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Resource: Empowering Eaters Summit: Panel – Food as Medicine

Panel Discussion on Food as Medicine. Presented at the Empowering Eaters: Access, Affordability, Healthy Choices, and Food is Medicine Summit in Support of a National Strategy on Hunger, Nutrition, and Health “The Health and Wellbeing of Future Generations in Policy.” Co-hosted by Duke University and Food Tank on March 3, 2024.

Panelists:

  • Chris M. Collins, Associate Director of Health Care, The Duke Endowment
  • Merry Davis, Healthy Food Director, Blue Cross and Blue Shield North Carolina Foundation
  • Debra Clark Jones, Associate Vice President of Community Health, Duke University
  • Elizabeth Cuervo Tilson, State Health Director, Chief Medical Officer, North Carolina Department of Health and Human Services
  • Moderated by Danielle Nierenberg, Food Tank

Transcript

Danielle Nierenberg, FoodTank

For our next conversation, we’re going to look at the idea of food is medicine to treat, manage, and prevent chronic illness. So joining us, we have Chris Collins, the Associate Director of Healthcare at Duke Endowment; Merry Davis, the Healthy Food Director for Blue Cross Blue Shield of North Carolina Foundation; Debra Clark Jones, the Associate Vice President of Community Health with Duke University, and Dr. Elizabeth Cuervo Tilson, the State Health Director and Chief Medical Officer for the North Carolina Department of Health and Human Services.

Debra, if I can start with you. I’m wondering if you can talk about how food is medicine initiatives can help us promote health equity.

Debra Clark Jones, Duke University

Absolutely. Can you all hear? Let’s just first start with the definition of health equity, because we throw the term around quite a bit, but not everyone fully understands what it means. And when we talk about health equity, we’re talking about everyone having a fair and just opportunity to achieve their highest level of health. We also know that there are many barriers to that. Socioeconomic barriers, food happening to be one of those. So it’s really important as we aim to address and advance health equity to make sure that we are being attentive to those social needs or unmet social needs in our community in order to achieve that.

Danielle Nierenberg, FoodTank

Thank you so much. I want to turn to Chris now and talk about some of the food is medicine work that you’re involved in that engages people with lived experience, and we’ve talked a ton about lived experience, but why is it so important that those voices are heard?

Chris Collins, The Duke Endowment

I’m with the healthcare sector at the Duke Endowment and we primarily fund the not-for-profit hospitals, and many of them have begun to do the new requirements, do screening for social determinants of health for their patients. So in that space they’re identifying people who are food insecure and we have a workforce shortage. So the nurses already have a lot on their plate. Social workers, we need them in the mental health arena. So there is a real effort underway and we have funded several health systems that are integrating what they call community health workers onto that clinical team. And that community health worker, when they’re picked correctly, is really a leader from the community. It is someone from that community who knows the barriers, whether that’s a food desert or the difficulty of filling out a SNAP benefit for someone who may be English is their second language. So they work very closely and help that individual navigate.

And often these things are interconnected. So we uncover that somebody is food insecure, but if they’re also homeless, they’re not going to be able to prepare the food, they’re not going to be able to store the food. So they can address the host of a really holistic approach to health. And there is no shortage unfortunately in this country of people with lived experiences and difficult experiences, and we’re finding them to be really effective in this work. And we’re actually worked with Dr. Tilson and some of the folks on her team and we’re tracking some of the outcomes that are also being tracked by the 1115 waiver. So we can see reductions in emergency room utilization or re-admissions, which in turn is beneficial for the health system in that they don’t have readmission penalties.

So that also helps a bit with the sustainability in a health system, if they’re helping to achieve those goals in value-based payments where they’re able to help meet clinical indicators if they’re bringing, improving the hypertension or the diabetes or any of those things. That’s an incentive to continue to maintain the staff, even though we may have seeded it with grant funding.

Danielle Nierenberg, FoodTank

Absolutely. A lot of what we’ve been talking about today feels about building relationships. So Merry, how do you go about developing those relationships with local communities that you work with? What has been most effective?

Merry Davis, Blue Cross and Blue Shield North Carolina Foundation

This week I was lucky enough to be at a convening of 10 of our community-based organizations that are delivering various kinds of food is medicine interventions, from the mountains to the shore of North Carolina, and they’re all doing it in their own way. And what I was really reminded is that food is love, food is community, food is connection, and food is culture. What these community-based organizations are delivering is so much more than food is medicine. It is so much more, kind of to your point, Chris. They’re addressing social isolation, they are supporting our local farmers, our local food producers, which also supports soil health and climate health. They’re building stronger communities, etc. So we are so happy to be working with them to help them build their capacity to deliver food is medicine in North Carolina.

