Association of food insecurity with changes in diet quality, weight, and glycemia over two years in adults with prediabetes and type 2 diabetes on medicaid.

Little is known about longitudinal associations between food insecurity (FI) and diet, weight, and glycemia in people with prediabetes and type 2 diabetes (T2D). In a secondary analysis of Medicaid-enrolled health center patients with prediabetes or T2D in Boston, Massachusetts (N = 188), we examined associations between food security (FS) and measures of diet quality, weight, and hyperglycemia. FS (10-item USDA FS module) was ascertained at baseline, 1-year, and 2-year follow-up and categorized as persistently secure, intermittently insecure, or persistently insecure. Associations between FS category and changes in Healthy Eating Index-2020 (HEI-20), body mass index (BMI), and hemoglobin A1c (A1c) from baseline to year 2 were assessed using multivariate generalized linear models. Participants had median (p25, p75) age of 52 (42, 57); 71.8% were female and 62.8% Hispanic. Over follow-up, 32.4% were persistently food secure, 33.0% intermittently insecure, and 34.5% persistently insecure. Baseline mean (SD) HEI-20, BMI, and A1c were 55.8 (14.5), 35.9 (8.7) kg/m2, 7.1% (1.6) and did not differ by FS category. FS category was not associated with changes in HEI-20, BMI, and A1c at 2 years (all p > 0.05). Results suggest that Medicaid-enrolled adults with prediabetes or T2D, regardless of FS status, would benefit from dietary and weight management interventions.

Association of Food Insecurity with Changes in Diet Quality, Weight, and Glycemia Over Two Years in Adults with Prediabetes and Type 2 Diabetes on Medicaid.

Little is known about longitudinal associations between food insecurity (FI) and diet, weight, and glycemia in people with prediabetes and type 2 diabetes (T2D). In a secondary analysis of Medicaid-enrolled health center patients with prediabetes or T2D in Boston, Massachusetts (N = 188), we examined associations between food security (FS) and measures of diet quality, weight, and hyperglycemia. FS (10-item USDA FS module) was ascertained at baseline, 1-year, and 2-year follow-up and categorized as persistently secure, intermittently insecure, or persistently insecure. Associations between FS category and changes in Healthy Eating Index-2020 (HEI-20), body mass index (BMI), and hemoglobin A1c (A1c) from baseline to year 2 were assessed using multivariate generalized linear models. Participants had median (p25, p75) age of 52 (42, 57); 71.8% were female and 62.8% Hispanic. Over follow-up, 32.4% were persistently food secure, 33.0% intermittently insecure, and 34.5% persistently insecure. Baseline mean (SD) HEI-20, BMI, and A1c were 55.8 (14.5), 35.9 (8.7) kg/m2, 7.1% (1.6) and did not differ by FS category. FS category was not associated with changes in HEI-20, BMI, and A1c at 2 years (all p > 0.05). Results suggest that Medicaid-enrolled adults with prediabetes or T2D, regardless of FS status, would benefit from dietary and weight management interventions.

Assessment of the Massachusetts Flexible Services Program to Address Food and Housing Insecurity in a Medicaid Accountable Care Organization.

