate. Purchase of program laptop and tablets.Phase Two (September/October 2022) will include all protocol trainings such as food insecurity screening, clinical and nutrition visit protocols, the voucher redemption protocols, data collections and accepting PPR vouchers, eligibility and referral process delineated, and all Health Care workers notified of their roles on the project. Create and print all materials and tools for trainings and recruitment. CCE staff, and Thera Farms and other vendors will be trained in joint sessions, NTAE will be contacted to plan out metrics and data collection methodology. Pre and post survey from existing Cornell screening which has been validated will be adjusted for program.Phase Three (October 2022-) will include schedules matched for health care and nutrition educators, materials to be prepared for nutrition education, food prep and cooking demos, create all data collection materials (including surveys), IRB clearance for senior staff, templates for success stories, and photo release/video testimonials. Distribution and follow up of outreach material to community centers; and referral procedure with healthcare workers reinforced.Project Referral Buildup will start within the first few weeks of program onset, which will include strengthening relationships between patient and provider, solidifying dates with health centers and address any challenges, start roll out of implementation as a dry run, prescreening of eligible participants and all information shared between CCE and health centers, set up of secure file cabinet for any non-electronic records at CCE office in Riverhead for participant information. Tablets will be populated with screening and surveys as well as program to assign participants a unique identification number.Program Implementation & Delivery, Data Collection: November 2022-August 2023 will include voucher distribution and 6 weekly/biweekly nutrition workshops, second round of health care staff prescreening training, activity monitoring. During October -December 2022, data and surveys will be compiled, and data reported to NTAE and successes and challenges will be shared. Results will determine any modifications that need to be made for upcoming months.Program Evaluation and Data ReportingSeptember 2023 will include all data that has been collected in agreed form with NTAE. The data will be uploaded by September 15, 2023 deadline.

Progress 09/15/22 to 02/14/25

Outputs
Target Audience:Fruit and Veggie Rx is a food as medicine program that served Suffolk County in Long Island, NY. Our partner with the program is Sun River Health System, a federally qualified health group that has centers throughout Suffolk County and in the Hudson Valley. We worked only within Suffolk County. Our target audience was low income patients of Sun River Health that had or was at risk for diabetes, including a diagnosis of pre diabetes, heart disease, obesity or high blood pressure. This diagnosis must be accompanied with a HgA1c, which showed the status of the patient as it relates to diabetes. Gestational diabetes was not included and all participants must be over 18 years old. The participants either were currently on SNAP or were SNAP eligible. A food security screening was also done, and participants all had a level of food insecurity. Changes/Problems:When we received funding, we had already piloted a smaller scale Fruit and Veggie Rx program and had worked through some of the issues. However, our first issue was recruiting people to come to the workshops. We worked with medical providers, and had signs, annoucements, and "prescriptions" for doctors/navigators to provide patients. Our first program did take some time to get the participants. We did find that by the health center sending a targeted text to qualifying participants, it helped to increase our participation. We also found that the food store which we chose which was steps away from the health center did not always have quality fresh vegetables, as it is very seasonal in the northeast and fresh vegetables can be costly. We found an alternative market to work with, which became a viable option for many. We had a group of homebound participants, which struggled to get to the health center on a regular basis, so we added a virtual component, which allowed many people with transportation challenges to join. This did provide the next challenge of food retail partners. We added About Fresh, which is a debit card option that works with Stop and Shop to provide the option for fruits and vegetable purchase. We did receive a grant from Stop and Shop to offset the cost of the debit card. When trying to expand into areas that historically had little participation, we were challenged again with having participants come to the program. We worked with the local medical center and community center to come up with the best time and day. However, participants did not come at that time. We canceled that series and gave the virtual option to the couple of registrants. We then reevaluated the location and found that most participants will not come- so just offered the virtual option. We were able to recruit participants virtually and able to break into this community. We also found that 8 weeks was not long enough, but with different holidays and natural breaks (End of year, end of school, etc), schedules changed and participants did not transition right over. We altered the scheduling to work between these time periods and at times extended or shortened the workshop series to get maximum participation. What opportunities for training and professional development has the project provided?We were able to have many discussions with other Food As Medicine programs and understand how other programs have worked. Additionally the annual meeting we met with provided other methods and ideas. How have the results been disseminated to communities of interest?Sun River Health has seen the results as well Cornell Cooperative Extension's board. NIFA has also been given the HgA1c results (pre and post). What do you plan to do during the next reporting period to accomplish the goals? Nothing Reported

