AVERA MCKENNAN-FOOD AS MEDICINE (FAM): A HOSPITAL-BASED APPROACH TO INCREASE ACCESS AND INTAKE OF FRUITS AND VEGETABLES TO REDUCE THE RISK OF CHRONIC DISEASE IN RURAL AMERICA

• Sponsoring Institution: National Institute of Food and Agriculture
• Project Status: ACTIVE
• Funding Source: OTHER GRANTS
• Reporting Frequency: Annual
• Accession No.: 1029423
• Grant No.: 2022-70424-38502
• Cumulative Award Amt.: $500,000.00
• Proposal No.: 2022-06995
• Project Start Date: Sep 15, 2022
• Project End Date: Sep 14, 2025
• Grant Year: 2022
• Program Code: [PPR]- Produce Prescription

Recipient Organization
AVERA MCKENNAN
1325 S CLIFF AVE
SIOUX FALLS,SD 57105

Performing Department
(N/A)

Non Technical Summary
Good nutrition is a critical part of health and development and is known to reduce chronic disease risk. One out of nine individuals in South Dakota experience low or very low food security and 12% live at or below the poverty level. However, to fully address food security, strategies need to not only ensure families have enough food but provide access and promote families to eat healthy foods, reducing the risk of obesity and other adverse health outcomes. Data shows that 87% of South Dakotans eat fewer than three servings of vegetables per day, and 37% eat fewer than one fruit per day. In the 2019, nutrition was found to be the top health indicator with the most need in Sioux Falls and community stakeholders suggested to consider individual decision-making processes alongside food systems. We believe the proposed produce prescription program will help "nudge individual choices about food towards healthy choices". In collaboration with local produce vendors and grocery stores, and community clinics, Avera Research Institute seeks to provide food as medicine for those with the most need. The Food as Medicine (FaM) project will provide a $25/week fresh produce incentive and nutritional education to 400 eligible participants for up to 6 months using two different modes of delivery, traditional in-store and produce box delivery. With this project, we aim to reduce food insecurity, increase fruit and vegetable consumption, and reduce chronic disease risk among adults, families, and children in the Sioux Falls community.

Animal Health Component

100%

Research Effort Categories

Basic

(N/A)

Applied

100%

Developmental

(N/A)

Classification

Knowledge Area (KA)	Subject of Investigation (SOI)	Field of Science (FOS)	Percent
703	6099	3020	100%

Knowledge Area
703 - Nutrition Education and Behavior;

Subject Of Investigation
6099 - People and communities, general/other;

Field Of Science
3020 - Education;

Keywords

food as medicine

sd

produce prescription

lifecourse nutrition

socioeconomic inequalities

Goals / Objectives
During the three years of funding, Avera Research Instiutewill work together with Avera providers, community clinics, local Hy-Vee grocery stores, local produce vendors and community stakeholders to implement a produce prescription program in the Sioux Falls (multi-county) community. The goals of this project are to reduce food insecurity, increase fruit and vegetable consumption and reduce chronic disease risk among adults, families, and children. This project will be determined successful by:Implementing a produce prescription program, called Food as Medicine (FaM), with two modes of delivery (traditional in-store and produce box delivery) using local produce vendors and/or Hy-Vee grocery stores within Sioux Falls.Evaluating the short- (3-month) and long-term (6-month) behavioral (f/v intake) and clinical outcomes (HbA1c, blood pressure and cholesterol) of the FaM program by mode of delivery.Determining the successes and challenges of the FaM program and whether they differ by mode of delivery.

