Overview

Fresh Food Farmacy is an organization that works improve the health of diabetic adults by providing them with free, nutritious food in addition to traditional healthcare services.

Organization Name

Geisinger Medical Home & Geisinger Health System

Organization Type

• Community hospital
• Community outpatient clinic
• Integrated healthcare system/network

National/Policy Context

• This intervention was prompted by the population health observation of rising food insecurity and diabetes. Due to this bidirectional relationship the healthcare system sought to improve the food insecurity with the plan to change behaviors and improve diabetes control.

Local/Organizational Context

• Fresh Food Farmacy is part of the Geisinger Medical Home, which is under the Geisinger system. The Geisinger system is a community-oriented integrated health system that includes 12 hospital campuses hospitals, over 200 outpatient clinics,  insurance products, a medical school, residency and fellowship training.
• Fresh Food Farmacy screens patients from the community clinic population and identifies the patients who are in need, and they enroll those patients in the program to receive food. The clinic is supported by resources including dietitians, social workers, and the entire Geisinger system.

Patient Population Served and Payor Information

• The Fresh Food Farmacy serves patients with diabetes out of control typified by a HBA1c>=7.5% who are also food insecure.
• Of these patients, about 40-50% have the Geisinger insurance health plan, and over half of the patients have Medicaid.

Leadership

The clinical champion and founder of the program is Dr. Andrea Feinberg, Chief Health Officer of the Geisinger Health System.

• Early on the program, she secured funds from a local supermarket and local foundation.
• She also recruited the help of her clinic’s health and wellness team, dietitians, and social workers.

Tools or Products Developed

Financing is managed through a collaboration between Geisinger Health and their health insurance company, Geisinger Health Plan (GHP).

• The program is funded through grants (40%), in-kind reciprocal contributions with GHP (30%), and private donations (30%).
  • Geisinger provides rent-free space for the food pantry and clinical areas, though they anticipate that, as they expand, it’s likely that the program will pay rent.
  • Employee expenses form the bulk of the costs; food accounts for only a small portion of the total.
  • Program costs (before clinical and behavioral gains) initially amounted to $3,000 to $5,000 per year per patient across the initiative, with that cost decreasing to about $2,200 as the program have progressed and learned.

Because Geisinger has a health insurance company, it is easy for them to access the payer-side claims data. This provides and in depth view of the financial costs of care and disease as well as the trends.

Tech Involved

• Electronic medical record
• Patient Portal

Team Members Involved

• Case Management
• Dietician
• Health Coach
• Pharmacist
• Physicians
• RNs

Workflow Steps

• Initially a patient gets identified in clinic by the physician and then the nurse would refer him or her to the program. The patient then would get informed about the expectations of the program: patients are required to attend diabetes health management classes and meet with a dietitian, and only after both of these things have been completed they could start receiving food every week indefinitely.
• Since its inception in 2016, this initiative has been a purposeful and iterative learning endeavor. They started the program in a county that has particularly high rates of diabetes, food insecurity, poverty, and unemployment.
• First, they queried their electronic health record’s (EHR) database for adult patients in selected zip codes who had a diagnosis of type 2 diabetes and hemoglobin A1c (HbA1c) levels ≥7.5 (indicating that their disease was not controlled). Then they screened these people for food insecurity with a simple tool linked to their EHR, asking them to respond to two questions:
  • (1) “Within the past 12 months I/we worried whether our food would run out before we got money to buy more,” and (2) “Within the past 12 months the food I/we bought just didn’t last, and we didn’t have money to get more.” Anyone who agreed with one or both of these statements was considered food insecure.
• They built a food pantry at one of their clinical centers so that patients can pick up food and receive care at one location.
  • Because the consequences of hunger affect entire families, the pantry provides patients and their families with the food, menus, and recipes needed to prepare two healthy, fresh meals five days per week.
  • However, providing nutritious meals is not nearly enough; achieving sustainable health and lifestyle improvements requires educating patients about healthy eating habits, goal setting, exercise, mindfulness, and diabetes management.
• Thus, in addition to receiving standard diabetes medical care, their program patients also participate in 15 hours of group classes on diabetes self-management.
  • They receive direct medication-management assistance from a pharmacist, follow-up with a registered dietitian, health coaching, and ongoing case management.
  • This care is provided through a medical home model so that participants receive reliable, patient-centered, multidisciplinary collaborative care.

Budget

• >$1M

Budget Details

• Program costs (before clinical and behavioral gains) initially amounted to $3,000 to $5,000 per year per patient across the initiative, with that cost decreasing to about $2,200 as we have progressed and learned.
• Employee expenses form the bulk of the costs, while food accounts for only a small portion of the total ($6 per patient per week).