Impacts
What was accomplished under these goals? When we embarked on this project, we planned on bringing more knowledge and accessbility to participants to make healthy choices and give them the means to purchase more fruits and vegetables. We utilized HgA1c as a medical metric and tracked the measurements over the course of the grant. We redeemed a total of $161,348 in vouchers, providing a total of 8060 vouchers. We had amended our target goal to 600 due to the workshop series being 10 -12 weeks instead of 8 weeks. We provided vouchers for 753 participants, with a 97% redemption rate. Over the grant period, 99% of the participants understood the accessibility to fresh produce. In all workshop series, resources such as Double Up Food Bucks and SNAP benefits were discussed, and 84% increased their knowledge in these benefits. Goal 2- 93% reported an intent to increase their consumption of fruits and vegetables. Goal 3- 93% reported increased knowledge f the benefits of fruits and vegetables in family meals and snacks, and 93% reported improved knowledge of the nutritional value of increased fruits and vegetables. Goal 4- 89% reported improved food preparation and storage skills. Goal 5- 97% utilized the vouchers for increased produce purchasing that related to improved HgA1c. It should be noted that we tracked HGA1c for up to 2 years for the participants. We found an improved HgA1c for participants while they were using vouchers, but within 1 year of not receiving their vouchers, the improvement lessened. Surveying participants about their long term results showedthat the vouchers provided the means to make healthier choices. The price of fruits and vegetables had a large increase over this time and difficult decisions were made. Participants also understood the correlation, between the increase in fruits and vegetables and lowering health care costs, but due to the economic climate, they could not sustain the change long term due to the lack of money to do so. Goal 6- 92% of participants understood the changes that needed to be made, and included daily walking and changing beverages to water as a cost savings matter. We still have several non voucher Fruit and Veggie Rx workshops, which our participants continue to come to for reinforcement of the lesson, and as a social outlet. Due to current economic climate, and the inclusion of Food As Medicine Medicaid Waivers, continued funding for Fruit and Veggie Rx has been difficult to find on a large scale number, however, we have been able to show the success and secure smaller funding sources for more localized programs.

Publications

Progress 09/15/24 to 02/14/25

Outputs
Target Audience:Since we received a no cost extension, we provided additional workshop series given vouchers to all eligible participants. Changes/Problems:Overall, we overcame most challenges. Once the new admistration was elected, we did see some level of apprehension among our Spanish speaking participants, and afraid to come to certain places. What opportunities for training and professional development has the project provided?This program did provide meal demonstrations for participants. We also had increased training with diabetes specific meals. How have the results been disseminated to communities of interest?We shared in a one pager to our stakeholders. What do you plan to do during the next reporting period to accomplish the goals?All goals accomplished, grant has finished.

Impacts
What was accomplished under these goals? We did see over 1200 participants for the total grant period. We had an increase in consumption of fruits and vegetables by 86%, 99% of vouchers used to increased produce purchases. 92% understand the value of incorporating fruits and vegetables. , 92% improved their knowledge.

Publications

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

Outputs
Target Audience:The target audience for our program thus far has been low income (SNAP eligible) participants that have diabetes, prediabetes or risk factors assocated with diabetes. We have been working with a FQHC, Sun River Health, to identify and target these patients to become participants. We have both English and Spanish language speakers in our target audience. Working with Sun River Health, we identified patients that have an A1c of 7 or above, indicating diabetes diagnosis and Sun River Health sent them messaging on the program. In addition, we had outreach within the centers, including through signage and doctors, looking for patients that have prediabetes, or risk factors associated with diabetes (obesity, high blood pressure, and heart disease). These participants were given a "prescription" to attend our program. Participants were also given SNAP eligible screening questions in order to verify their low income status. We also piloted a program at the Shinnecock Tribal Reservation, with low income diabetic patients (adults). Changes/Problems:We honestly had worked most of the problems out in the first year. We still have the challenge of homebound patients and currently have received a grant that provides the delivery of fresh produce to home bound patients. Virtual programming has been very successful to work with the transporation and time challenge that has existed. We are also challenged with finding Hatiaian Creole nutrition educators and continue to look. What opportunities for training and professional development has the project provided?Our nutrition educators had increased awareness of cultural differences and ways to to bridge those differences. One prime example is working with the Shinnecock and native foods that are culturally specific. We learned to find recipes that can be altered for diabetic patients and still hold some cultural significance. Additionally, learning about other projects and successes and challenges has allowed us to better our program. How have the results been disseminated to communities of interest?We have given preliminary results to the health care partner and have utilized some results to work with legislators and local organizations to leverage more money to continue the programs. What do you plan to do during the next reporting period to accomplish the goals?Our project is almost complete. We have seen significant improvement in the patients both physically and mentally. We will continue to do the workhshops and provide vouchers to very low income individuals.