Danielle Nierenberg, FoodTank

It’s so lovely what you just said about food is medicine is all of these other things, it’s love, it’s labor, it’s community building, but it’s very difficult work to do. And those relationships take a long time. And I’m wondering if maybe you all can answer this. It takes a long time to build those relationships, to build the trust. To have outsiders come in and start telling folks what to do, that’s a very difficult endeavor, and I’m wondering if maybe we can all talk about that.

Merry Davis, Blue Cross and Blue Shield North Carolina Foundation

The wonderful thing about the community-based organizations being involved in food is medicine is that they have the relationships, they’ve been there, they’re not popping in because this is the new hottest topic. They are there. The difficult relationship is how they can partner with healthcare in an equitable way to deliver this.

Debra Clark Jones, Duke University

Sure. Just two things based on what Merry was just saying about social isolation. I was just looking at some data recently about Meals on Wheels, and over 90% of those seniors felt safer knowing that a volunteer was coming by the house to deliver food. And I think that that’s something that we have to be mindful of. At Duke, I just want to highlight a program, it’s actually an analytics program that we started a couple of years ago. It’s called the Collaborative for Advancing Clinical Health Equity, CACHE for short. And we’re looking at inequities in our clinical outcomes. But one of the most important aspects of the program is that we work closely with community-based organizations in better understanding those inequities. But even more important, they are helping to co-design the interventions. Once again, getting back to those lived experiences, making sure that we have the right voices around the table. And those programs by far would not be as successful as they’ve been without those voices at the table.

Danielle Nierenberg, FoodTank

Those right voices around the table, I wonder if any of you have encountered opposition, like, “Hey, we don’t want to work with you. We’ve been doing this on our own.”

Debra Clark Jones, Duke University

Most folks that are in the healthcare profession are excellent at what they do. Preeminence is the term that we certainly use at Duke Health when it comes to the type of healthcare that we deliver, but we don’t often or always recognize the assets in our community. So I’m really happy to be a part of an academic medical center because this is something that our researchers are very keen on, community engaged research, many of those researchers are also providers. I will also say that I was just talking to a provider at one of our hospitals the other day and he is working around some housing initiatives. He just took it upon himself, just with a passion to help patients. And he stated to me, “I am a better provider based on this engagement in community.” So that’s something that we really want to socialize more just to understand the benefits to the health system through that engagement.

Danielle Nierenberg, FoodTank

That’s really great to hear. Elizabeth, I am so excited to turn to you because we all know that the private sector is invaluable to all of this work, and I’m wondering if you can talk about how the public sector’s approach to food is medicine is evolving at the state level and what it’s most exciting to you right now? What are you most optimistic about?

Elizabeth Curevo Tilson, NC Department of Health and Human Services

I’ll answer that, but I also want to get back to some of the questions about the partnering. I think one of the risks, I think a huge benefit is linking healthcare and social services, because where the money is when we think about food is medicine, how are we going to pay for it, and leveraging healthcare dollars, huge opportunity. The risk is healthcare comes in and says, “Oh, we know how to do it. We can figure out housing, we can figure out food,” and that healthcare system feels like they then will be the delivery system for social services, where we have the expertise, the trust, the intentional routing in community. So that’s one of the risks we have to think about, is not having the healthcare system come and take over, but how do we connect and lift up and really leverage the expertise that is there in the community pieces. And I think in general, we’re getting there, but sometimes there’s those sources of tension there.

But getting to the role of state government, and I think there’s incredible opportunities of collaboration between federal, state, and local governments. And when I think about in North Carolina, what we’re doing is one, thinking about do we maximize enrollment in our federal benefits? So we’ve talked a lot about WIC, a lot about SNAP. How do we think about maximizing enrollment? We’ve been doing some work internally with our own data systems. You’re enrolled in Medicaid, you’re enrolled in SNAP, you’re not enrolled in WIC, but you’re likely eligible. So how do we think about our own data so that we can then give it to our local department of social services and health department so that they can do that outreach and get people maximally enrolled?

The other federal program that we haven’t talked about is Medicaid and thinking about Medicaid expansion, which I am so thrilled to say happened in North Carolina and day one we enrolled 274,000 people. We’ve been enrolling more than 1,000 a day. We’re up to almost 384,000 people that we’ve enrolled since December 1st.

And we don’t think about Medicaid certainly as a food program, but when we can cover people’s medical costs, then their dollars can go to food and housing and we can help people get access to care so they get more healthy so that they can get a job and be stably employed. So Medicaid expansion I think is incredibly important, and I really hope that North Carolina by expanding will be that opening door for the rest of the southeast, because when we think about equity and disparities and what populations are disproportionately impacted by food and security, it is our populations in the southeast. That’s just an incredibly important lever.