Importance: Health systems are increasingly addressing health-related social needs. The Massachusetts Flexible Services program (Flex) is a 3-year pilot program to address food insecurity and housing insecurity by connecting Medicaid accountable care organization (ACO) enrollees to community resources. Objective: To understand barriers and facilitators of Flex implementation in 1 Medicaid ACO during the first 17 months of the program. Design, Setting, and Participants: This mixed-methods qualitative evaluation study from March 2020 to July 2021 used the Reach, Efficacy, Adoption, Implementation, Maintenance/Practical, Robust Implementation, and Sustainability Model (RE-AIM/PRISM) framework. Two Mass General Brigham (MGB) hospitals and affiliated community health centers were included in the analysis. Quantitative data included all MGB Medicaid ACO enrollees. Qualitative interviews were conducted with 15 members of ACO staff and 17 Flex enrollees. Main Outcomes and Measures: Reach was assessed by the proportion of ACO enrollees who completed annual social needs screening (eg, food insecurity and housing insecurity) and the proportion and demographics of Flex enrollees. Qualitative interviews examined other RE-AIM/PRISM constructs (eg, implementation challenges, facilitators, and perceived effectiveness). Results: Of 67 098 Medicaid ACO enrollees from March 2020 to July 2021 (mean [SD] age, 28.8 [18.7] years), 38 442 (57.3%) completed at least 1 social needs screening; 10 730 (16.0%) screened positive for food insecurity, and 7401 (11.0%) screened positive for housing insecurity. There were 658 (1.6%) adults (mean [SD] age, 46.6 [11.8] years) and 173 (0.7%) children (<21 years; mean [SD] age, 10.1 [5.5]) enrolled in Flex; of these 831 people, 613 (73.8%) were female, 444 (53.4%) were Hispanic/Latinx, and 172 (20.7%) were Black. Most Flex enrollees (584 [88.8%] adults; 143 [82.7%] children) received the intended nutrition or housing services. Implementation challenges identified by staff interviewed included administrative burden, coordination with community organizations, data-sharing and information-sharing, and COVID-19 factors (eg, reduced clinical visits). Implementation facilitators included administrative funding for enrollment staff, bidirectional communication with community partners, adaptive strategies to identify eligible patients, and raising clinician awareness of Flex. In Flex enrollee interviews, those receiving nutrition services reported increased healthy eating and food security; they also reported higher program satisfaction than Flex enrollees receiving housing services. Enrollees who received nutrition services that allowed for selecting food based on preferences reported higher satisfaction than those not able to select food. Conclusions and Relevance: This mixed-methods qualitative evaluation study found that to improve implementation, Medicaid and health system programs that address social needs may benefit from providing funding for administrative costs, developing bidirectional data-sharing platforms, and tailoring support to patient preferences.

Food Insecurity and Diet Quality Among Adults on Medicaid With and Without a Mental Illness Diagnosis.

BACKGROUND: Adults with mental illnesses are more likely to have low income and diet-related chronic diseases. OBJECTIVE: This study examined associations of mental illness diagnosis status with food insecurity and diet quality and whether the relationship between food security status and diet quality differed by mental illness diagnosis status in adult Medicaid beneficiaries. DESIGN: This was a secondary cross-sectional analysis of baseline (2019-2020) data collected as part of the LiveWell study, a longitudinal study evaluating a Medicaid food and housing program. PARTICIPANTS/SETTING: Participants were 846 adult Medicaid beneficiaries from an eastern Massachusetts health system. MAIN OUTCOME MEASURES: Food security was measured with the 10-item US Adult Food Security survey module (0 = high food security, 1-2 = marginal food security, 3-10 = low/very low food security). Mental illness diagnoses included health record-documented anxiety, depression, or serious mental illness (eg, schizophrenia, bipolar disorder). Healthy Eating Index (HEI-2015) scores were calculated from 24-hour dietary recalls. STATISTICAL ANALYSES: Multivariable regression analyses adjusted for demographics, income, and survey date. RESULTS: Participants' mean (standard deviation) age was 43.1 (11.3) years, and 75% were female, 54% Hispanic, 33% non-Hispanic White, and 9% non-Hispanic Black. Fewer than half (43%) of participants reported high food security, with almost one third (32%) reporting low or very low food security. The 341 (40%) participants with one or more mental illness diagnosis had greater odds of low/very low food security (adjusted odds ratio [OR], 1.94; 95% confidence interval [CI], 1.38-2.70) and had similar mean HEI-2015 scores (53.1 vs 56.0; P = 0.12) compared with participants with no mental illness diagnosis. Mean adjusted HEI-2015 scores did not significantly differ by high vs low/very low food security for those without a mental illness diagnosis (57.9 vs 54.9; P = 0.052) or those with a mental illness diagnosis (53.0 vs 52.9; P = 0.99). CONCLUSION: In a cohort of adults with Medicaid, those with mental illness diagnoses had higher odds of experiencing food insecurity. Overall, diet quality among adults in this sample was low but did not differ by mental illness diagnosis or food security status. These results highlight the importance of augmenting efforts to improve both food security and diet quality among all Medicaid participants.

