Community Servings (CS) has humble beginnings as a Jewish outreach organization responding to AIDS in the late ‘80s. To this day, but especially early during the AIDS epidemic, malnutrition was a major cause of death. The simple act of feeding people properly who were diagnosed HIV+ could keep them alive. Food was a viable form of medicine. Community Servings has evolved to develop more diverse eligibility criteria, drawing clients from over 200 referral partners. It now provides medically tailored meal services to homebound families and individuals with acute life-threatening illness. Roughly 1000 individuals receive packages of five meals per week. It’s not just any healthy food. Community Servings has learned the importance of preparing beautiful, colorful, fragrant food that appeals to people who lack an appetite due to chronic illness.
Crafting such a complex menu falls on the shoulders of Chef Kevin Conner. Conner has almost two decades of experience in kitchens, including as a culinary arts professor and executive chef at the Federal Reserve. When Connor was 16 he lost his mother to diabetes so he knows how food can help and harm a body.
“With this job, the people don’t just come into the restaurant, eat the meal, then forget about it.” Connor says. “The five meals we’re delivering weekly touch their hearts and souls. We try to give the clients comfortable, familiar meals. We’re always adapting the menu. For instance, we might make a meatloaf, but we have to be careful with ketchup (sugar) for diabetics so we come up with recipes for a tasty, ketchup-free meatloaf.”
Connor works closely with Community Serving’s nutrition department to understand the best ingredients for the clients’ diverse needs. Connor is currently developing a cookbook with over 100 meals tailored to specific diets, a veritable pharmaceutical catalog of food is medicine. Everything is scratch-made to control preservatives, especially sodium and sugar. The kitchen operation is big, fast, mechanized and efficient. Because of clients’ weakened immune systems, extra care must be taken to remain 100% free of bacteria, especially since a large chunk of kitchen prep work is done by volunteer groups (65,000 volunteer hours/year).
“We (Community Servings) consider ourselves to be essential role players in the creative treatment of low-income individuals,” says Jean Terranova, director of Food and Health Policy at Community Servings. “We can make the case to health care providers that our meals range around $25 per day per patient while a hospital bed costs around $2500 per day. If healthy, appropriate food can keep those high-frequency patients from returning to the hospital, which Medicaid might not pay for, then that’s a big savings for hospitals and a big opportunity for us and others in our field.”
There is nothing new to the idea that poor nutrition leads to chronic long-term illnesses like diabetes and heart disease. Healthy eating has long proven to be one of the most effective preventative measures, although access to healthy food remains a major challenge in many low-income communities. But what about food’s role in the treatment of sick patients? What about looking at food is medicine? Community Servings has been trying to fill that need, on a small scale, for decades. Now there’s hope that new policies could shift the movement into higher gear. The Affordable Care Act (ACA) has opened the door to a vigorous conversation about new strategies for bringing together food and nutrition security providers to the table with hospitals and insurers.
Since 1969, federal standards have mandated that non-profit hospitals provide community benefits in order to maintain tax-exempt status. The majority of “community benefits” covered the cost of care for uninsured or underinsured patients. The ACA aims to have two profound effects on that model. For one, the ACA will vastly reduce the number of uninsured Americans, many of whom were without coverage due to pre-existing conditions. So there will be less need to allocate community benefit funds to cover costs of uninsured patient care. Secondly, the ACA better articulates the community benefit obligations for non-profit accountable care organizations (ACO), groups of doctors, hospitals and other health care organizations that voluntarily coalesce to give coordinated care to Medicare patients.
“The goal of coordinated care,” says Terranova, “is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.”
Part of the pathway toward improving community benefits involves collecting rigorous knowledge of the community. The ACA requires that hospitals conduct community health needs assessments (CHNA) every three years. CHNA’s will improve the hospital’s understanding of community health needs and require a plan of action to address those needs. Plus, the language of the ACA, in regards to community benefit requirements, states, in part, “…the need to prevent illness, to ensure adequate nutrition, or to address social, behavioral, and environmental factors that influence health in the community.” To ensure adequate nutrition is a key phrase and an opportunity for a food is medicine approach to caring for patients with chronic illness.