Second, I think state government can help to build some of that infrastructure and ecosystem that we’ve talked about so that it really helps our health systems and our other payers be able to innovate. Chris talked a little bit about screening. So one of the things we did was had a standardized set of screening questions. We have a statewide referral platform, so when a provider screens for and finds food insecurity, we can refer to the food pantries and have a closed loop function. So thinking about those ecosystems that can be used across all of our populations. And then third, an incredibly important place that states can lean in, and not that all food insecure people are covered by Medicaid, because there’s a lot of food insecurity everywhere, but Medicaid is an incredibly important lever. So if we can lean in and leverage our Medicaid dollars to not just buy healthcare, but by health, that’s an amazing thing.

And we’ve done a lot of that in North Carolina. Just with our Medicaid managed care plans, there’s lots of financial levers and incentives that we can do to make it easier for health plans to pay for food and housing, and as you’ve heard a couple of times, we have our 1115, which that’s a wonky term, but that means that we got permission from the federal government to be flexible in how we can use Medicaid dollars. So what we’re doing now in three areas of the state, we are paying for 29 services. Food, housing, transportation, interpersonal violence. Are starting to show amazing results. Our next interim evaluation will be coming the end of this month looking at can we actually effectively deliver services? Does it decrease social risk? Does it decrease ED utilization, hospitalization? Does it improve health and does it save money? So we’re really excited to see that. And then what we’re excited too is that we also proposed our next 1115, so submitted that to the federal government in October, and our goal is to hopefully be able to do that statewide, which will be great.

And the other piece, just getting back to some of the climate change from the earlier panels, because North Carolina, we’re hit by hurricanes over and over, and it’s the exact same population. So one of our proposed eligibility categories is that if you’ve been the victim of a natural disaster, for 12 months after that, you’d be eligible for the pilots as well because we know families need to rebuild. So we’re really excited about that. And that, again, is that collaboration between federal, state government and then we are completely reliant on our local partnerships to actually deliver that program.

Our pilot regions are mostly rural, actually rural area. So North Carolina has the second largest rural population in the country. So our pilots are in the western part of the state, and then in the southeastern part of the state, and then the eastern, northeastern part of the state for now.

Danielle Nierenberg, FoodTank

Thank you so much, Elizabeth.

Debra Clark Jones, Duke University

If I could just mention this also, the 1115 waiver program has really also incentivized members of our team, some of whom are in the audience right now. Even though we’re not a pilot, they have been working with community-based organizations for years now, helping to prepare the infrastructure for reimbursement, knowing that none of us can do this work alone. So even though the funding didn’t flow to it, still great work, great benefits, just knowing that that is happening right now and really proud of our folks too.

Danielle Nierenberg, FoodTank

Thank you. This is a question for you all, but I want to start with Merry. I’m wondering if you can talk about some of the broader benefits beyond individual health of food is medicine programs on local food systems. Because you said before that this goes beyond the individual, but specifics, what are you seeing?

Merry Davis, Blue Cross and Blue Shield North Carolina Foundation

Sure, and thank you for that question. So I’ll just speak to the 10 community-based organizations that we fund in North Carolina, and among those organizations are two food hubs who purchase their food locally, support farmers locally, and then aggregate and distribute that food. So already food is medicine is supporting local farmers. And then we have a farm, we have an actual farm that’s also participating with their local health system there and growing the food for the patients of the health system than providing that food. So I mean there’s direct benefit in terms of more dollars flowing to our local farmers and local producers, and those people that serve those markets and serve those farmers.

Danielle Nierenberg, FoodTank

And that will make folks want to be farmers.

Merry Davis, Blue Cross and Blue Shield North Carolina Foundation

Well, it might make folks want to be farmers, but it’s bringing more money into the system and that’s a good thing. And those are rural, lots of eastern North Carolina places that I’m talking about. So we need those dollars in those communities, and that’s why we really talk about food is medicine is this is good for community health and this is good for community wealth. And it’s that multi solution that Rachel was talking about earlier. That’s how we see it.

Danielle Nierenberg, FoodTank

Chris, can you talk about some of these broader benefits?

