Poster Presenters - Community Based Organization Category

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Q1 Please provide your contact information below.

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Q2 Please describe your company or organizations overall goals and mission.

Northwell Health is the largest integrated not–for profit health system in New York state comprised of 23 hospitals, 6,500+ hospital and long–term beds, nearly 15,000 affiliated physicians, 650 outpatient facilities, the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and the Hofstra Northwell School of Graduate Nursing and Physician Assistant Studies. The mission of Northwell Health is to provide the highest quality of patient care, promote health and wellness, advance excellence in medical education and training, accelerate discovery through biomedical research, and care for the entire community regardless of the ability to pay. Northwell Health believes total health can be achieved by empowering communities to create sustainable socioeconomic models to address their unique Social Determinants of Health (SDH). Northwell Health utilizes evidence–based models to empower communities to implement self–sufficient solutions that remove barriers and promote better health outcomes for all.

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Q4 Innovation Executive Summary. Please describe the innovation, and how it addresses the social determinants of health. Please identify how the innovation addresses the 6 innovation criteria (i.e. ROI, scalability, feasibility, evidence–based support for innovation, relevance to the Medicaid population and speed to market).

Food insecurity and lack of access to fresh produce worsens nutrition related diseases such as cardiovascular disease, diabetes, hypertension, obesity and malnutrition and its risk factors resulting in increased avoidable medical utilization and costs. LIJ–Valley Stream service area, Elmont, Valley stream, Franklin Square, Springfield Gardens, Rosedale, Jamaica, Saint Albans and Cambria Heights) consisting of consistently emerged in the highest quintiles of all PQI Composite, Cardiovascular and Diabetes Prevention Quality Indicators indicating high rates of disease and poorer health. The service area has populations with low income levels below the NYS average, poverty rates above the NYS average, and 47–51% currently experience a significant rent burden. The Food as Health Program will be part of Northwell Health´s Community Health strategy of addressing food insecurity. Approximately 8,231 unique Medicaid patients per year are discharged from LIJVS with a high prevalence of acute and chronic diseases coupled with nutrition related secondary diagnosis. National surveys have shown that about three–quarters of households receiving SNAP benefits had at least one member receiving health coverage through Medicaid or the Children´s Health Insurance Program (CHIP), and even more SNAP households may be eligible for one of those programs. This represents an opportunity to engage a significant vulnerable population of Medicaid and potential SNAP beneficiaries in the Food as Health Program. By having the Food As Health pilot at LIJ – Valley Stream patients can receive food, medical care, nutritional counseling and navigation to food entitlements and community resources to reinforce their self–management of their nutrition related conditions and overall wellness.

A partnership of community–based food access organizations and Northwell Health will launch a Food As Health Program in July 2018 that services patients with nutrition related diseases, who identified as food insecure. Services tailored to individual needs include: emergency food supplies distributed at the Food as Health LIJVS site, delivered to homes via a mobile food pantry, meals on wheels or home delivery of medically tailored meals; nutrition education; food entitlement program enrollment; and navigation to community food resources. The Food as Health Program utilizes healthy food, nutrition education and navigation to community food resources as an adjunct therapy to the management of nutrition related diseases, removes the stigma of referrals to community food access programs and improves engagement in care. Creating a healthcare community–based organization partnership enables patients to access services appropriate for their medical condition when and where it is needed.

Inpatient and outpatient LIJVS clinical partners will identify and refer patients who screen positive for food insecurity using the Hunger Vital Sign™ screening tool to 1 of 3 strategies:

1. hospital brick and mortar Food as Health site staffed and serviced by Island Harvest Food Bank and stocked with Northwell produce and employee donated non–perishable foods;
2. non–ambulatory patients with food preparation abilities will receive food delivery and nutrition services from LI Cares Food Bank or meals on wheels programs; and
3. non–ambulatory patients unable to prepare meals with dietary restrictions will receive medically–tailored home delivered meals/nutrition services from God´s Love We Deliver.

Participants will receive outreach and follow–up from the Food as Health staff. Future plans include having the Food as Health Program become a USDA Farmstand that will be eligible to redeem Supplemental Nutrition Assistance Program (SNAP) benefits such as electronic benefit transfers, Farmers Market Nutrition Program checks distributed to eligible seniors and WIC participants.

Research on similar components of the Food as Health Program demonstrate the following outcomes 2,3,4:

• Improved HgbA1c
• Increase in Primary Care Visits
• Decline in ED Utilization & Readmission
• Decreased food insecurity
• Increased food entitlement enrollment
• Increase connection to community resources

Currently, the CBO partners are independently working to provide these community food access services and by creating a partnership among Northwell and the organizations to collectively provide services whose outcomes can be quantified will enable the program to be sustainable through extramural funding including Medicaid Managed Care Value–based contracts based on the reduced medical utilization costs related to avoidable readmissions and worsening of chronic disease.

Since our program will incorporate all three components into a comprehensive initiative that addresses each patients´ unique needs and methods of nutrition service delivery, we expect to demonstrate enhanced outcomes as well as a reduction of avoidable medical utilization and costs. In addition, as we add the USDA Farmstand to the Food as Health Program we expect to have revenue from the redemption of the SNAP benefits. After the pilot is launched the Food as Health Program can be scaled to other Northwell Health facilities.

1. Gundersen C. The determinants of Food Insecurity Among Food Bank Clients in the US. Journal of Consumer Affairs. Fall. 501–518. 2017.
2. Berkowittz SA. Etal. Meal delivery Programs Reduce the Cost of Health Care in Dual Eligible and Medicaid Beneficiaries. Health Affairs. (4) 535–542. 2018.
3. Samuel LJ. Etal. Does Supplemental Nutrition Assistance Program Affect Hospital Utilization Among Older Adults? The Case of Mayland. Population Health Management. (21) 88–95. 2018
4. Health Research & Educational Trust. (2017, June). Social determinants of health series: Food insecurity and the role of hospitals. Chicago, IL: Health Research & Educational Trust. Accessed here.

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