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Creating a remarkable health experience

Social Determinants of Health: Food as Health

“At Highmark Health, we’re laser-focused on addressing the root causes of poor health, improving health outcomes and reducing cost. It’s not just a corporate social responsibility initiative, it’s a core component of Living Health, an integrated approach to deliver whole person care,” says Nebeyou Abebe, senior vice president, social determinants of health (SDOH).

One of the root causes is lack of access to nutritious food. I caught up with Nebeyou to learn more about how our organization’s “food as health” approach can make a difference in the communities Highmark Health serves.

Nebeyou Abebe, senior vice president, social determinants of health (SDOH)

The ripple effects of food insecurity

Catherine Clements: Why is food-focused programming such a big part of Highmark Health’s SDOH strategy?

Nebeyou Abebe: When we look across our organization’s footprint, food, housing, and transportation are the top three health-related social needs for our members and the communities where we operate. Food is a tremendous opportunity for Highmark Health to improve the health and wellbeing of children, adults, and seniors, both in terms of prevention and disease management.

National health data shows that diet-related chronic conditions are a major issue. In 2020 alone, an estimated 800,000 people died from cardiovascular disease. To put that in perspective, that’s an even greater number of people than the toll that Covid-19 took that same year. Obesity increases the risk for other diet-related chronic conditions and has reached historic levels in children and adults — especially during the pandemic.

Catherine Clements: Who does food insecurity predominately impact?

Nebeyou Abebe: It’s important to understand which populations are disproportionately impacted by food insecurity and diet-related chronic conditions. Most of the time, this includes people of color, lower incomes, or rural communities.

Nearly one in four households in the U.S. have experienced food insecurity on an annual basis, with nearly 34 million Americans either unable to acquire enough food to meet their needs or uncertain of where their next meal might come from. It has been observed that Black families are twice as likely as whites to face food insecurity; according to the USDA data, 19.1% of Black households and 15.6% of Hispanic households have experienced it. Last year, white Americans fell below the national average, with 7.9% experiencing food insecurity. There's a huge disparity.

Where you live is another important factor at play. People who live in food deserts — which is about 6% of the U.S. population (19 million people) — are often more likely to experience food insecurity because of limited access to affordable and nutritious food. According to the USDA, in 2015 there were 2.1 million households who both lived in a food desert and lacked access to a vehicle. It presented a vast crisis that cut across racial and ethnic lines, socio-economic status, and geography. Additionally, the removal of nutrition education programs from public school systems meant that a generation of young people may not understand the importance of food on overall health and well-being. Therefore, there is an opportunity to build knowledge and awareness focused on prevention and wellness for future generations.

Catherine Clements: How might food insecurity impact other health conditions — physically, socially or emotionally?

Nebeyou Abebe: Food insecurity can cause serious health issues when people must choose between spending money on food or health care. For example, it’s challenging to manage diabetes if a person is food insecure. When we think about prioritizing the care plan, do we focus on their social needs or their physical needs? Oftentimes a person is unable to adhere to their medication protocol or clinical program because they're dealing with drivers of poor health like food insecurity, housing issues, or transportation issues.

Food insecurity also makes it more difficult for a child to learn and grow. If you go to school with an empty stomach, you’re going to be focused on that the entire day and not your schoolwork. This is a contributing factor to low rates of high school graduation and entering college. You can see why it's critically important for us to move care upstream to address the needs of our youth so that they can thrive and pursue their dreams. The only way to do that is to eat a well-balanced meal three times a day.

Crafting a “food as health” strategy

Catherine Clements: Food insecurity is such a big problem. Where did Highmark Health even begin to address this?

Nebeyou Abebe: We recognized early on that the needs of each community are unique — so tailoring each program to a specific market was critical. Across our four-state footprint, we conducted a community health assessment. Through a simple algorithm, we identified 14 priority communities based on high membership density, high social vulnerability, and high chronic disease prevalence. It was clear that food was a big factor in driving a lot of the public health challenges across those communities.

Through in-depth interviews with key community stakeholders from nonprofit organizations, government entities, health care organizations, academia, philanthropy, we gathered even richer insights that helped inform our strategy. This included identifying strategic partners that we could collaborate with to help us with the design, implementation, and evaluation of our food as health programming.