Social Determinants of Health and Hypertension Control in Adults with Medicaid.

BACKGROUND: Social determinants of health (SDOH) are associated with cardiovascular disease, but little is known about mechanisms underlying those relationships. We hypothesized that SDOH would be associated with uncontrolled hypertension (HTN) in adults with Medicaid. METHODS: This was a retrospective analysis of adults in a Medicaid accountable care organization who had HTN diagnoses, received regular care at community health centers, and enrolled in a cohort study between December 2019 and December 2020. Baseline surveys collected demographics and SDOH, including food insecurity, unstable housing, cost-related medication underuse, and financial stress. Blood pressure (BP) measurements over 12 months after survey completion were obtained from the electronic health record. Participants were categorized as: uncontrolled HTN (mean systolic BP ≥ 140 mm Hg and/or mean diastolic BP ≥ 90 mm Hg), controlled HTN, or unknown HTN control (no BP documented). We examined the association of individual and cumulative (count, 0-4) SDOH with uncontrolled HTN and unknown HTN control using multivariable logistic regression adjusting for demographics, smoking, diabetes, and HTN medication. RESULTS: Participants (n = 245) were mean (SD) age 51.3 (8.6) years, 66.1% female, 43.7% Hispanic, 34.3% White, and 18.0% Black. Overall, 58.0% had food insecurity, 38.0% had unstable housing, 29.4% had financial stress, and 20.0% reported cost-related medication underuse. BP was documented for 180 participants; 44 (24.4%) had uncontrolled HTN. In multivariable models, neither individual nor cumulative SDOH were associated with uncontrolled HTN or unknown HTN control. CONCLUSIONS: In a Medicaid-insured population receiving care at community health centers, adverse SDOH were prevalent but were not associated with HTN control.

Predictors of engagement and retention in care at a low-threshold substance use disorder bridge clinic.

INTRODUCTION: People with substance user disorder (SUD) have frequent intersections with the health care system; however, engagement and retention in SUD care remain low, particularly for marginalized populations. Low-threshold treatment models that aim to eliminate barriers to care are one proposed intervention to increase access and equity in SUD treatment. METHODS: This is a retrospective, cohort study of patients treated at a low-threshold bridge clinic from 2016 to 2021. The study's primary aim was to describe patient characteristics associated with engagement, defined as two or more completed visits, and treatment retention at 60 days, defined as a completed visit 45-to-75 days after first visit. A secondary outcome was transfer to ongoing treatment after bridge clinic. The study analyzed multivariable models assessing demographic and clinical predictors for each outcome using generalized estimating equations. RESULTS: The study found that 1857 patients completed 2730 care episodes. The mean age was 38.7 years old, 70 % were male, 30 % female, 79 % White, 7 % Black, 9 % Latinx, and 97 % spoke English. Opioid use disorder (OUD) was the most common type of SUD, seen among 84 % of episodes, followed by alcohol (30 %), and stimulant use disorder (28 %). Seventy percent of bridge clinic episodes of care resulted in engagement, 38 % were retained at 60 days, and 28 % had transfer to care documented. In adjusted analyses, engagement was lower for Black patients compared to White patients and higher for patients who received buprenorphine or naltrexone. Retention for Black patients was also lower compared to White patients and higher for patients who were unhoused and patients who received buprenorphine or naltrexone. Transfer of care was more likely among patients who received buprenorphine. CONCLUSIONS: At a low-threshold bridge clinic 70 % of patients successfully engaged in care and 38 % were retained at two months. While OUD and AUD were most prevalent, stimulant use was common in this population. Patients who received buprenorphine or naltrexone had higher engagement, and retention, and those receiving buprenorphine also had higher care transfer. Black patients had lower rates of engagement and retention. Treatment providers need to adopt low-threshold SUD care models to eliminate racial disparities and address the needs of people using stimulants.