Population Health Innovations and Payment to Address Social Needs Among Patients and Communities With Diabetes.

Policy Points Population health efforts to improve diabetes care and outcomes should identify social needs, support social needs referrals and coordination, and partner health care organizations with community social service agencies and resources. Current payment mechanisms for health care services do not adequately support critical up-front investments in infrastructure to address medical and social needs, nor provide sufficient incentives to make addressing social needs a priority. Alternative payment models and value-based payment should provide up-front funding for personnel and infrastructure to address social needs and should incentivize care that addresses social needs and outcomes sensitive to social risk. CONTEXT: Increasingly, health care organizations are implementing interventions to improve outcomes for patients with complex health and social needs, including diabetes, through cross-sector partnerships with nonmedical organizations. However, fee-for-service and many value-based payment systems constrain options to implement models of care that address social and medical needs in an integrated fashion. We present experiences of eight grantee organizations from the Bridging the Gap: Reducing Disparities in Diabetes Care initiative to improve diabetes outcomes by transforming primary care and addressing social needs within evolving payment models. METHODS: Analysis of eight grantees through site visits, technical assistance calls, grant applications, and publicly available data from US census data (2017) and from Health Resources and Services Administration Uniform Data System Resources data (2018). Organizations represent a range of payment models, health care settings, market factors, geographies, populations, and community resources. FINDINGS: Grantees are implementing strategies to address medical and social needs through augmented staffing models to support high-risk patients with diabetes (e.g., community health workers, behavioral health specialists), information technology innovations (e.g., software for social needs referrals), and system-wide protocols to identify high-risk populations with gaps in care. Sites identify and address social needs (e.g., food insecurity, housing), invest in human capital to support social needs referrals and coordination (e.g., embedding social service employees in clinics), and work with organizations to connect to community resources. Sites encounter challenges accessing flexible up-front funding to support infrastructure for interventions. Value-based payment mechanisms usually reward clinical performance metrics rather than measures of population health or social needs interventions. CONCLUSIONS: Federal, state, and private payers should support critical infrastructure to address social needs and incentivize care that addresses social needs and outcomes sensitive to social risk. Population health strategies that address medical and social needs for populations living with diabetes will need to be tailored to a range of health care organizations, geographies, populations, community partners, and market factors. Payment models should support and incentivize these strategies for sustainability.

Use of Survival Analysis to Predict Attrition Among Women Participating in Longitudinal Community-Based Nutrition Research.

OBJECTIVE: To identify participant characteristics and study methodology that influenced the completion of a 15-month community-based longitudinal study evaluating the impact of the Supplemental Nutrition Assistance Program Education and Expanded Food and Nutrition Education Program. DESIGN: Observational longitudinal 15-month study across 12 data collection timepoints. Sociodemographic characteristics were collected with a paper-based survey at baseline. SETTING: Five counties across central and southern Illinois. PARTICIPANTS: Women, aged 18 to 65 years (n = 297), recruited at sites likely to serve families eligible for the Supplemental Nutrition Assistance Program Education and Expanded Food and Nutrition Education Program (housing departments, child care centers, etc). MAIN OUTCOME MEASURES: Predictors of participant attrition during the study duration. ANALYSIS: Cox proportional hazard models. RESULTS: Ninety-seven participants were retained across the full study. In unadjusted models, greater income and education levels were significantly related to lower attrition; however, this relationship did not persist in a multivariate model. When adjusted for other characteristics, larger household size was the only measured variable significantly related to greater odds of attrition (odds ratio = 1.09; 95% confidence interval = 1.02, 1.17). CONCLUSIONS AND IMPLICATIONS: Several characteristics predicting attrition in other settings were not significant in this study. Future attrition analyses that evaluate social support, transportation capacity, and type of phone in longitudinal nutrition education studies are warranted.

A systematic review of food pantry-based interventions in the USA.

OBJECTIVE: Food pantries play a critical role in combating food insecurity. The objective of the present work was to systematically review and synthesize scientific evidence regarding the effectiveness of food pantry-based interventions in the USA. DESIGN: Keyword/reference search was conducted in PubMed, Web of Science, Scopus, Cochrane Library and CINAHL for peer-reviewed articles published until May 2018 that met the following criteria. SETTING: food pantry and/or food bank in the USA; study design: randomized controlled trial (RCT) or pre-post study; outcomes: diet-related outcomes (e.g. nutrition knowledge, food choice, food security, diet quality); study subjects: food pantry/bank clients. RESULTS: Fourteen articles evaluating twelve distinct interventions identified from the keyword/reference search met the eligibility criteria and were included in the review. Five were RCT and the remaining seven were pre-post studies. All studies found that food pantry-based interventions were effective in improving participants' diet-related outcomes. In particular, the nutrition education interventions and the client-choice intervention enhanced participants' nutrition knowledge, cooking skills, food security status and fresh produce intake. The food display intervention helped pantry clients select healthier food items. The diabetes management intervention reduced participants' glycaemic level. CONCLUSIONS: Food pantry-based interventions were found to be effective in improving participants' diet-related outcomes. Interventions were modest in scale and usually short in follow-up duration. Future studies are warranted to address the challenges of conducting interventions in food pantries, such as shortage in personnel and resources, to ensure intervention sustainability and long-term effectiveness.