Catherine Clements: What are some barriers to scaling nutritional benefits and how did Highmark Health overcome them?

Nebeyou Abebe: There are a lot of players working to solve the food insecurity crisis — the government, health care and nonprofit organizations. The key question is how can all these stakeholders work more efficiently together to address the needs of the broader population? That's the biggest challenge and opportunity we have.

Our philosophy at Highmark Health is that we can’t do it alone. It requires multi-stakeholder collaboration. To develop sustainable programs, we take a human-centered design approach, engage the community very early on and identify the right evaluation framework. Informing public policy to support new models requires demonstrating value, impact and return on investment. Whether a program is government funded or our own investment, we must prove that this model is better than what we currently have in place. The examples of food as health initiatives across our footprint demonstrate how we're working with a diverse group of community stakeholders and multisector partnerships to support this mission.

Catherine Clements: How do practitioners or payers identify individuals for food as health programs?

Nebeyou Abebe: The starting point is assessing health plan members and patients to identify any health-related social needs. Once we identify those needs, we then either connect them to a food program as part of their health benefits and or we connect them to a local resource like a food bank or nonprofit entity that can provide free or low-cost food and services to meet their needs.

We use a universal SDOH 15-question assessment that covers 10 domains. For our food-focused section we ask, “within the past 12 months, were you worried that your food would run out before you got money to buy more?” The second question is, “within the past 12 months, if the food you bought didn't last, did you have enough money to get more?”

We work closely with our hospital system, health plan case management, our network of providers and community health workers to identify and triage individuals who have physical, mental and social needs.

Delivering food access and education across markets served

Catherine Clements: Tell me about the Medically Tailored Meals program. How is this supporting the Living Health strategy?

Nebeyou Abebe: The Medically Tailored Meals program (MTM) is a SDOH pilot to address food insecurity among Highmark insurance members suffering from chronic health conditions like chronic kidney disease, congestive heart failure, hypertension and/or diabetes. Living Health is all about the Quintuple Aim: improving health, lowering cost, improving quality, enhancing the member and provider experience, and addressing health inequities. The MTM program is a great example of how we’re achieving those goals.

The uniqueness of the program is that beyond just providing nutritious medically tailored meals, we're also wrapping around additional support services such as a social worker and a wellness coach who will collectively aim to address the person's long-term plan for food security and meal planning respectively. This interdisciplinary approach allows us to expand awareness of the role food has on overall health.

Catherine Clements: What has been the impact of the MTM program to date? Will this expand to more members?

Nebeyou Abebe: Since going live in November 2022, the program has enrolled more than 30% of the members reached. As of April 2023, 394 members have accepted the program. Further expansion of this initiative will be based on program performance indicators such as member experience and engagement, net promoter score, increased knowledge of condition/diet, barrier remediation and more. As a result of working with the wellness coaches, patients self-reported reduced swelling in extremities and abdominal areas, improvement in blood glucose, weight loss, better eating habits, and reduced blood pressure.

Catherine Clements: Highmark Health is part of the Portion Balance Coalition, a multi-sector collaborative focused on education around nutritiously balanced foods. Why is this part of the food as health strategy?

Nebeyou Abebe: Our food as health strategy focuses on food insecurity, access and education. The Portion Balance Coalition, convened by Georgetown University, includes food manufacturers, food retailers, academia, health care organizations, and other stakeholders. This group is implementing demand and supply-side innovations to support a balanced healthy lifestyle.

I felt it was important to be part of this coalition because it is like-minded organizations coming together, to try to build knowledge of the importance of the right portions, food variety and quality of foods you eat. Often people don't recognize the importance of portion control — and a lot of this stems from education. I can only speak for myself, but when I went through the public school system, I was not taught in a structured way the importance of a well-balanced diet.

If everyone was able to have access and eat the right types of foods, chronic disease would be less of an issue in this country. Doing more to address that issue will contribute to improving health outcomes, which would lead to reductions in health care costs and ultimately put us on a path of sustainability as a country.