Where We Are

• The intervention is ongoing as of August 2018.
• After they saw success with the program including a positive change clinical outcomes they expanded in March 2017.
• Currently the program reaches around 200 families, roughly 800 people in total providing on average 8,000 meals a week.

Outcomes

• With 12 months of healthy food and lifestyle changes, HbA1c levels dropped more than two points, from an average of 9.6 before the program to 7.5, far greater than the 0.5 to 1.2 point drop seen when adding on a second or third diabetes control medication. This initiative has had a greater impact on diabetes control (albeit in a small population) than expensive medications that have significant side effects. Additionally, they have also seen significant improvements in patients’ cholesterol, blood sugars, and triglycerides, improvements that can lower the chances of heart disease and other vascular complications.
• Strikingly, looking at retrospective costs before the initiative started, care for their pilot  patient population costed GHP $8,000 to $12,000 average per person per month. They have seen these payer-side costs drop by two-thirds on average across the program.

Future Outcomes

Future Outcomes To Be Studied:

• In order to demonstrate medical efficacy and health savings, they plan to run a randomized controlled trial starting in Fall, 2018 with the hopes of publishing the results in 24-36 months months. They plan to use the resulting tangible data to persuade health insurances to pay for the intervention in order to achieve sustainability. They believe that by 2021, they will have private insurance plans and Medicaid paying for this intervention.

Benefits

• Improved diabetes control, with an average decrease in HBA1C after intervention
• Patients are now more engaged in healthcare, with a higher likelihood of being put on appropriate medications and closing diabetes related care gaps such as getting regular diabetic foot exams to prevent podiatric diabetic complications.

Unique Challenges

• Some patients had difficulty engaging with the program due to issues related to the social determinants of health. For example, some patients had difficulty getting to the clinic due to transportation issues (did not own a car or could not use public transportation easily).  This led to the hiring of a community health assistant to help patients navigate real-world socio economic problems that are barriers to exceptional care.
• Also, they noticed early on that when patients switched from their existing low-nutrition diets to eating the foods they provided, some experienced potentially dangerous drops in blood sugar levels. Essentially, their bodies, having become accustomed to certain blood-sugar-lowering medications, had come to expect unhealthy high-sugar and high-fat foods. When those were replaced with healthier foods, the medications decreased blood sugar levels too much.
• Though they offered diabetes-education classes from the beginning, they did not initially require attendance. Yet patients who reliably attended the classes had significantly greater improvements in blood sugar and HbA1c. For that reason, they transitioned to require class attendance.

Metrics

Key Quality Metrics: 

2018 MIPS Quality Payment Program (QPP) Measures:  Providers participating in the QPP are required to report their performance on at least six metrics chosen from a list provided by CMS. Providers may be able to improve their performance on a number of these metrics by improving care for high risk diabetic patients. Sample metrics include:

•  Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)
  • Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.  This is a high priority measure.
• Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
  •  Percentage of patients – all considered at high risk of cardiovascular events – who were prescribed or were on statin therapy during the measurement period.  One high-risk subgroup includes adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL

More details can be found here.

Medicare Shared Savings Program (MSSP) ACOs: Clinics associated with an MSSP ACO are required to report their performance on measures for Hemoglobin A1c (AbA1c) Poor Control (>9%).  More information about this measure and requirements can be found here.

HEDIS Diabetes-Related Measures:

The HEDIS Comprehensive Diabetes measure for 2018 includes components for:

• A1c testing
• A1c control or lack of control
• Eye exam
• Attention for nephropathy
• LDL screening and LDL control

More information available here.

Medicaid ACOs: As of 2017, a number of states operating Medicaid ACO or ACO-like programs included measures related to diabetes care in order to assess quality.  Most commonly, these measures assess the percentage of patients with an A1c that is controlled/uncontrolled.  Most states require participating organizations to submit diabetes quality measure performance; in some cases, submission is voluntary.  More information can be found here.

Commercial Insurance: A number of large commercial insurers use provider performance on at least one diabetes metric (typically the HEDIS composite diabetes metric) to either award bonus payments or determine a provider’s quality tier. Examples of such programs include those sponsored by United Healthcare, Humana, and Aetna.  For information on programs offered by other insurers, providers should visit each insurer’s provider portal.

Direct Billing

Beyond services provided by physicians or nurse practitioners, practices may be able to bill for additional services provided.  Practices may be able to bill for dietician services delivered to Medicare patients with Diabetes if those services meet criteria for Medical Nutrition Therapy (MNT).  More information about billing for MNT can be found here.  Practice-embedded pharmacists may also be able to bill certain commercial insurers for their services, depending on the practitioner’s state and the specific insurer.  More information can be found here.