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When Mountain Comprehensive Health
Corporation (MCHC), a federally qualified health center in rural Kentucky,
started sending patients to farmers’ markets with vouchers to buy fresh fruit
and vegetables two summers ago, 125 patients and their families were served.
In all, they lost 105 pounds, their
glucose levels dropped by a cumulative 267 points, and their blood pressure
levels improved by 25 percent.
“That was the catalyst to keep going the
next year,” says Teresa Fleming, director of financial affairs.
So was the fact that more than 100
patients were on a waiting list, hoping that additional funds would allow the
health center’s Farmacy program to grow. Funding was secured, and the program since
has expanded at its original site and added farmers’ markets in two other
“And for our next project, we are
working on a community kitchen,” says Mike Caudill, MCHC’s CEO.
MCHC’s program is one of the many ways that
provider organizations are addressing the link between poor nutrition and poor
health among their patients.
Food insecurity, as defined by the U.S.
Department of Agriculture, is a “household-level economic and social condition
of limited or uncertain access to adequate food.”
According to Feeding America, a network
of 200 food banks across the country, 42 million Americans lived in
food-insecure households in 2015. That means 13 percent of all U.S. households
experienced food insecurity at some point during the year.
Among households with children, 17
percent—one out of six—experienced food insecurity in 2015. Thirty percent of
households with children headed by single women and 22 percent of those headed
by single men were food-insecure.
Until recently, health system leaders
shook their heads at the sad statistics but did not consider them directly
relevant to their work. That is changing as leaders embrace the need for
population health management, which means finding effective, efficient, and
sustainable ways to improve the health of their patient population.
The role of food security in population
health management increasingly is becoming clear. In 2015, researchers
published a study of 62,000 Canadians that documented the connection between
food security, health, and healthcare costs.1 Among the findings:
ProMedica, based in Toledo, Ohio, provides
healthcare services in 27 counties in northwestern Ohio and southeastern
Michigan. About six years ago, the system started working on an anti-obesity
initiative in response to its community health needs assessment. As its
trainers went out into the community to discuss obesity, they kept hearing
reports of hunger.
Surprised by the finding, Randy Oostra,
ProMedica’s president and CEO, said his first reaction was, “Wait a minute,
this isn’t what we signed up for.”
But as he and ProMedica colleagues
educated themselves about America’s food-insecurity statistics, Oostra began to
see a direct line between food security and spiraling healthcare costs.
“We spend $3.2 trillion on health care
and prescribe drugs that our patients will never be able to afford—and we don’t
ask people about their basic needs,” he says. “To us, it seems like a lack of
Beyond the fiscal consequences of
ignoring patients’ food security, Oostra sees a moral imperative for provider
organizations. Many health systems are not-for-profit, mission-based
organizations that were established specifically to serve the poor and have
grown to become major economic drivers in the communities they serve. “We are
the anchor institutions in our communities—who better to start taking on these
issues than us?” he says.
In 2015, ProMedica and the AARP
Foundation co-founded the Root Cause Coalition, a nonprofit membership
organization that addresses the root causes of health disparities by focusing
on hunger and other social determinants of health. The coalition estimates that
hunger contributes more than $130 billion a year to U.S. healthcare costs.
The coalition’s members—health systems,
insurers, food banks, and others—are working together on research, advocacy,
and education, including monthly webinars.
Meanwhile, ProMedica is working to get a
handle on food insecurity among its own patients.
“Last year we screened over 57,000
people for food insecurity,” Oostra says. “Very few social service agencies
would have the ability to touch that many lives that quickly. So we think that,
working with others, we really need to be in the center of this issue.”
ProMedica screens both inpatients and
outpatients. It has embedded the Hunger Vital Sign—a two-question screening
tool—into its electronic health record so that every patient is screened upon
admission to the hospital. (Sidebar: Screening
for Food Insecurity.)
A patient who screens positive for food
insecurity receives a visit from a care team member to discuss community
resources that may help, as well as a food “care package” at discharge.
