The Food and Nutrition Services Bundle

The Food and Nutrition Services Bundle

Findings from a pilot project

A coordinated and accountable network bridges healthcare and local community food and nutrition resources for food insecure persons in the Bronx

Authors

Zachariah Hennessey Mireille Mclean Lauren Haynes Arielle Burlett Sandra Jean-Louis Ailin Liu

Thanks

Public Health Solutions (PHS) would like to thank all the people who have made this project possible, starting with the Food Security Specialists, Catalina Gonzales, Gabrielle Miller, and Roseanne Rodriguez, and our partners at NYC Health + Hospitals/Lincoln, Colette Barrow, Grace Kim, and Lara Rabiee; at NYC Health + Hospitals/Jacobi, Dana Ferrante, Lorraine Adler, Naomi Buchanan, Sara Costenino, Molly Gittleson, and Elana Sydney; and at OneCity Health, Marianne Krauskopf, Anita Ginsberg, Grace Wong, and Jasmine Warrick. At our Community-Based Organizations, we deeply thank Bibi Karim, Kim Wong, Kate Janeski, Alexandra Roem, Dorella Walters, Alissa Wassung, Lisa Zullig, Laine Rolong, Russell Gordon, Travias Cunningham, Stephen Cacace, Roslyn Shoulders, Maria Cintron, Rosa Bernard, Emaeyak Enakem, Emily Hespeler, Jose Cepeda, Jeannette Joseph, and Cheryl Seeley. At Healthfirst, Susan Beane, Rashi Kumar, Ronald Sanchez, and Tom Wang. At PHS, we also would like to thank Juanita Martinez, Flor Angel Rosario, Jackeline Bautista, and our intern, Joshua Souane, for their support with monitoring and evaluation.

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Public Health Solutions

Table of Contents

Executive Summary

4

Background

6

What Did We Do?

7

PHS' Approach

7

Reducing Gaps in Access to Services

8

Meeting the Needs of People Who Are Hungry: Increasing Access to Food Pantries

9

Solving Barriers to Enrollment

10

Who Did We Serve?

11

Demographics and Needs

11

Comorbidities, Healthcare Utilization, and Estimated Savings

13

Lessons Learned and Recommendations

14

Last updated: November 2019

Food and Nutrition Services Bundle

3

SNAP/WIC (648) Emergency Food (389) Medically Tailored Home-Delivered Meals (31)

Congregate Meals (3)

SNAP/WIC

648

Emergency Food

90 389

55 Home Delivered 31 Medically Tailored

Meals

Unable to contact (31%) Ineligible for services (28%) No show (17%) Declined services (13%)

Received information (8%) Other (3%)

Number of Participants

3 - 9

10 - 39

40 - 59

60 - 99

100 - 200

Referrals

Age

60 years old or older (37%)

Mate Sta

Pregnant have a chil

or younge

60 years old

Age

or older (37%)

67% 13%

Preferred Language

English (52%) Spanish (46%) Other (2%)

Preferred

English (52%)

Executive Summary Language

Other (2%) Spanish (46%)

Not currently enrolled in SNAP

Not enrolled in WIC among potentially

eligible clients

49% 7%

ESTIMATED AVERAGE SAVINGS OF

RELATIVE TO ESTIMATED

COST OF

$625 $375 On November 1, 2018, with support fPrroemgnaant aOndn/eor City Health

platform, Unite Us, to manage the activities of the network,

Performing Provider SysteMmateIrnnnaol vatiohoarnvyeoAuanwcgheairlrd(2d51,%yeP)aursblic

with integrated consent, assessment tools and outcome

Health Solutions launchedSttahteusFood and Nutrition ServiceInsterested in free meal sites

Bundle (FNS Bundle), offering screening and navigation to

measuCurreresn.tlyPhHasSaalso provided contracting and management

specific disease

servoirccehrsontioc ceonndaitbiolne

flexible

anPdERpePrAfoRrTmICanIPcAeN-bTased

PER

PARTICIPA

community food and nutrition resources for food insecure

contracting between network partners.

