Food is Medicine: Trust between Community and Health Systems

Food insecurity and food that is not tailored to an individual’s medical condition can contribute to poor health outcomes and high healthcare utilization and expenditures ($1800 greater for an individual assessed as food insecure). One of the greatest challenges many patients with complex disease experience is attempting to change their diet as they face barriers including food affordability, food insecurity, food proximity, physical disability, and education around food as treatment. Medically tailored meals can help to get past these barriers by providing appropriate meals directly to patients in need. California is the first state to prescribe food as medicine, which is formally covered under their expanded Medicaid program.

UC Davis Health, which has the second-largest primary care patient population in the UC Health system, has led in the development of a framework to obtain social needs data, engage community organizations, and potentially prescribe medically-tailored meals to improve food insecurity through trust-building activities.

The initiative includes purchasing social needs data, using this data to guide screening conversations with patients, developing closed-loop referrals with community-based organizations, and will include prescribing food as medicine. These workflows required significant sensitivity to:

1. historical concerns of trust between the health system and communities;
2. privacy concerns about purchasing data and how communication with patients would occur; and
3. follow-up concerns that patients would be monitored over time if they were successful in linking to referrals and resources.

• Actively uplifting the patient experience and identified community needs to guide priorities
• Following the Principles of Trustworthiness in Healthcare framework by the AAMC
• Breaking down silos both within the organization (strategy, finance, population health, equity and inclusion, community engagement care teams) and between organizations (health system care managers with food banks, community resource centers, community leaders)
• Engagement from leaders who are willing to use novel approaches grounded in the primacy of community trust and patient wellbeing to address upstream social influencers to impact health outcomes

UC Davis Health engaged with community leaders to evaluate what our communities thought was of highest priority for the health and healthcare of their communities. The Community Health Needs Assessment involved multiple community leaders, community-based organizations, community members, and patients. This assessment identified social needs of food insecurity, housing, and jobs as top priorities. Population Health with the Health Equity, Diversity, and Inclusion leadership in the organization focused on community needs and highlighted that food insecurity is also linked with medical outcomes, patient experience, and unnecessary healthcare utilization. They are joining forces to pull together existing and new community relationships, patients, strategy, finance, and IT members to develop a full circle framework and intervention to address food insecurity. There was a clear opportunity to address patients’ holistic needs and build trust with a more holistic and sustained effort over time.

The practice had a goal to develop deeper relationships with community-based organizations, which continue to grow. The pilot focuses on communities with high food insecurity as identified by zip code. Integration of social needs data and a closed-loop referral platform in the EHR has been completed. Workflows use this data in directing proactive outreach, use sensitive communication to discuss patients’ food insecurity, link patients to local resources, and monitor their follow-up. There is reason to believe trust is being improved in that this practice is directly focused on a priority area identified from the community: social needs.

Yes, this is being started in a few communities with high food insecurity (identified by zip code) where UC Davis also offers primary care. Future plans include learning from these experiences and expanding to all primary care practice regions at UC Davis Health.