One could call Toledo, Ohio-based ProMedica hospital system a good neighbor. The non-profit is a driving force in building a new $1.5 million fresh produce-filled grocery store in one of the city’s so-called food deserts. Last year, ProMedica reclaimed tens of thousands of pounds of unserved food from a local casino; its 12 hospitals in northwest Ohio and southeast Michigan repacked it into some 50,000 meals for hungry individuals. Last fall, the system began screening for food insecurity at some of its hospitals, signing up at-risk patients for food stamps or sending them home with emergency stashes of groceries upon discharge.
ProMedica is tackling hunger as a health issue. Last year, the integrated delivery system organized its growing anti-hunger efforts—including food drives in public schools, anti-hunger fundraising events with local restaurants and ensuring poorer students have healthy food on weekends—into the “Come to the Table” initiative. Since 2011, ProMedica has helped to provide 10.5 million meals to residents who are considered food insecure—those who lack resources to provide themselves with enough food.
“There is nothing more fundamental to population health than food and other social determinants of health,” explains Randy Oostra, ProMedica’s president and CEO. Food insecurity affected nearly one in six U.S. households in 2011, according to Feeding America, a hunger-relief charity. In Ohio, the rate is higher than the national average, with more than 2 million residents who are food insecure.
As it turns out, addressing issues like hunger, housing and education can have more of an impact on people’s health than the traditional medical services hospitals deliver. Studies show that behavior and environment account for about 70 percent of our health outcomes, and medical care only about 10 percent. But nearly all of the nation’s health expenditures are focused on medical care, with a pittance dedicated to prevention, according to a 2013 University of Maryland report.
Health care reform is changing how hospitals and health systems view and address a community’s, or population’s, health. Largely through payment carrots and sticks, the Affordable Care Act (ACA) attempts to turn a system that has rewarded the provision of services to treat illness into one where providers will prosper by keeping people well and preventing disease.
As a result, hospitals are experimenting with care-delivery transformations—including revamping the patient discharge process, tightening collaborations with community doctors and other providers, forming accountable care organizations (ACO) and merging with other hospitals and health care organizations. Others are going farther, teaming up with local stakeholders, including neighborhood activists and employers, in hopes of moving the needle on social determinants of health in communities.
Integrated health systems (those operating hospitals, medical groups and health plans), like ProMedica and Kaiser Permanente, tend to be leaders in this space. With the incentives in the controversial health law, more hospitals are beginning to address root causes of disease in their communities. A study in last month’s Health Affairs by a University of California, San Francisco, research team shows why addressing food insecurity is not just altruistic for hospitals, but a move that can impact their bottom line as value- or risk-based payments increase. The study found that for low-income patients with diabetes, the risk of hospital admission for hypoglycemia increased 27 percent in the last week of the month versus the first week. (This was not the case for higher income populations.) The researchers suggested the spike in admissions is linked to paychecks and Supplemental Nutrition Assistance Program (SNAP, formerly known as food stamps) running out before month’s end. Hypoglycemia is an easily avoidable condition, as long as you have adequate food intake; still, Congress last week voted to reduce the SNAP program by $8 billion over 10 years.
“Hypoglycemic episodes have important clinical implications and health care costs,” the researchers said, postulating that “the exhaustion of food budgets late in the month also influence admission patterns for other diet-sensitive diseases, such as congestive heart failure.” “These are the absolute things you want to avoid” in a value-based payment environment, says Oostra.
Some hospitals have established protocols to identify patients who have difficulty affording food. Since 2008, Massachusetts General Hospital has screened its senior and youth patients for food insecurity. A “yes” response to one of two screening questions prompts hospital staff to help patients complete the SNAP application.
Mass. General has taken a bigger step at two of its primary care clinics in nearby Chelsea and Revere. Beyond screening all patients for food insecurity and signing up qualified individuals for SNAP and Women, Infants and Children (WIC) programs, the clinics also offer food pantries and a six-week healthy meals cooking course, thanks to a partnership with Cooking Matters Massachusetts.
“It’s the right thing to do,” says Melissa Dimond, manager of Mass. General’s community initiatives/healthy living, adding it becomes even more important under the ACA’s move to prevention. Last year, 41 percent of pregnant mothers coming to the clinics were identified as food insecure, for example. “Foods are one of the main drivers of health or disease,” she says.
“The Affordable Care Act provides several opportunities for hospitals to pursue initiatives to address the interrelated issues of hunger, malnutrition and obesity,” says Marydale DeBor, founder and director of Fresh Advantage, a Connecticut-based consultancy helping organizations support healthy food choices. In addition to its emphasis on population health, the law (also known as Obamacare) encourages hospitals and other provider groups to form ACOs to better serve Medicare beneficiaries. ACOs enter into shared savings and other payment arrangements with Medicare to rework health care delivery, even working more closely with public health officials.
“Another major opportunity to address food insecurity,” notes DeBor, a former hospital executive, “is Section 9007 of the law, which creates a greatly strengthened requirement for non-profit hospital to provide ‘community benefit’ programs in order to justify their tax-exempt-status.” Besides requiring a “much stronger” method for how non-profit hospitals account for charity care and other community benefits it provides, every three years hospitals have to work with stakeholders to conduct a community needs assessment, highlighting their intention to address such needs.
Under the ACA, fewer patients will be uninsured, thereby “nudging (hospitals) into public health prevention on a population health basis” through the community benefit, notes DeBor, who is working with hospitals interested in addressing food insecurity as part of the community benefit.
DeBor became involved in food issues several years ago as a senior executive at Connecticut’s New Milford Hospital, where she noticed high malnutrition rates among older patients. Too often, patients would be readmitted, she says, because a lack of food would exacerbate underlying health conditions. Through its community benefit program, the hospital started “senior suppers” and youth “chef advocates” programs, which were developed in tandem with local senior centers and youth agencies to address malnutrition among seniors and rising diabetes rates among youth.
Today, New Milford Hospital’s Senior Suppers program is offered seven days a week and, since starting in 2009, has served 14,560 seniors at a discounted rate of $5 per meal, or about half the actual cost. Last year, the hospital received a grant to transport seniors with accessibility issues to the dinners. The hospital is involved in a range of food-related community initiatives, including serving fresh and healthy foods from local sources and activities to raise awareness about the role of food in good health.
“We do believe that good food is good medicine and that quality food choices equate to yet another aspect of overall quality care that we are committed to provide,” says Deborah Weymouth, executive director of the 85-bed hospital. “Our community has come to know that New Milford Hospital will provide them freshly cooked, wholesome, healthy meals that are properly portioned, coupled with education, music and socialization.”
For most hospitals, this is new territory and will challenge them, says DeBor. “This is a platform that can help hospitals achieve their non-profit and health care objectives,” she says. “There is a process you can use and it doesn’t have to be overwhelming.”
ProMedica’s Oostra agrees. “It’s not a burden from a resource standpoint.” ProMedica, which provided about $130 million in charity care last year, spends about $30,000 on two part-time food packers to reclaim unused food from casinos and its own hospitals. Partnering with local food banks, that translated to more than 50,000 meals served to needy individuals. “So much of it is connecting the dots,” says Oostra. “It doesn’t take much effort to have a tremendous impact.”