Sarah Downer is a Clinical Instructor of Law at the Center for Health Law Policy & Innovation at Harvard University. She sees the biggest potential impact coming in the way payments are distributed to providers.
“The ACA has created health care models that will allow for hospitals using Medicare and Medicaid to treat a patient or group of patients in a creative way,” Downer says. “Most people in the medical community accept that jobs, stable housing, and access to food have a huge impact on health. Many health care providers today are going for the Triple Aim: improve patient experience, better the health of the overall population, and do it at a lower cost. There’s finally an opportunity to do that now since the ACA has brought billing from a fee-for-service system to a lump sum model, which can save them (hospitals and patients) dollars in the end. That is at the heart of these innovation and reform models.”
The insurers want to know their costs will be lower. The providers want positive health outcomes. Providers know the importance of healthy food. The lump sum payment plan offers more freedom to construct treatment plans that lower costs and impact the diverse needs of patients. Proof to the efficacy of medically tailored meals as medicine is trickling in. A study recently conducted via UPenn and MANNA, a community food security organization in Philadelphia similar to Community Servings, revealed outcomes such as reduced hospital visits, improved patient satisfaction and costs savings over time among a group of patients provided with healthy meals as part of their treatment versus a group of patients who did not get meals.
Another vital piece of the ACA package incentivizes hospitals to send high-frequency patients home and ensure that they don’t return often. Within the ACA, insurers have put their foot down on what they see as ineffectual treatments that don’t keep patients from returning. Under certain circumstances, if a high-frequency Medicaid patient returns to the hospital within a month of release, the insurance companies can deny payment.
“It’s the insurers way of saying to the hospitals, ‘Do a better job,’” says Terranova.
The Community Servings kitchen is also a job-training environment. A twelve-week, full-time culinary course works with 10-12 students, many of them unemployed, recently incarcerated, or referred there by addiction-treatment programs. CS prepares them to be line or prep cooks in university or institutional kitchens. The day-to-day work of the kitchen, packaging and delivery hum like a delicious smelling assembly line, but a lot of Community Serving’s work happens in the offices and on the front lines of policy politics, proving to the medical, insurance and legislative community that food needs to be recognized as a powerful, cost-effective medicine for malnourished patients.
“Because of the lump sum option now for payments,” says Terranova, “We’ve been able to work with OneCare and Senior Care Options on demonstration projects with 135 Medicaid-Medicare patients. The provider understands the benefit of proper nourishment for the patient and it’s worth paying Community Servings to provide that service. As far as shifting policy, we want to see food is medicine be universally accepted across the medical landscape, but our sweet spot is within Medicaid since it’s managed on a state level and for low-income patients.”
Brenda Webster is one such patient. The fifty-one-year-old has diabetes and asthma and lives on disability since she can no longer perform her previous work as a home day care provider. She rents a room in a shared home and walks with a cane twenty minutes to the nearest grocery store since she has no form of transportation. Ms. Webster has been receiving CS meal plans for a year now. The pharmacy delivers her medications and now CS delivers five meals each Friday. Her diet has drastically improved. It’s not curing her illness but CS believes that its likely reducing her hospital visits and providing a level of comfort that medicine and insulin cannot.
Terranova and CS know that change is slow. They are hoping their work and similar pilot projects of other organizations will gradually begin to make the case for more widespread employment of healthy food is medicine. The ACA is a barely chartered terrain. It’s a mix of new regulations and new freedoms, like the lump sum payment method and the allowance for insurers to deny payment to hospitals for high-recidivism patients. There’s a lot of free-market vistas within the landscape, too. The challenge for food is medicine, as with any new product on the market, is proving its worth and telling its story.
“The question is,” says Downer, “do the health care providers and hospitals know how to include healthy meals as treatment and do they have a resource to fit it into their model of care.”
“Hospitals and providers know that malnourishment among acutely ill low-income patients is an issue. The challenge for now is that we don’t fully understand how all these developing systems will fall into place. Insurers and hospitals are afraid to get too far into it. But take-up will increase. New models will mature.”