Chris Collins, The Duke Endowment

So we also have an initiative that’s really trying to go upstream, called Healthy People, Healthy Carolinas. And it’s really trying to prevent chronic disease and obesity. So what those drivers, access to healthy food is a really important component of it. And the way it’s organized is a collective impact model, which is we’re trying to bring schools and employers and the farmers and the churches and everyone to the table, city, county government, and we let the community decide where they want to start. It’s not anyone coming in saying, you need to start with this particular program, but it might be starting a farmer’s market. It might be a garden at the school where children learn to grow and see how vegetables actually are grown and eat them right, to build the love right there. So it’s really that collective impact because I don’t think any of us are going to solve this on our own.

Government doesn’t have enough money, philanthropy doesn’t have enough money. It’s going to take us all really working hard together, and everyone has a role to play in making their space healthy. We want to make the healthy choice the easy choice, and that’s employers, that’s everybody all together. And I will say when you start to do this work in community, communities become empowered, programs become less siloed, and many of our Healthy People, Healthy Carolinas have gone on and gotten USDA grants that then help the local farmers. I do want to add one thing to the question you had with communities, and if communities ever push back. If you have them at the table right from the start and they help decide what they need and what they want, that’s really important.

And I would add one other thing that we’re really sensitive to is everyone else at that table is paid and the community member is not necessarily paid. So being respectful and valuing their time, either you let the community health worker, 20% of their job is sitting at the table representing the barriers they see when they try to help patients get, what are those community barriers. But I think that’s another thing is not to take… There’s pushback when you take the community for granted and there’s pushback when you ask them what they need, you don’t deliver or you ask them again what they need and again what they need and you’ve not done anything about it. So I just wanted to go back to that question about where sometimes there’s a little bit pushback, but if you design it right from the start and you empower people right from the start, then usually there’s not.

Danielle Nierenberg, FoodTank

Again, so common sense. Elizabeth, what are those broader benefits?

Elizabeth Curevo Tilson, NC Department of Health and Human Services

I think part of the design of our pilots was specifically creating a network of existing, what we call human service organizations on the ground. So not necessarily contracting with big national partners, but who is already doing the work on the ground. We actually were able to have capacity building dollars to firm those organizations up and then start having the flow of dollars to those organizations. So it is the opposite of vicious circle. I don’t know what that is. A beneficial circle?

A virtuous cycle. Because our social service sector has been woefully underfunded forever. So we start getting money flowing to those organizations. Then they can then increase their capacity, their technical skills, and then they can hire people. And then we start flowing the money in. So not only are we helping the individual who’s receiving that food box, but we’re also helping that individual who now can be employed because that human service organization now has a stable funding, and that you’re creating that community wealth which also is an investment in health as well. So it’s just a win-win-win when you can leverage dollars to pay for food. It’s a win-win.

Danielle Nierenberg, FoodTank

It’s so many wins.

Elizabeth Curevo Tilson, NC Department of Health and Human Services

We’re very committed to making sure that we’re funding our local community-based organizations through this.

Danielle Nierenberg, FoodTank

Debra, do you want to comment on broader impacts?

Debra Clark Jones, Duke University

Well, I’d like to actually comment on something slightly different. I just have to say, and I’m going to borrow Mayor Williams’ term, but our students are dope. They have truly been on the forefront of a lot of great food security, nutrition security initiatives, working with our providers, receiving actually referrals for patients that are food insecure. There’s an organization called Root Causes, they have a fresh produce program. Doing phenomenal work, delivering food on a biweekly basis. We also have the Food Recovery Network. They are collecting the surplus food with our dining services. It’s also a climate initiative, but they are delivering that food to community-based organizations. But just to see that integration of what our students are doing, a lot of volunteer work that they’re doing to advance this particular topic and I just did not want the chance to, or miss the chance to actually celebrate what they’re doing.

Danielle Nierenberg, FoodTank

Thank you so much. So important. Just very quickly, and we only have a minute 45 left. I know. So whoever wants to answer this, I think… How do we keep sustaining this food is medicine work in a way that involves all of the players that we’ve been talking about? How do we do that? Is it funding? Is it having folks like you on stages like this? Is it more academic programs? What is actually going to move this forward? You look like you want to answer.

Merry Davis, Blue Cross and Blue Shield North Carolina Foundation

I mean, policy change. So let’s be honest there. So we need policy change. We have great stuff going on in North Carolina. We also need great stuff going on at the federal level. Right now these initiatives are being sustained through champions at health systems and champions in the community, and that’s not going to cut it for long… And grant funding. That’s only going to go so far. So we need systematic change to support these efforts. And the other thing I’ll say is that the CBO, the community based solution is a beautiful solution, as we’ve all acknowledged here, and we need to make sure that they are not boxed out as the generally for-profit companies can see the dollar signs are flashing and as they start to get into this space and are able to offer solutions at scale. So we need to all be mindful of that as the field evolves.