Episode Transcript:

Social determinants of health—such as food insecurity--have a profound impact on people living with chronic kidney disease and other related conditions. In part two of our exploration of Food Is Medicine, I talk with veteran health and wellness expert Allison Hess, Vice President of Health Innovations at Geisinger, and one of the masterminds behind the company’s successful Fresh Foods Farmacy. Allison and colleagues are advancing this new approach to medicine by empowering patients to manage their health conditions through food-related behavior and lifestyle changes. By putting research into action, and providing fresh, healthy food to those most in need, Allison and team are shining a light on the vital role healthy foods play in improving patient outcomes.

DR. MADDUX: I’m here today with Allison Hess and Allison, thanks for joining me.

Allison Hess: Absolutely.

DR. MADDUX: Tell us a little bit about your role at Geisinger.

Allison Hess: My role at Geisinger is that I’m the Vice President of Health Innovation and so, I get to oversee a lot of the new programs that we’re doing in the health and wellness space, specifically around programming that we’re doing to fundamentally change the way that we deliver care and using innovative processes and looking really at root cause issues to try and determine how we can close gaps for our patients.

DR. MADDUX: One of the things we’ve been very interested here at Fresenius Medical Care is how social determinants of healthcare impact our patients with chronic kidney disease and I know that you were very sentinel and central to the development of the Fresh Food Pharmacy. I wonder if you could talk to us just a little bit about what that is and how it came about.

Allison Hess: Several years ago as an organization, we kind of took a step back and it was really when we started hearing a little bit more about the social determinants of health, we were starting to see more literature around that and some evidence about the impact that that has on health outcomes and we really took a deep look at our own populations, specifically our diabetes population. As a healthcare system, we had invested significantly in programs and services, education for our diabetes patients. We’re heavily invested in programming and we’re nationally recognized for our efforts in diabetes. But despite that, we were still challenged in many cases with our patients that had type 2 diabetes, with really getting those numbers controlled and at a level that we really felt was clinically appropriate and so, as we started to kind of peel back the layers and hearing more and more about how food and diet responsive conditions specifically really impacts the health, especially in regards to social determinants of health and other unmet social needs, we decided to pilot a program to see if we could have impact in our own patient population, and so, with that, we took six patients and we decided to see if we provided the food for them if they could in turn have clinical success with managing their type 2 diabetes. They were food insecure patients. So, they had self-identified as having food insecurity, had hemoglobin A1Cs in many cases in double digits for a consistent period of time. One patient hadn’t had a hemoglobin A1C less than 10 in the past five years-- so, significantly unmanaged and we assigned a registered dietician. We put a CDE registered nurse connected with them, and we provided the food. We went out and shopped and got food for ten meals a week every week for the patient and for their entire household and in that preliminary exercise, we saw incredible outcomes. We saw significant reductions in hemoglobin A1Cs at three months, continued reductions at six months, and sustained outcomes. In fact, one of our first six pilot patients is getting ready to graduate the program and she has had a hemoglobin A1C less than six consistently for over the last two years. So, just really has seen a huge impact and has changed her life and the way that she takes care of herself as well as her entire family and household.

DR. MADDUX:  It’s quite impressive to hear that kind of result. It’s very clear to me that we underestimate the degree of food insecurity and it always has shocked me when I’ve heard objective findings on how prevalent that is. We have lots of resources of food in this country, yet they aren’t getting to some of the people that actually need that food. How does the Fresh Food Pharmacy sort of address the population as opposed to the individuals you just described? How are you looking at trying to solve this for the larger population in your area?

Allison Hess: I think we do that a couple different ways and you bring up a really good point, that identification is so crucial and that’s why one of the first things that we did when we went down this journey was we embedded into our electronic medical record the two USDA food insecurity questions and we make sure that we’re asking our patients these questions periodically as they’re coming into our health system and we’re able to then use that data and match that up to see who also has type 2 uncontrolled diabetes and we’re able to then refer and recommend them for the program. So, we do a lot of targeted kind of data mining behind the scenes to try and help identify those employees. But what you just mentioned was a large part of the reason why we made the conscientious decision with this program to not just offer it to the patient, but to offer it to the entire family and then the other piece of this is we offer it to anybody in the community, regardless of whether or not they’re a patient with us or that they’re insured by us. So, we really have embraced this as a community outreach program and so, a large portion of our population who is participating are actually not affiliated with Geisinger but are members of our community in need and again, that support not just for the patient but for the entire household is our approach to helping to stand up the entire community.