Impacts
What was accomplished under these goals? This program accomplished significant results by not only providing increased knowledge and gained understanding of nutrition and diabtes, but empowerment of the participants to make the change and continue to follow up with health care providers for the diabetes/risk factors. Many of the participants reported increased fruit and vegetable consumption and better choices overall. We provided food recipes, demo's and tastings, all well received with significant buy into the new food choices. Vouchers were redeemed by most partipants right away; however some held a couple weeks. But most of the vouchers were spent on produce.

Publications

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

Outputs
Target Audience:The target audience for our program thus far has been low income (SNAP eligible) participants that have diabetes, prediabetes or risk factors assocated with diabetes. We have been working with a FQHC, Sun River Health, to identify and target these patients to become participants. We have both English and Spanish language speakers inour target audience. Working with Sun River Health, we identified patients that have an A1c of 7 or above, indicating diabetes diagnosis and Sun River Health sent them messaging on the program. In addition, we had outreach within the centers, including through signage and doctors, looking for patients that have prediabetes, or risk factors associated with diabetes (obesity, high blood pressure, and heart disease). These participants were given a "prescription" to attend our program. Participants were also given SNAP eligible screening questions in order to verify their low income status. Changes/Problems:Our first workshop series was changed from 6 to 12 weeks. We found that there was too much we wanted to educate on to get everything in. Additionally, the change in A1c would be relevant after at least 3 months, so we found that providing the programming and vouchers for that time may be beneficial. The first cohort would have liked the programming for longer, as they were very engaged and wanted more support. We then altered the program to an 8 week program for the next group as it was in between holidays (July 4-Labor Day). The summer proved to be more of a challenge for participants in some areas, but the length of time was appropriate. For the third cohort, we kept the 8 week series with a check in event one month after the 8 weeks has completed. What opportunities for training and professional development has the project provided?The project utilized trained SNAP -Ed educators which was given an overview training from diabetes dietitians on how to change My Plate to My Diabetes My Plate. The training that the educators provided included basic knowledge and education around nutrition educator for diabetes specific participants. There was a Supermarket tour, which showed how to look at labels, where to shop, finding deals on shopping. We also provided food demonstrations which included how to make zucchini noodles and other low carbohydrate changes. How have the results been disseminated to communities of interest?They have not. We did share some of the preliminary findings with the Health Center, but the work is far from complete to make any reports relevant at this time. What do you plan to do during the next reporting period to accomplish the goals?We have increased our programming to bring in more participants. We have done more outreach and have been working with local supermarket partners to work towards our goal.

Impacts
What was accomplished under these goals? As soon as we received word of funding, we started to work right away. However we were told there was an embargo and couldn't start certain things right away. Until that embargo was lifted at the end of November, our work was limited. We found IRB exemption to be challenging, which held up the progression of the program in the original timeline. Once that was received, we set up programming to start in March 2023. As of September 1, 2023 we have seen approximately 300 participants. The participants are given vouchers but have a month after receiving the vouchers to completely utilize. As of September 1,2023we have had 82% redemption rate of vouchers. As of Sept. 1, 2023, there has been 67% increase in the consumption of fruits and vegetables for those that have reported (we are in the middle of a program series, and have not had all report back yet). There has been a 75% increase in the knowledge of the nutritional value of fruits and vegetables. 98% had a positive or very positive experience with Fruit and Veggie Rx. We are measuring changes in A1c. Not all participants have been able to get a post A1c yet. However, of those that did, none have increased and 100% have either remained unchanged or have decreased.

Publications