MRT Innovations in Social Determinants of Health Initiative

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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.

NYC Health + Hospitals is committed to excellence in health care. Our providers work together to provide comprehensive, personalized care to all New Yorkers. Our mission is:

To extend equally to all New Yorkers, regardless of their ability to pay, comprehensive health services of the highest quality in an atmosphere of humane care, dignity, and respect.

To promote and protect, as both innovator and advocate, the health, welfare, and safety of the people of the City of New York.

To join with other health workers and with communities in a partnership which will enable each of our institutions to promote and protect health in its fullest sense – the total physical, mental and social well–being of the people.

OneCity Health is the NYC Health + Hospitals – sponsored partnership of organizations and healthcare professionals collaborating to meet community needs by transforming healthcare delivery and to ensure that innovations sustained.

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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).

In New York City, there are an estimated 300–400,000 SNAP–eligible but unenrolled individuals. There is a strong evidence base that SNAP is highly effective at living families out of poverty and reducing food insecurity. Some studies have targeted the health– and health care–related impact of SNAP enrollment and found that SNAP enrollment is associated with an improvement in overall health status and with a reduction in patients´ avoidable inpatient and emergency department health care utilization. NYC Health + Hospitals, in collaboration with Public Health Solutions (PHS), Memorial Sloan Kettering, Lenox Hill Neighborhood House, and The Mayor's Office of Food Policy, leveraged its position as NYC´s largest safety net provider, to launch an initiative to expand our patient´s access to healthy foods through a co–location of food benefit counselors/coordinators at 5 hospital sites. These coordinators pre–screen and enroll eligible patients in SNAP and provide to all patients local, culturally and linguistically competent food navigation and food care planning services, which currently includes connecting patients to SNAP, WIC, emergency food, congregate meals, and medically–tailored home– delivery meal services. The initial prototype of this program has been extremely successful and is being scaled to 5 days per week at 4 hospital sites, with future plans of scaling to full implementation at additional hospital and community center sites.
Scaling of this initiative presents an opportunity to optimize it around new digital food and diet apps and national health system innovations, while leveraging validated food behavioral economics. Core findings of this research according to the USDA suggest that:

1. People have problems of self–control when choosing food (seeking immediate gratification or under influence of hunger);
2. People place more weight on "default options.";
3. People categorize income into mental accounts and respond to foods being allocated into specific categories;
4. Food decisions are often based more on emotion than rational thought (impulsiveness will lead to unhealthy food choice); and finally,
5. People undervalue fixed costs relative to variable costs (will prioritize items that can be pre–paid).

NYC Health + Hospitals plans to conduct an opt–in pilot of nudging patients towards using FreshEBT, an app developed to help empower SNAP enrollees to more effectively use their benefit through: budgeting, eliminating the burden or embarrassment of program participation with the self–service app, finding EBT–participating stores, and by offering healthy recipes and food discount coupons to guide food choice. FreshEBT has started to expand into other social services, currently offering financial tools and a job listing board, potentially allowing patients using the program to an additional pathway towards empowerment and self–management of their benefits. A future possibility for this initiative is leverage this app or an existing referral mechanism to emulate Geisinger´s Food Farmacy" initiative and identify enrolled SNAP–eligible patients with expensive medical conditions and enable them or refer them to a downstream partnering food pantry to pick up pre–paid healthy meals for themselves and their families either exclusively with SNAP benefits or in combination with a health plan´s and/or hospital´s contribution.

ROI: SNAP has an extensive evidence base of its effectiveness and efficiency and is associated with a reduction of expensive, avoidable ED and inpatient utilization. FreshEBT has evidenced suggesting that is stretches the SNAP benefit by 4% via budgeting and has had early success in improving the financial situation of its users with coupon savings, job listings, and financial savings partners. We plan to measure the impact of this app and understand whether its targeted features improved food consumption and behaviors.

Scalability: Scaling usage of this app can leverage scaling of access to food coordinators at NYC Health + Hospitals. The app has no inherent cost. A partnership with FreshEBT app developers could result in QI improvements around SNAP benefits and food benefit coordination, as well as an additional opportunity to collaborate with downstream healthy food providers.

Feasibility: This is an expanded component of an existing program that is "expanding" in hours and to new sites and will leverage the momentum and quality of the NYC Health + Hospitals and community–based team to improve access to healthy foods among patients. Building in mechanisms to improve the quality and efficacy of the program will enhance its feasibility.

Evidence based support for innovation: SNAP and FreshEBT both have significant evidence–bases and suggest that NYC Health + Hospitals, by improving access to SNAP enrollment and through leveraging the benefits of FRESH, will contribute to improved food access for its patients. Further scaling downstream into evidence–based programs, such as Geisinger´s "Food Farmacy", and pushing patients towards a default healthy option with defined benefits could extend the impact, based on existing behavioral studies.

Relevance to the Medicaid population and speed to market: This initiative will directly impact the Medicaid population; of those patients screened to date due to their food insecurity issues, 1/3 were SNAP–eligible and had applications submitted, while the remaining 2/3 are largely Medicaid and other safety net populations and received food coordination assistance. According to an analysis by NYC Health + Hospitals´ Office of Population Health, food insecure patients are of increased risk for super–utilizer status, suggesting a significant opportunity to reduce health care costs among this group based on the strength of the existing evidence base. In the 2016 Community Health Needs Assessment, NYC Health + Hospitals found that patients reporting gaps in food access were twice as likely to have an ED visit in the prior year as those not reporting food access issues.

As the innovation is a component of scaling of the existing food care planning and care coordination program, and leverages an existing app, it can get to the market nearly immediately (post–basic training of the coordinator staff). Collaborations with FreshEBT parent company, Propel, managed care plans and food pantries are subject to negotiation but could be initiated alongside the scaling of the program.

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