DR. MADDUX: I think that’s a fantastic observation that you’ve made, that the entire family, actually, is in need and if only one individual in the family gets the medically tailored meal or the action, the others in the family may actually be getting that result. So, I think you have to treat the whole family ecosystem. That was an interesting insight that you all had quite early into that. Do you find patients are willing to self-report food insecurity or is there some reluctance to expose that to others?

Allison Hess: There’s absolutely a reluctancy to disclose that and I think that was one of our lessons learned is we rolled this out to a broader population. So, after our pilot, we created a fresh food pharmacy on one of our hospital campuses. It’s over 2,000 square feet. Our clinicians sit in that facility. It looks like a grocery story. Our patients can come up. It is a choice pantry. They can walk in and select what they want. We have recipes available for them that match the food options. They get the education. They have diabetes self-management classes that are group classes. They get the education from the registered dietician. So, they really have everything there that they need and when we opened that, we knew that there was a huge rate of food insecurity in that particular region and we were frankly concerned that we would not have the capacity to serve everybody in need and in fact, it was the opposite. It goes exactly to your point of that willingness for individuals to kind of come forward and participate in the program. There was some reluctancy and really, our engagement came from others who were participating or had participated who reached out to friends and family. It was kind of a word of mouth campaign and then additionally we were able to hire one of our participants who went through the program and they became part of the Geisinger family and they do a lot of our recruitment and they also help teach the Diabetes Self-Management Program, which can be taught by a layperson and so, adjusting the program to incorporate them into it was a really important piece as well.

DR. MADDUX: That concept of peer mentoring, I think, surely makes it easier for some people to sort of expose the issues they’re dealing with. So, it’s primarily less on producing meals for families, but actually food access for families. Is there any degree of medically tailoring of the food that’s available or if there were meals, to try to help people make sure they’re choosing wisely the foods that they choose to eat or prepare?

Allison Hess: Yeah. Absolutely. I think what makes our food pantry unique is that we only stock our shelves with foods that are going to be ADA-approved or appropriate for our patients with diabetes. So, lean meats, whole grains, fresh fruits and vegetables, frozen fruits and vegetables, proteins. So, we really ensure that everything that’s available is going to meet the nutrition requirements for our patients. So, they don’t have to worry about leaving something on the shelf that may not be good for them. Everything in there is something that they would be approved to be able to take and so, that was a really important piece for us and we worked closely with our friends and partners at the Central Pennsylvania Food Bank and they’re associated with Feeding America and this was a really kind of new concept for them as well and they were great with trying to help us secure the foods that really met those nutritional guidelines and we’re pretty strict at adhering to those. So, the participants who come in aren’t forced to choose.

DR. MADDUX: Have you all affiliated with any community-supported agriculture to try to use some of the local Pennsylvania resources around the Danville area to try to stock the pantry in that way or has it been strictly through traditional acquisition of food?

Allison Hess: We have partnered with local community gardens or farmers who are interested. We do have to run that produce through our Central Pennsylvania Food Bank channels, but we have definitely partnered with local community organizations, community gardens, and things like that to be able to provide food to the patients.

DR. MADDUX: During this COVID-19 pandemic, I’m curious what has been the impact either on the Fresh Food Farmacy or from the Fresh Food Farmacy to the community during the pandemic?

Allison Hess: Yeah. So, on the Fresh Food Farmacy, we had to very quickly pivot and adjust. As you can imagine, we had lots of patients coming through every day that were getting food in our location in Shamokin, Pennsylvania. We have 250 patients a week who come in and get food for themselves and their families. They’ll see their care team member. So, we had to quickly adjust to a curbside pickup, kind of online ordering type of approach or we even did in home delivery in some cases, where we would drop the food at the residence home to try and limit people coming in on site through the pandemic. So, we were able to do that and still retain the telephonic communications with our patients or be able to do virtual communication. So, we pivoted very quickly so that there was limited disruption to our patients through that process and in fact, we’re retaining some of those services obviously now, but we will continue to do that as we were able to gain some efficiency there too. As far as new programs, we also recognize that while this program is very much tailored for those who have a diagnosed condition and food insecurity, we do have requirements for the program. There were many others who stepped forward and identified that they had a need and so, in partnership with our Fresh Food Farmacy location, we stood up an emergency food box distribution program, where we provided food to any member of the community regardless of whether or not they had a condition or were enrolled in the program and we did that at all three of our locations to try and help with that need.

DR. MADDUX: The pandemic itself seems to have exposed some of this underlying food security issue that we have across the country. So, I’m not surprised that you’ve both wanted to and had to respond to broader needs than simply the diabetic patients that are in the community.