86% patients at two public hospitals in thOMFeARDEBEFETrROoRTnAHLxES. This report

presents a summary of accomplishmNAeEDTOnWCtOUsRM,KEeHNATvEDaDluation OUTCOME

57% findings, and lessons learned from tOhFeREpFEiRlRoAtLSproject. RESULTED IN ENROLLMENT IN FOOD AND

A Network of Local Partners NUTRITION SERVICES

Our Impact

? The FNS Bundle reached important populations of focus for social determinants of health improvement. Among those reached:

Public Health SolutionsMseteroPrlvuseHesaltah Pslana trusted broker fo2r2%

healthcare providers, manageHedalthcFairsrt e organizations,2a0n%d community-based organizSatratiigohtnMesdictaoid develop acco1u6n%table care networks that connect paMteideicanrets and memb1e5r%s to

37% 76%

high-quality community rNeosinosuurarncceeatsallthat meet th14e%ir non-medical needs and improve the N/A - Client has HHC options socia7l%determinants

WERE OLDER ADULTS

WERE ON MEDICAID/ MEDICARE

of health. The FNS BundleUniwtedaHesalthacarcelos2e%partnership

with Health + HosNp/Ai-tCalielnst h/aLs pirnivcateoinlsnuraHncoe sp1i%tal and Health

+ Hospitals/Jacobi Hospital,FiGdeolisdCa'sre Lo1v%e We Deliver, BronxWorks, Food BEmapinrekBluFe oCrorssNBlueewShieYld or1k%City, and Healthfirst. Collaborative design of theEmsbclermeHeeanlthing1%tool and workflows and continuous quality imAfpfinrityoHveaelthmPleannt0%were essential to our approach. The project used a WellCare of NdeywnYoarkm0i%c care coordination

14%

WERE UNINSURED

21%

ARE PREGNANT OR NEW PARENTS

4

Public Health Solutions

DNeocslhinoewd (s1e7r%vi)ces (13%) RDeceliinveedd sinefrovricmeasti(o1n3%(8)%) ORethceeriv(3e%d )information (8%) Other (3%)

Number of Participants

3 - 9

10 - 39

40 - 59

Number of Participants

3 - 9

10 - 39

40 - 59

60 years old

Age

or older (37%) 60 years old

Age

or older (37%)

67% 13% 67% 13%

Not currently

Not enrolled in WIC

enrolled in SNAP

among potentially

Preferred Language Preferred Language

English (52%)

OEnthgelirs(h2%(5)2%) SOpthaenris(2h%(4)6%)

Spanish (46%)

Not currently enrolled in SNAP

NoetleignirbollelecdliiennWts IC among potentially

eligible clients

49% 7%

49% 7% Pregnant and/or

? The FNS Bundle was successful in hmaeveetinag tchheinldee5dsyears ? Participants who were connected to emergency

of food insecMureaftaemrinlieasl. Food andoPnrrueytrgoitnuioannngstearrvni(c2de1/so%r) food, such as a pantry or soup kitchen, had not

were providedStota87t1ufsamilies overhaa1v0e-maoncthhipledri5ody.ears ? The FNS BunMdleaatsesrenssamlent tool aondr tyeochunnogloegry(21%) platform wereShitgahtlyuesffective in connecting

participants to resources.

pbreefvoiroeIun. sTtlehyerkenpsorotwepnodratiibononuot fopr aursteicdiptahneCtsseuirrnernseoenuetrdlcyeosfhas a

emefrrgeeencmy feooadl rseistoeusrces who wesrepeabcliefitco adcicseesas se

such rIenstoeurrecessterodseinfrom 6% too5r6%cCh.urorennictlycohnadsitaion

? The fFrNeSeBmunedalel wsiatseesffective in cosnpneecctiifingc disease

participants to multiple resourceosrthcrhourgohnoicnecondition

OF REFERRALS MADE TO THE

86% NAOOMNUFEEDATTTRODWWCECEOFOOUETMRRMROEKKRETAHHNHLAAETSEDDD 86% ORAOEFUDSTROUCECLOFTUEMEMRDEREAINNLTSED 57% EINORENNNEFUSRFRRTOUOOREOLFLILTTELLDEIMMRODARNEENAINNNSDLTTSERVICES

IN FOOD AND

57% NUTRITION SERVICES

encounter, with the most frequent combination being enrollment in SNAP plus use of a food pantry: 58% of all enrollments were in SNAP, and 38% of all enrollments were in Food Pantries.

? The FNS Bundle reduced the administrative burden on participants and healthcare workers to access services with complex eligibility requirements, such as medically tailored home-delivered meals.

? Outcomes suggest a positive healthcare savings return on investment.

MetroPlus Health Plan

22%

MetroPlus HHeeaaltlhthPFilrasnt StraighHt MeaeldthicFiarisdt

Food and NutritionSStrearvigichet sMMBeeuddniiccdaaleride No insuraMnceediactaarlel

202%2% 16%20% 1156%% 141%5%

37% 5 WERE OLDE

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