Catherine Clements: What is the West Virginia Healthy Neighborhood Program? How does it work?

Nebeyou Abebe: The West Virginia Healthy Neighborhood Program is a multi-stakeholder initiative to reduce food insecurity in Charleston, West Virginia — one of our 14 priority communities.

When we did the needs assessment, we realized that in rural West Virginia there may not be a grocery store for 20-40 miles — but there is a Dollar General. We connected with Dollar General’s chief medical officer, Dr. Albert Wu, to discuss our ambitions to create an innovative model that would address food insecurity. Dollar General is currently in the process of becoming a health and wellness destination — converting many of their stores into what they call transformed dollar stores, which have refrigeration that would allow them to stock more healthy food items and produce.

Providers, such as the West Virginia Health Network and Cabell Huntington Hospital, help identify people who are food insecure and have one or more chronic conditions. InComm Healthcare, our technology partner, issues debit-based cards loaded with money that the participants can use to purchase healthy items at the Dollar General stores. Providers also share nutrition education and connect participants to clinical programs that can support conditions. We monitor and evaluate the program for improvements in overall health and well-being, quality of life, their experience and cost reductions in the long term.

We're looking to expand that program to include West Virginia University and a network of Federally Qualified Health Centers. We’re really excited about the possibility of making this a state-wide initiative — expanding the number of retailers beyond Dollar General to include others like big box retailers, convenience, and grocery stores.

Catherine Clements: How are we leveraging the food prescription model to solve for insecurity and education across markets?

Nebeyou Abebe: In New York, the commitment to addressing food insecurity and inequities is strong; community affairs and the Blue Fund has awarded $3.2 million in grants to organizations addressing food insecurity since 2019. A great example of this is the Blue Fund’s funding of Buffalo Go Green’s Fresh Take Healthy Communities Program. This $370,000 grant will help provide access to healthy food options and cooking demonstrations, and nutrition education to families living in underserved communities throughout Western New York. The Buffalo Go Green project will act as a mobile market supporting a fruit and veggie prescription program. The mobile unit visits three local health clinics each week and partners with doctors to support individuals’ medically tailored diets. Patients receive vouchers to use to purchase fresh and healthy food and produce, and the mobile market will accept SNAP/EBT benefits as well.

In Delaware, we’re focused on reducing health disparities that are prevalent in minority communities such as high blood pressure, diabetes, obesity and other illnesses. These health conditions are caused or exacerbated by diets that lack fresh vegetables and fruit. Through corporate giving to Central Baptist Community Development Corporation in New Castle County, we’re advancing the Urban Acres Home Delivery Online Market and Education program to make fresh produce readily accessible with home delivery, and affordable because of a sliding scale cost structure. This is one of many initiatives to combat food insecurity and increase education, made possible by BluePrints for the Community.

In western Pennsylvania, we have the Healthy Food Centers, which I know this magazine did a video article on.

We’re really focused on innovating, leveraging existing coalitions, and supporting efforts that achieve sustainability and scalability. We want to make an impact by identifying programs that work, then refining and scaling to bring to more communities we serve.

Catherine Clements: The food as health strategy is just one part of the organization’s 80% project — what will you be working on in the near future?

Nebeyou Abebe: We are going to expand our food as health initiatives to more priority communities. We’re beginning to address other health-related social needs such as social isolation, health literacy, digital literacy, transportation and housing. We’re looking to expand our high performing social care network, which is an innovative value-based reimbursement model with community benefit organizations. We're also capturing race, ethnicity, language, sexual orientation, and gender identity data, to help us better tailor our interventions to ensure they’re culturally and linguistically appropriate for our members and patients. Lastly, we're focused on understanding the role and impact that SDOH has on maternal health outcomes, with a particular focus on perinatal mental health.

We have an all-star team of talented and passionate leaders and have integrated SDOH into our Living Health business strategy, which is key to sustaining and scaling. We have great support from leadership, and now it’s time for us to execute.

Read more articles about social determinants of health efforts across the enterprise on Highmark Health’s Digital Magazine.

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Highmark Health and its subsidiaries and affiliates comprise a national blended health organization that employs more than 42,000 people and serves millions of Americans across the country.

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