Allison Hess: Even prior to COVID, the patients in our program span all different ages. They span all different-- if you look at insurance, all different lines of business, whether it’s Medicaid, Medicare, even commercial. We have individuals who are working, but still can’t make ends meet and still have a challenge providing for their families and so-- and we have some situations-- we have a great story where we had a truck driver who actually lost his job because in Pennsylvania, you have to maintain certain clinical criteria in order to be able to safely operate a vehicle and he was not able to do that. His diabetes was too far out of control. So, he lost employment and he was really struggling, himself and his family and we got him enrolled in the program after he had been enrolled with specialists and others trying to really get at getting his numbers where they needed to be but had not identified the underlying root cause of food insecurity really driving the largest part of his diabetes being uncontrolled. So, we got him in the program. We got him set up with the food for himself and his family, had the education that he needed in order to get his diabetes under control and after six months of being in the program was able to regain his employment and has been successfully employed for the last year. So, those are some of the stories too where it may be a moment in time. It may not be something that somebody is dealing with over the course of a couple years. It could be a moment of time where they need the support and help, but it goes back to your comment earlier. We don’t do the pre-cooked meals or the pre-planned meals largely because we feel that this is a program really about teaching a man to fish and we want to make sure that they have all the tools and resources in order to do that and as part of the onboarding process, we often find out sometimes our patients don’t even have the equipment needed to prepare the food and so, helping them come up with long-term solutions or plans to be able to do that is a really important tenet of the program.

DR. MADDUX: I know you have a role in the work that your health plan does in creating innovations and so forth, but this strikes me that one of the questions that all of this uncovers across our country, not just in your market areas is that we spend a certain amount in medical spending that is highly influenced by social issues and these social determinants are probably going to lead to, if we address them, lead to lower medical spending but higher needs for social spending and I’m just curious how you all have seen this interaction between medical spending and social spending in this regard.

Allison Hess: We’re looking at that really closely. So, there’s a couple things that we monitor and measure. We obviously look at the clinical criteria and while we’ve seen about a two-point reduction on average in hemoglobin A1C across all of our patients, which is phenomenal when compared to medication reductions of 0.5 or 1.0 reduction. So, we’re really pleased with the reduction of hemoglobin A1C and we know that that ties back to reduction in cost. So, a lot of already published literature out there that supports that. In addition to that, we were very pleasantly surprised to also see that as employees got more-- or as patients became more engaged in their health, they also started getting their preventative care done at a higher rate. So, we have about a 20% higher care gap compliance rate for the participants in our program. They’re also losing weight. Their LDLs are reducing. Their triglycerides are reducing. They want to quit using tobacco. So, we see this level of engagement that also supports other health measures other than what we’re specifically measuring for this program and then we also look at kind of a cohort comparison of those in the program compared to similarly situated individuals and we see lower ED use. We see lower admissions and so, we have a study in place right now where we’re looking at this a little bit closer and we’ll continue to look at the results on the true financial impact, but we’re definitely seeing that correlation between the healthcare spend and the clinical results in the program, at least in the preliminary look.

What I struggle to be able to capture is the impact on how this just makes patients feel and how it changes their life and if you’ll just entertain me for a moment, I’ll tell a quick story about a patient who came in and I met her for the first time. I was actually there when she enrolled in the program-- and we have permission to share her story. But she came in and she was using a walker to assist her, very, very downtrodden. Every step she took, she waited a couple seconds. There was a heavy sigh, then another step. Every question we asked her, it was just exhausting for her to even answer and respond to the questions to get her enrolled in the program and I just remember thinking there’s just this level where people have kind of given up and a lot of our participants in the program, food insecurity is not the only social determinant they’re dealing with. They have many other challenges and part of this program was identifying that it’s not always just food insecurity. We’ve got to have resources in place to help our patients and we’ve done some of those things to support that. But anyway, a couple months later, probably about six or eight months later, I was in the Fresh Food Pharmacy and I heard this hooting and hollering coming out of the registered dietician’s office and everybody’s cheering and I thought “What in the world is going on?” and so, I walked out around the corner and poked my head in and there’s this same individual and she’s standing on the scale and her arms are in the air and there’s no walker and she has the biggest smile I have ever seen and she just had tears of joy because she had met her 50-pound weight goal. Her hemoglobin A1C was normalized and had been running-- she hit her A1C goal. It was like the perfect day for her. She hit all these measures. But what impressed me the most was just how she was radiating this happiness and this joy and self-accomplishment and I remember thinking “How do I measure that? How do I quantify that situation?” because we see that all the time with our patients.

DR. MADDUX: I do think the engaged patient and whatever trigger gets them to be fully committed to their own success is critical in kind of turning around these lives, which is what you’ve described. I’m curious whether you all have tried to measure engagement through patient activation measure or some other scoring system to try to quantitate this in the study that you’re looking at.

