It was so encouraging to read Associate Editor Heather Landi’s report on an exciting initiative at the Danville, Pennsylvania-based Geisinger Health System. As she noted in her report, under the headline, “Can a Prescription for Fresh Food Treat Diabetes? At Geisinger, an Informatics-Driven Project Is Showing Promising Results,” she noted that, “With the aim of addressing food insecurity, as a significant social factor impacting health, and to improve patients’ diabetes management, Geisinger launched an IT- and data analytics-driven Fresh Food Farmacy initiative to give away fresh, healthy food to diabetes patients. The health system initially launched the program in July 2016 as a pilot project at Geisinger Shamokin Area Community Hospital in Coal Township, in Northumberland County, which has the second-highest rate of long-term diabetes complications in central Pennsylvania.”
As Andrea Feinberg, M.D., medical director of Health and Wellness at Geisinger Health, and the clinical champion of the Fresh Food Farmacy, put it to Landi, “Geisinger is very focused on approaching medical conditions from a population health perspective—we not only want to take care of each person that’s in front of us and provide them with the best state-of-the art care that we can, but we also look at our patients in their communities and see how we can improve the overall health of those that we serve.”
As Landi further noted, “While Geisinger healthcare leaders are using an old approach, essentially “food as medicine,” to tackle medical conditions, the Fresh Food Farmacy initiative is an informatics-driven project that relies heavily on data integration, analytics and mobile technology to do everything from tracking clinical outcomes to managing the food supply chain.”
Meanwhile, Jonathan Slotkin, M.D., director of spinal surgery in the Geisinger Health System Neurosciences Institute, also serves as medical director of Geisinger in Motion, a department focusing on digital engagement and patient- and provider-facing mobile device technologies, within the division of informatics at the health system. Slotkin helps lead the informatics work that underlies the Fresh Food Farmacy project. “For me,” he told Landi, “it’s fascinating from an informatics standpoint because it brings together traditional clinical care, which we’ve all gotten pretty good at, but it also brings in the harder issues around data and the transactional level of social determinants of health, costing, supply chain and distribution, things that most medical systems are not yet optimized for. I think as we all endeavor to manage and help our populations with social determinants of health, we are going to be faced with these challenges more and more.”
So here’s what’s fantastic about all of this: first, the leaders at Geisinger are approaching this issue broadly and strategically. Focusing on food and nutrition in aiming to improve the health status of their diabetic patients, is exactly the right kind of thing to do. The reality, as Geisinger’s leaders know, is that most of what makes the difference for diabetics, in controlling their blood sugar levels in their day-to-day lives, is not connected with the purely medical, but rather, is connected with nutrition and exercise—the so-called “lifestyle” factors (though really, to be honest, nutrition is so much more fundamental than being about “lifestyle”—but there, the English language fails us to some extent, I would say).
What’s more, this is absolutely an area in which leveraging information technology not only makes sense, but really is a critical success factor. As Landi noted in her report, “The project team also leveraged the MyGeisinger patient portal tool, which links to the health system’s Epic EHR, to screen patients for food insecurity. Care managers also called patients to screen them for food insecurity.” As Dr. Feinberg told her, “Our hypothesis was, and still is, that if you have unmet social needs and if you are faced with food insecurity and you cannot afford to pay for healthy, nutritious food, then your diabetes cannot be well controlled.”
The third major element here has to do with leadership, management, and process. In the past, what used to be called “disease management” programs tended not only to be very limited in size and scope—they also tended to lack c-suite support, and tended to be run as “one-off” efforts disconnected from overall operations in patient care organizations. I remember interviewing the clinician leaders of a CHF (congestive heart failure) disease management program at a Southern California hospital way back in 1997. A time-pressed cardiologist and two very harried cardiac nurses were attempting to run the entire program, and, in visiting them in their facility, it was clear that they were overwhelmed on a practical level. Their initiative was great, at least in theory; but making it work was just so difficult, given their limited resources.
This Geisinger program clearly has support from the top of the organization, and, importantly, the resources—human and financial—to make it work—as well as the commitment to pursue it across time.
What’s more, Geisinger’s leaders have been willing and able to dig into the web of IT and data challenges that inevitably emerge in these initiatives. As Landi noted in her report, “Early on in the project, program leaders recognized specific data governance issues that needed to be addressed to make the program more effective,” as she quoted Dr. Slotkin as noting that, “In a lot of health systems, medical problems being added to the EHR problem list is something that usually only happens under physician direction. We felt that food insecurity was both pervasive enough and devastating enough that we needed to liberate it, so non-physician providers, like dieticians or others, could have the authority to add food insecurity to the problem list,” he told her. “Food insecurity does have a recognized diagnostic code. We took that through our senior leadership governance committee, and Andrea was successful in getting approval for non-physicians to add that to the EHR problem list.”
As Landi noted, “The program has now been expanded to 115 patients, with the goal of reaching 250 patients for the Fresh Food Farmacy in the next six months”; and she quoted Dr. Feinberg as noting that the food provided to patients is enough to feed the patients as well as the family members in their households. “Once we get up to 250 patients, we’ll be feeding somewhere between 750 and 1,000 people per week,” she told Landi. Geisinger has several community partners, including the Central Pennsylvania Food Bank, that provide food, mostly fresh fruits, vegetables, lean proteins and whole grains, for the program, at a reduced cost.
And, the Geisinger leaders confirmed for Landi that they are committed to making this initiative work over the long haul.
So, all of those elements—focusing on a set of big-picture issues; meeting patients where they live; strategically planning and implementing the data and IT elements needed for success; achieving executive leadership buy-in and commitment to the initiative; obtaining the commitment for ensuring the financial and human resources needed; scaling up the initiative intelligently over time; and ensuring a constellation of community-based participation and allyship—all of those elements are vital to the success of any program like this one. As a result, Geisinger’s clinicians and care managers are obtaining the patient buy-in and engagement that they need. What’s more, Geisinger leaders have the advantage of being able to partner with the leaders of their own health plan, in order to attract patients/plan members into this program, and to be able to marry clinical and claims data in order to make the program work optimally.
All of those elements have been key to achieving real patient engagement—not the superficial, check-the-boxes kinds of patient engagement markers so common in this kind of endeavor. As Dr. Feinberg told Landi, “We found historically that these are often very disengaged patients; they have been disappointed, they don’t know how to take care of themselves and they don’t have resources to buy healthy food. We’re giving them the education and the tools they need, we’re removing the obstacles, and with that, we follow the improved health and improved fiscal outcomes as well,” she said.
My prediction? This Geisinger program could prove to be a model for this kind of work that really could be replicated in patient care organizations across the U.S. I can’t wait to hear what this initiative looks like a year from now—the path ahead looks genuinely exciting for pioneering program.