When Food Becomes Medicine

A diabetic, elderly, housebound man has irregular blood sugar from running low on food at the end of the month. A family living in an apartment miles away from a grocery store is forced to shop for food at a local bodega with no healthy food options. A single parent must make the difficult decision to pay for utilities instead of groceries.

Members of the Boston community who face insurmountable medical and social challenges could benefit from nutritious food, but they cannot access it.

A desire to increase available healthy food options is the driving force behind one of the newest programs from Boston Medical Center Health System: a three-tiered nutrition intervention program. “We have recognized food as medicine for decades,” explains BMC Pediatrician and Associate Director of the Grow Clinic Megan Sandel, MD, MPH. “Now, we are making food and nutrition an integrated part of our care delivery system.” Sandel credits the program’s philanthropic roots in effecting change of such magnitude. “Philanthropy really seeded this project and now it’s growing into a national model,” she notes. “It’s a great testament to how Development and our operational system are working hand in glove, influencing how we care for patients and the community.”

The program emerged not long after the system, which includes BMC, physician practices and the BMC HealthNet Plan, shifted to the Boston Accountable Care Organization (BACO) in March 2018. BACO is designed to help patients manage their illnesses and reduce health care costs by preventing unnecessary or duplicate tests, and reducing preventable admissions to the hospital and emergency room visits. It aims to do so by addressing the root causes of poor health outcomes and high health care utilization with food insecurity being one of the most pressing.

Patients with food insecurity are identified through a new social determinants of health screening and referral tool known as THRIVE. “People don’t walk into a hospital saying they’re food insecure,” Sandel says of the importance of active screening. The questionnaire is designed to identify eight potentially unmet social needs, including food insecurity, directly associated with health outcomes and health care use. Patients with identified social needs are connected to additional support.

Based on their risk and medical complexity, patients with food insecurity may be referred to one of three interventions: a medically-tailored meal (MTM) intervention (Tier Three) for those most complex patients; a mobile grocery store intervention (Tier Two) for those living in food deserts; and a limited disbursement food pantry intervention (Tier One) for those who identify food insecurity but have relatively low medical and social risk. Together, these tiers will ensure BMC is able to deliver the right level of food access and nutritional intervention to the right patient at the right time.

Patients who are high health care utilizers and suffer from nutrition-related conditions such as congestive heart failure, end stage renal disease, diabetes mellitus, HIV, cancer and chronic obstructive pulmonary disease will be placed in Tier Three. At this level, meals tailored to their dietary and nutritional needs will be delivered to their homes, in an effort to easily facilitate dietary behavior changes and promote optimal health. For these patients, food insecurity poses the greatest risk to having unnecessary hospitalizations and emergency department visits, requiring the highest level of intervention.

Tier Two is intended for patients who have very limited access to healthy and affordable foods and are at risk for their chronic diseases to become worse as a result. These are patients who live in food deserts—areas where wholesome food and fresh fruits and vegetables are scarce at best. Other patients suited for Tier Two are those who have limited transportation options and financial resources. In Tier Two, healthy foods are brought to these areas, by way of mobile grocery stores: vehicles stocked with nutritious foods, fruits and vegetables for patients and other community members to purchase at a reduced cost. An on-site nutritionist provides consultation and direction for shoppers, reinforcing clients are making the best choices for their health and budget.

Unlike other food pantries where qualified individuals are provided with a limited amount of food, Tier One sets out to open access to even more healthy foods, for more people. The limited disbursement food pantry intervention builds on BMC’s experience with its own food pantry, in order to meet the challenge of serving a larger patient population under BACO. This tier best meets the needs of low-income patients who would benefit from an increased amount of healthy food.

BMC is working with community partners to develop the program, threading together existing programs and services and building greater collaboration among them. “Through these networks we’re creating a delivery system for health, not just handing off a phone number,” Sandel explains. Doing so will help cement the program’s sustainability and longevity, advancing BMC’s mission to create health equity over the long-term. “It’s our focus on the long-term that sets this program apart,” concludes Sandel. “We are making food as medicine a routine part of care.”