Allison Hess: We look at it a couple different ways. So, we have done some self-reported surveys, where we’re asking people to evaluate their current health status when they start the program, how many fruits and vegetables they eat, how much physical activity do they do, and then we do a pre and post comparison and we’ve seen some really strong impact there. Certainly, we see people who rate their overall health much higher. They’re more engaged in their overall health. They feel better. So, we do have some self-reported data that we collect as part of this and we’re looking at qualitative and quantitative data as part of the study as well. But yeah, we’re consistently trying to determine how we want to evaluate that and measure that piece of it.  A lot of the programming that we offer and that we include is a direct feedback response from our patients who participate in the program.  So, as they become more engaged, they’ll start saying things like “It would be great if we could have a walking group or do a walking program,” or “Can we do a walking challenge?” They love the group and peer support settings. So, they want to do more of that. They want to do maybe some cooking demonstrations or have some resources come in and support that. So, we’ve really adapted and built the program out based on their feedback.

DR. MADDUX: I strongly believe in patient education, but I also think that sometimes in healthcare, we spend so much time thinking that if we teach somebody what we know about the problem, they’ll come to the same conclusion we have and their behavior will change, but in reality, there are other things that influence behavior so much and I’m curious whether you’ve run across any interesting things beyond education that have really been big influencers to get people really committed to these programs or to end up with results that are different.

Allison Hess: Obviously, the food is a big part of it. I mean, we’re solving for a very real, very important need, not even just clinically, but in many cases, this is impacting a household and people are deciding whether to eat or treat in some cases and so, I think removing that burden allows individuals to have the opportunity to be more focused on their health and until you remove some of those burdens, I think it prevents people from being able to really take that education and do something with it. So, we added a community health assistant to our clinical care team and as part of the onboarding process, we identify if there are other unmet social needs. If there is an issue with transportation, if people identify early on that they may not be able to get transportation, we supplement transportation for them so they can get to the program. So, it’s really about understanding the whole person and all of their needs versus just saying “Here’s kind of a program in a box and see how you fit into it,” we really try and work at a very individualized level with all of our patients to make sure that we can close those gaps and we’ve recently stood up a platform in conjunction with Aunt Bertha and that’s something that we’re using as well to connect them to local resources and also state and national resources and that’s been a huge benefit. So, I think that piece of it is really critical, understanding what all of the needs are and making sure that we have the opportunity to try and get the resources, even if it’s a referral, but get those resources available for the patients.

DR. MADDUX: What would you ask policymakers to do to try to resolve some of these issues nationally, not just in the area of Pennsylvania that you all are in, but what do you think should actually be done?

Allison Hess: I think there needs to be continued support for these types of programs. We have to get at the root cause if we think we’re really going to make a clinical impact and if we really want to get upstream of this, we have to look past the patient and look at the household and look at the family. I have learned so much in this process and in many cases, families who are in need, if the patient is in need, there’s likely other families and generations of family members who could benefit from programs like this and the support. So, we’ve got to figure out how to continue to focus on kind of the health and wellness and prevention aspect so that we can start to get upstream and not just get focused on the treatment or how do we lower the cost of those who are already diagnosed? We need to get really focused on cost avoidance and we need to celebrate the wins of cost avoidance, which is sometimes challenging to do because we’re all so focused on the high-dollar patients, which we need to be and we understand that, but there’s equal opportunity in that prevention space as well.

DR. MADDUX: This has been a great conversation with you. Anything else you’d like to add that you think we should try to cover here and make sure that we talk about?

Allison Hess: I really appreciate the opportunity to talk about the program. We’ve learned a lot over the course of the last couple years. We’re still learning. We’re still innovating. We’re still adjusting the program as we go. Our goal is to have a sustainable model that will stack up against that next new med that comes out on the market and we can say that we can demonstrate the same clinical impact and therefore potentially the same financial impact, but also serve for a greater need and get at the root cause of some of these issues. Prescribing a med for somebody who is already food insecure and adding that additional expense is going to be very, very challenging for that individual to continue to be successful and so, really, what our hope is, is that we can get others to recognize the value of food as medicine and maybe even in some way create kind of national network of Fresh Food Farmacy or versions of this. We’re very mission-driven. So, like I said earlier, I hope others kind of replicate this model and then it becomes something that’s just part of a standard benefit and we’re able to continue to cover those types of benefits for our members.

DR. MADDUX:  That’s a great vision for the future that we could extend something like what you’ve done with the Fresh Food Pharmacy nationally. Allison Hess, thank you for joining us today.

Allison Hess: Thank you so much for having me.