Project Methods
Recruitment will be conducted at community clinics throughout the Sioux Falls area. All clinic staff will identify potentially eligible participants using an eligibility screener completed at their clinic visit as part of the clinic intake process (this process has been success in previous and current ARI research studies). Once identified, they will be referred to our FaM enrollment specialist who will confirm eligibility based on the GusNIP eligibility criteria. If eligible and interested, participants will be enrolled and complete a baseline research visit before receiving their first prescription of $25/week. We will enroll a total of 400 participants, 200 participants into the traditional in-store mode and 200 participants into the produce box delivery mode.The traditional in-store mode of delivery will allow participants to shop for produce in-person at the Farmer's Market (during season) or at one of the seven Hy-Vee stores within the communty. The weekly $25 prescription will consist of five, $5 vouchers, each needing to be spent in full during a transaction during the specified week. The produce box delivery mode of delivery will provide a box of fresh FV to participants every 1-2 weeks (worth $25-50, respective of frequency) and will be delivered to the participant using Lyft. When the Farmers Market is in-season, and depending on produce availability, we will partner with the Farmer's Market produce vendors to provide a community supported agriculture (CSA)-like produce box. During off-season periods or for produce supplementation, we will use produce from Hy-Vee. A prescription lasts three months and participants will receive one refill when they complete their 3-month research visit.We will conduct process and outcome evaluation. For process evaluation, we will focus on three dimensions -implementation, mechanisms of impactand context. Implementation represents the resources and processes through which the program was delivered, using constructs such as fidelity, reach, dose, and adaptation. The mechanisms of impact focus on how program activities and participant's interactions trigger change using constructs such as participant responses, mediators and unintended pathways and consequences. Context evaluates how external factors influence the delivery and functioning of the program. For outcome evaluation, we willfollow guidelines developed by the NTAE centers to ensure an appropriate level of comparability of methods, outcomes, and measures, including collection and sharing of core GusNIP PPP metrics (participant-level and firm-level). We will also collect additional outcome data on clinical and psychosocial measures (blood pressure, waist circumference, cholesterol, HbA1c, anthropometrics, perceived distress, self-efficacy; see Figure 5). We will use GusNIP metrics to evaluate sociodemographics, program satisfaction household characteristics, food assistance, FV intake, and food security.

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

Outputs
Target Audience:Avera patients referred by Family Medicine, Pediatrics and OB/Gyn clinics. The initial inclusion criteria are the following: Meet eligibility criteria for the Supplemental Nutrition Assistance Program (SNAP) program, Special Supplemental Nutrition Program for Women, Infants and Children (WIC), or Medicaid/CHIP. Live in the Sioux Falls area Participants must be 8 years or older; if under the age of 18 yrs, must have a participating guardian/parent Able to speak and understand English or Spanish Changes/Problems: Translation of FaM material to Spanish - we had some translational issues that delayed the start of implementing the enrollment of Spanish speaking individuals. These issues were identified and addresses and we have now started enrolling Spanish-speaking individuals. However, this was delayed by about 6 months. Sioux Falls Farmers Market - we had trouble engaging the Farmers Markets this year. As an organization, they were not responsive. We are working to focus on individual vendors to see if they are interested in participating in a program like FaM. For any vendor, we will work them to ensure they have appropriate signage to inform buyers that FaM vouchers are accepted. Voucher Resources - The process to use paper vouchers and invoicing is time and resource intensive. I am working to identify additional funding (i.e. through a foundation) to support the implementation of a FaM debit card. 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? Continue to complete similar activities as this reporting period Engage local Farmers Market vendors to accept FaM Vouchers Work towards receiving funding to support the implementation of a FaM purchasing debit card to reduce the time and resource burden of the paper vouchers.

Impacts
What was accomplished under these goals? As of August 2024, we have enrolled 177 participants into the FaM program. With the recent implementation of our Spanish enrollment, we anticipate the rate of enrollment will increase. We continue to work with Avera clinics to identify, refer and enroll potentially eligible participants. We have developed a process to refer patients to the FaM program through our integrated EMR system. We worked with the Sioux Falls Mobile Market to allow participants to use the FaM vouchers to purchase fresh fruits and vegetables. The goal of the mobile market is to increase food access for Sioux Falls residents living in low-resourced food deserts. We implemented the use of Spanish documents to increase inclusion and diversity in our FaM population and coordinated our clinic recruitment, so it aligns with the schedule of the Sioux Falls Mobile Market that comes to a local clinic location. We continue to partner with our local Hy-Vee stores to create and deliver produce boxes throughout our study period and accept our FaM vouchers. We send monthly educational newsletters to particpants and provide opportunities for store tours and food demos.

