MedPage Today recently published a very interesting report, entitled “Addressing Food Insecurity in Type 2 Diabetes: Fresh food initiative cut HbA1c 20% among patients with poor glycemic control.” In that report, published online on April 11, Judy George, a contributing editor, wrote that “More than 14 percent of all households in the U.S. are food insecure, meaning they cannot reliably get nutritious food. And, the link between food insecurity and diabetes is strong: people with food insecurity carry twice the risk of type 2 diabetes.” What’s more, she wrote, “Food-insecure patients are more likely to have poorer glycemic control, have 5 times more encounters with doctors each year, and experience more frequent episodes of hypoglycemia.”
George quoted a number of experts on the subject, including Madeline Shalowitz, M.D., an endocrinologist at NorthShore University Health System, based in the Chicago suburb of Evanston, Ill. "If your patient is food insecure, he or she may not be able to afford the essential nutrition you are prescribing. They may not share that information unless you ask, and you must ask them in a sensitive way,” Dr. Shalowitz noted. “Otherwise, "you may assume your patient is non-adherent," she added. "You may prescribe insulin for glucose control, perhaps unnecessarily."
George also wrote that, “In 2011, Kaiser Permanente in Colorado studied households in two pediatric clinics—one in an underserved, low-income community, the other in a more affluent area—and found that, in the low-income neighborhood, 18 percent of households were food insecure. Surprisingly, so were 11.5 percent of the middle-class families.” "This led us to realize food insecurity may be more widespread than we had imagined," Sandra Hoyt Stenmark, MD, of Kaiser Permanente in Denver, told George. Further, Kaiser clinicians began at that time to ask patients about food insecurity, offering patients who screened positive the hotline number to Hunger Free Colorado, a statewide nonprofit organization. But when they tracked results, they found only 5 percent of patients had connected with the food bank.
"We realized that was an insufficient strategy, so we developed an outreach process in which we asked patients for their permission to send only their demographic information to the hotline, so they could then provide nutrition services," Stenmark told George. "And what we discovered is that 78 percent connected to resources." The next step, George noted, “was to develop ways to help more physicians address the topic and connect patients with resources. This led to the Food Insecurity Screening Algorithm for Adults with Diabetes, a document that Stenmark collaborated on with the CDC's Nutrition and Obesity Policy Research and Evaluation Network (NOPREN).” And she quoted Enza Gucciardi, Ph.D., an expert in food insecurity and diabetes at Ryerson University in Toronto, Canada, as noting that, if physicians don't screen for food security, they can't see the full picture or make realistic recommendations.
In that context, it was very encouraging to read both George’s MedPage Today article, and an article that Healthcare Informatics Associate Editor Heather Landi wrote back in February, about 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,” “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.”
And Landi quoted Andrea Feinberg, M.D., medical director of Health and Wellness at Geisinger Health, and the clinical champion of the Fresh Food Farmacy, as stating that “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.”
As Landi reported in her February article, “The Fresh Food Farmacy pilot began two years ago with just six patients, all diagnosed with Type 2 diabetes. To start the program, Feinberg says the project team first queried the health system’s electronic health record (EHR) to identify adult patients in selected zip codes who had a diagnosis of type 2 diabetes and hemoglobin A1C levels over 8.0, indicating that their disease was not controlled. Well-controlled diabetic patients typically have A1C levels under 7.0, Feinberg says. The program also targeted patients who received primary care through Geisinger physicians to enable the team to study and track clinical outcomes.”
What’s more, she noted, “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. “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,” Dr. Feinberg told her.
Making the connection
What the leaders at Kaiser Permanente Colorado and Geisinger Health System are doing is not rocket science; and yet it is potentially revolutionary, given how completely disconnected the traditional healthcare system has been from broader social welfare issues, including that of food insecurity. What’s troubling about the disconnect is that, even as more and more hospitals, medical groups, and health systems take on the challenges of risk-based contracting, in the forms of accountable care organizations (ACOs), bundled payment contracts, and population health-driven initiatives, with the public and private payers of healthcare in the United States, so much of what impacts the actual health of patients remains outside the traditional medical system. And that is particularly troubling when it comes to managing the care of populations with chronic illness, most especially diabetes, as nutrition and food consumption are factors essential to the management and control of hemoglobin a1c levels in people living with diabetes.
The bottom line here is both conceptually simple and operationally tremendously complex: as the U.S. healthcare system moves more and more into a value-based payment system from a volume-based one, traditional healthcare providers will need to connect clinical care with the social determinants of health, including issues around nutrition, food insecurity, exercise/activity, and poverty/economic viability. That is inevitable. Will the lift be a huge one for the U.S. healthcare system? Absolutely. And will healthcare IT leaders need to play an important role in establishing and optimizing information systems and data analytics to support patient care organizations in this work? Definitively.
But I am heartened at some of the first initiatives in this area, as they are providing templates for what others might do. And the fact that both integrated provider systems like Geisinger, and health plans like Kaiser-Colorado, are leaping into the void, is especially heartening, as it will absolutely take intensive and extensive collaboration between and among providers and health plans, to make this work.
With total U.S. healthcare expenditures set to go over a cliff in the next decade, we really have no choice but to connect healthcare with health. And while the challenges are manifold, so are the possibilities. It’s time for provider leaders to start somewhere.