ProMedica also screens patients for food
insecurity when they visit primary care physicians. In the Toledo area,
physicians write prescriptions that entitle food-insecure patients to visit a
“food pharmacy,” located in a ProMedica office, to receive several days’ worth
of food for their entire household. The prescription is linked to a patient’s medical
record, so staff members at the food pharmacy can help patients choose healthy
foods that support their specific nutritional needs.
“We provide lots of healthy recipes and
information on other community resources,” says Stephanie Cihon, ProMedica’s
associate vice president for community relations, advocacy and grants. “And the
patients are able to come back and see us once a month for up to six months
before they need a new referral from their physician.”
Meanwhile, ProMedica is working on
several innovative programs to increase the availability of food for those who
need it. Those include:
food reclamation program. Leftover
food from Hollywood Casino Toledo and from ProMedica hospitals is packaged,
frozen, and delivered to soup kitchens and homeless shelters. Since the program
started in early 2013, it has collected enough food for more than 275,000
meals. (Leadership Blog: Food for Health: Taking Care of Our Patients' Most Basic Needs.)
A full-service grocery market in a food
desert, (i.e., a neighborhood that lacks access to healthy, affordable food). The Market on the Green is staffed by neighborhood
residents who receive a year-long training program that provides work
experience, financial coaching, and other education as needed. The market is
part of the ProMedica Ebeid Institute for Population, which seeks to address
the social determinants of health through programs focusing on hunger,
nutrition, education, and job training.
mobile farmers market. Since 2013,
ProMedica has been dispatching a “veggie mobile” that sells fresh fruits and
vegetables to rural communities in one of the Michigan counties it serves. The
market visits senior housing complexes, community centers, and other sites in
food-desert neighborhoods. A registered dietitian rides along to provide
nutrition counseling and education.
meals for kids. Recognizing that only
about 10 percent of children are eligible for the USDA’s Summer Food Service
Program, ProMedica Toledo Children’s Hospital partnered with its food vendor to
become a summer meal sponsor. More than 550 meals were provided to children in
the hospital cafeteria last summer.
In the Appalachian communities served by
MCHC, the Farmacy program links patients who need food with farmers’ markets
that provide it. Caudill, the CEO, considers it a community development program
that addresses both food insecurity and economic challenges caused by the diminished
“On the one hand, we saw this as a way
of helping supplement the income of unemployed or underemployed miners who are
involved in farming,” he says. “And on the other hand, we saw it as a way of
helping patients, many of whom are unemployed miners, to afford fresh fruits
The program targets two groups of MCHC
patients: pregnant women and patients with Type 1 diabetes, regardless of
income; and patients with a chronic disease and income at or below 100 percent
of the federal poverty level. The program works like this:
Based on the program’s success in 2015,
MCHC received support from a local health plan and a grant from the federal
government to expand the initiative.
“We provided over $117,000 in vouchers
between the three counties last year,” Fleming says.
Pushing ahead, MCHC is partnering with a
county extension office and local food groups to create a new nonprofit—Community
Agricultural Nutritional Enterprises, Inc.—located in a former school cafeteria.
The new organization will help farmers develop products, such as jellies and
salsas, that can be sold at markets and grocery stores.
“And we’ll have an educational program
to teach people how to preserve foods and to eat healthy,” Caudill says.
Lola Butcher writes about healthcare
business and policy topics for several HFMA publications.
for this article: L.M.
Caudill, CEO, Mountain Comprehensive Health Corp., Whitesburg, Ky.;
Stephanie Cihon, associate vice president for community relations, advocacy and
grants, ProMedica, Toledo, Ohio; Teresa
Fleming, director of financial affairs, Mountain Comprehensive Health
Corp., Whitesburg, Ky.; Randy Oostra, president and CEO, ProMedica, Toledo,
1. Tarasuk, V., Cheng, J., de Oliveira, C., et al., “Association
between household food insecurity and annual health care costs,” CMAJ, Oct. 6, 2015.
This study, which used the
same scale for assessing food security that is used in the United States,
provides a perspective that is impossible to get in this country. Unlike in U.S.
research, this study examined healthcare costs from a central data source
because of Canada’s single-payer health insurance system. The universal
coverage also reduced the potential for selection bias related to health
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