Publications

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

Outputs
Target Audience:Avera patients referred by Family Medicine, Pediatrics and OB/Gyn clinics. The initial inclusion criteria are the following: Meet eligibility criteria for the Supplemental Nutrition Assistance Program (SNAP) program, Special Supplemental Nutrition Program for Women, Infants and Children (WIC), or Medicaid/CHIP. Live in the Sioux Falls area Participants must be 8 years or older; if under the age of 18 yrs, must have a participating guardian/parent Able to speak and understand English (Spanish once we are ready to implement, see accomplishments section below) ? Changes/Problems:Below are the change requests submitted to NIFA during this reporting period. Add a recruitment site - The Avera Health Care Clinic in Downtown Sioux Falls, a free community clinic, provides health care to members of our community who are uninsured, including a large Hispanic and Spanish speaking population. Given the prevalence and severity of food insecurity seen at the clinic, we are requesting to add them as a recruitment site for our program. Add a firm-level site - A Sioux Falls non-profit organization (Sioux Falls Thrive) recently received funding to launch a mobile food unit to serve much of the same population we are targeting for our produce prescription program. Given the synergy, we would like to partner with this program by adding them as a firm-level site to allow our participants to use their produce prescription vouchers at the mobile food unit. Replace the development of a Community Advisory Board with the participation in the Sioux Falls Food Security Action Team - Sioux Falls Thrive is a non-profit organization, located in Sioux Falls, SD, that helps facilitate collaboration on community initiatives, such as food security and access. The Food Security Action Team brings together a wide variety of community leaders focused on creating equitable and sustainable access to food in each Sioux Falls neighborhood in a dignified and culturally appropriate manner. The primary goals of the team are 1.) to facilitate collaboration among food rescue/recovery efforts in the Sioux Falls area, 2.) identify and support community builders in and for each neighborhood, 3.) create opportunities for people to buy affordable food in the neighborhood, and 4.) to reduce the distance between the people who produce the food and those who need the food. These goals align well with the proposed Food as Medicine (FaM) CAB, therefore in an effort to not duplicate work, to find synergy, and to respect the time of community members we would like to propose that instead of creating a FaM CAB, members of our FaM team will participate as a Food Security Action Team member. We are working closing with the Sioux Falls Thieve President in this effort. Add randomization to incentive arm - One of our project goals is "to determine the successes and challenges of the FaM program and whether they differ by mode of delivery". We have two modes of delivery - traditional in-store vouchers and produce box delivery. To increase the scientific rigor of our evaluation, we would like to add the randomization of incentive arm to our project. Once consented and enrolled into the project, we would like to randomize the participant into one of the two arms (in-store vouchers or produce box delivery). Changed New Authorized Representative to Ronda Hinsch 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? We plan to continue to work with Avera clinics to identify, refer and enroll potentially eligible participants. We plan to implement the use of Spanish documents to increase inclusion and diversity in our FaM population. We will work with the Sioux Falls Farmers Markets to identify producers interested in participating in FaM. MOUs will be completed as producers are identified. We will work them to ensure they have appropriate signage to inform buyers that FaM vouchers are accepted. We will work with Sioux Falls Thrive Mobile Market to allow participants to use the FaM vouchers to purchase fresh fruits and vegetables. The goal of the mobile market is to increase food access for Sioux Falls residents living in low-resourced food deserts.

Impacts
What was accomplished under these goals? Worked with Hy-Vee (our brick-and-mortar partner who strongly supports local producers) to create a process for in-store voucher use, tracking and reporting. Hy-Vee is also partnering with us to create and deliver produce boxes throughout our study period. We provide a monthly produce calendar that lists specific fresh fruits and vegetables (focusing on what is in-season in our region) that are then included in the produce box and delivered to our participant for that week. Training of Hy-Vee staff on the use and tracking of in-store vouchers and produce box creation and delivery. Created the appreciate financial accounts with the six (6) Hy-Vee stores we are working with in Sioux Falls. Completed signed MOU between Avera and Hy-Vee. In collaboration with NTAE, we developed and finalized the participant survey. We are pilot testing about 5 questions for NTAE regarding measuring participants' self-reported healthcare utilization. We worked with NTAE to develop Spanish versions of our surveys; these will be implemented in Fall 2023. Received Institutional Review Board (IRB) approval for the FaM study through the Avera Health IRB Created Manual of Procedures (MOPs) for clinic visits, which include recruitment, consenting, enrollment and baseline data collection. Trained study staff on clinic visit procedures. Working with Avera clinics to identify and refer potential patients eligible for our Food as Medicine (FaM) program. Once the patient is referred then we screen them using our FaM eligibility screener. We currently have three (3) participants enrolled into FaM. Engaging with Sioux Falls Thrive and the Food Security Action Team to ensure that FaM aligns with community goals such as creating equitable and sustainable access to food.

Publications