Rising food prices have been straining consumers’ wallets in the United States for the past several years. Numerous causes have been cited, including supply chain bottlenecks, the war in Ukraine, excessive profit-taking and a reduction in the number of egg-laying chickens due to an outbreak of highly pathogenic avian influenza. Healthcare providers have struggled to find solutions for food-insecure patients having to make a choice between maintaining their health and buying groceries.

When healthcare takes a backseat

In the United States, food insecurity affects up to 50 percent of people living with HIV/AIDS.² For a particularly vulnerable health population challenged by housing instability, lack of access to reliable transportation and other social determinants of health, food insecurity has emerged as a major obstacle diverting patients from carefully mapped out treatment pathways.

For many people living with HIV, simultaneously affording food, household expenses like rent and school tuition, medications, healthcare fees and transportation costs represents a never-ending and dispiriting struggle. While clinics can tap readily available resources like non-emergency medical transportation services to help patients get to and from clinic appointments, food insecurity presents a thornier problem.

Healthcare professionals have increasingly recognized how food insecurity both heightens vulnerability to HIV infection and exacerbates poor clinical outcomes among people living with HIV. As food-insecure patients are forced to prioritize survival needs over their medical care, they are likely to skip medical appointments, or even trade medication for food. And because people living with HIV have higher nutritional needs to maintain body weight and muscle mass, food insecurity can trigger a devastating cycle of malnutrition and disease. The condition can worsen health outcomes by making them more vulnerable to opportunistic infections and severely hindering their adherence to antiretroviral therapy (ART), causing malnutrition that accelerates viral progression.³

For Katy Wendel, vice president of care delivery innovation at CAN Community Health (CAN), patients’ food insecurity brings to mind Maslow’s Hierarchy of Needs, a psychological theory of motivation portraying five levels of human needs in a pyramid, with physiological needs such as air, water, food and shelter at its base. Higher up on the pyramid are the needs for physical safety, love and belongingness, esteem, and self-actualization. Psychologist Abraham Maslow theorized that individuals are not able to focus on higher-level personal growth or self-actualization needs until their basic physiological and safety needs are met. Even though good nutrition is fundamental to good health, when people can’t afford to feed themselves, healthcare becomes secondary.

Seeing a growing number of food-insecure patients, members of the patient care staff at CAN’s Miami Gardens, Florida clinic approached Wendel and asked: Is there anything we can do? What if our patients could receive an immediate benefit that would help them overcome food insecurity? Implemented effectively, it could go a long way toward helping them adhere to life-saving treatment plans.

Foundation grant enables immediate assistance

The solution developed by Wendel and her care delivery team is a new program called Nourish to Flourish. Funded by a $25,000 grant from the Susan Terry Foundation, the Nourish to Flourish program provides $50 grocery gift cards from partner retailers to patients experiencing unmet basic needs, helping fill gaps where community food assistance resources or external funding are unavailable.

Wendel describes the program as a lifeline for patients facing nutrition-related barriers. Citing Maslow’s time-tested theory, she says if patients are able to meet their basic nutritional needs, they will be much more likely to adhere to their appointment schedules, stay engaged with their care and ultimately improve their overall health. CAN’s patient access specialists are eager to take on the program’s additional administrative responsibilities because it delivers a direct and immediate benefit to patients and doesn’t require them to join a waiting list or be referred by any social services agency.

Channeling her staff’s enthusiasm, Wendel said, “The patient access specialists are excited about this, and more than happy to take on [the extra work] to have this additional resource for patients. One of the things they like about it the most is that it's instant, so they can help patients right then and there, versus having to refer them over somewhere and wait two weeks or a month for something to take effect. This is something they can do right there on the spot.”

Ray Carson, the Foundation’s executive director, said, “One of the most inspiring aspects of CAN Community Health’s mission is their broader focus on whole-patient care and their commitment to go beyond clinical services to address social determinants of health. Because this initiative is so well aligned with that commitment, we’re happy to support them and grateful to play a role in their patients’ positive outcomes.”

How Nourish to Flourish works

With a robust administrative and electronic medical records (EMR) infrastructure in place, CAN will cover all administrative and staffing costs, including financial assessments, the required documentation and training of patient access specialist (PAS) team members. The entire grant will go toward the purchase of 500 grocery gift cards. To augment the program’s reach, CAN also intends to develop partnerships with food banks near their clinic locations in Florida, Texas, South Carolina, Virginia, Arizona and Nevada.

Carson adds that, while the Foundation typically funds programs serving the Tampa Bay region, enabling CAN to offer Nourish to Flourish at all of its clinics represented a unique opportunity. He said, “Given the way food costs vary so widely around the country, our grant review committee recognized the potential value of CAN’s ability to collect data from multiple markets and see how those demographics affect the relative impact of the program.”

Financial assessments will be used to measure patients’ eligibility for the program, and social wellness screenings will be used to identify food insecurities. When a patient is deemed to be food-insecure, the PAS will hand them a grocery gift card during their clinic visit. To ensure that patients spread out over a large geographical service area can easily redeem the cards, one retail grocery chain per state will be chosen.

Wendel outlined five expected outcomes for the Nourish to Flourish program:

1. Reduce food insecurity: PAS team members will track any changes in patient-reported food access, or lack thereof, over the 13-month program duration.
2. Improve appointment adherence: Patients’ visit attendance will be tracked and compared to that of pre-gift card distribution.
3. Enhance patient stability and engagement in care: Patients reprioritize healthcare once basic needs are met and exhibit an improved ability to remain engaged in their ongoing care.
4. Increase staff capacity to address social needs: Frontline staff will have the resources to respond quickly and consistently to patients’ food-access barriers.
5. Build sustainable partnerships: CAN plans to establish collaborations with community food resources that extend well beyond the initial grant period and achieve long-term food access options.

Over the 13-month program timeline, CAN will configure a regional distribution plan for the $50 grocery gift cards based on patient volume and need, and train PAS team members with regard to policy, procedure and documentation requirements. By the second or third month following rollout, the team plans to begin distributing the cards to eligible patients in more than 30 clinics across the provider’s six-state footprint, and reach out to food banks and community organizations to firm up long-term food access options. Program monitoring and quality improvement throughout the timeline will gather early indications of patient engagement, and this frontline feedback will be used to make adjustments in policies and workflows. Overall program effectiveness will be measured by looking at patient stability, with a focus on how well patients adhere to their appointment schedules.

Hoping the program will become a model for integrating social support into healthcare delivery, Katy Wendel shares her patient care staff’s enthusiasm, saying, “I’m very thankful the Susan Terry Foundation was able to help us put this in place. If it helps patients to reprioritize their health and stay engaged with their care, it’s been well worth it.”