Nutrition Environment Food Pantry Assessment Tool (NEFPAT): Development and Evaluation.

OBJECTIVE: To develop and evaluate a nutrition environment assessment tool to assess the consumer nutrition environment and use of recommended practices in food pantries. METHODS: The Nutrition Environment Food Pantry Assessment Tool (NEFPAT) was developed based on a literature review and guidance from professionals working with food pantries. The tool was pilot-tested at 9 food pantries, an expert panel assessed content validity, and interrater reliability was evaluated by pairs in 3 pantries. After revisions, the NEFPAT was used in 27 pantries. RESULTS: Pilot tests indicated positive appraisal for the NEFPAT and recommendations were addressed. The NEFPAT's 6 objectives and the overall tool were rated as content valid by experts, with an average section rating of 3.85 ± 0.10. Intraclass correlation coefficients for interrater reliability were >0.90. CONCLUSIONS AND IMPLICATIONS: The NEFPAT is content valid with high interrater reliability. It provides baseline data that could be valuable for interventions within the nutrition environment of food pantries.

Examining Internet Access and Social Media Application Use for Online Nutrition Education in SNAP-Ed Participants in Rural Illinois.

OBJECTIVE: To examine Internet access and interest in receiving nutrition education via social media applications among low-income adults participating in the Supplemental Nutrition Assistance Program Education (SNAP-Ed). METHODS: A cross-sectional survey was distributed during 25 SNAP-Ed classes throughout the 16 southernmost counties of Illinois. RESULTS: From 188 responses, the majority of participants had Internet access (76%). Among participants aged 18-32 years (n = 51), 92% owned a smartphone with Internet access and 57% indicated that they would use online nutrition education, with most interest in e-mail (41%), Facebook (40%), and text messaging (35%). There was little interest in using blogs, Vine, Twitter, Tumblr, and Pinterest. Overall, 49% of middle-aged adults aged 33-64 years and 87% of seniors aged ≥65 years reported they would not use online nutrition education. CONCLUSIONS AND IMPLICATIONS: Results indicated similar Internet accessibility in southern Illinois among low-income populations compared with national rural rates. Interest in using online nutrition education varied among SNAP-Ed participants according to age. Young adults appeared to be the most captive audience regarding online nutrition education. Results may be useful to agencies implementing SNAP-Ed to supplement current curriculum with online nutrition education for audiences aged ≤32 years.

Assessing the Network of Agencies in Local Communities that Promote Healthy Eating and Lifestyles among Populations with Limited Resources.

OBJECTIVES: We assessed the network of agencies in local communities that promote healthy eating and lifestyles among populations with limited resources. METHODS: Network surveys were administered among 159 Illinois agencies identified as serving limited-resource audiences categorized into 8 types: K-12 schools, early childhood centers, emergency food providers, health-related agencies, social resource centers, low-income/subsidized housing complexes, continuing education organizations, and others. Network analysis was conducted to examine 4 network structures - communications, funding, cooperation, and collaboration networks between agencies within each county/county cluster. RESULTS: Agencies in a network were found to be loosely connected, indicated by low network density. Reporting accuracy might be of concern, indicated by low reciprocity. Agencies in a network are decentralized rather than centralized around a few influential agencies, indicated by low betweenness centrality. There is suggestive evidence regarding homophily in a network, indicated by some significant correlations within agencies of the same type. Agencies connected in one network are significantly more likely to be connected in all the other networks as well. CONCLUSIONS: Promoting healthy eating and lifestyles among populations with limited resources warrants strong partnership across agencies in communities. Network analysis serves as a useful tool to evaluate community partnerships and facilitate coalition building..

Community partnerships in healthy eating and lifestyle promotion: A network analysis.

Promoting healthy eating and lifestyles among populations with limited resources is a complex undertaking that often requires strong partnerships between various agencies. In local communities, these agencies are typically located in different areas, serve diverse subgroups, and operate distinct programs, limiting their communication and interactions with each other. This study assessed the network of agencies in local communities that promote healthy eating and lifestyles among populations with limited resources. Network surveys were administered in 2016 among 89 agencies located in 4 rural counties in Michigan that served limited-resource audiences. The agencies were categorized into 8 types: K-12 schools, early childhood centers, emergency food providers, health-related agencies, social resource centers, low-income/subsidized housing complexes, continuing education organizations, and others. Network analysis was conducted to examine 4 network structures-communication, funding, cooperation, and collaboration networks between agencies within each county. Agencies had a moderate level of cooperation, but were only loosely connected in the other 3 networks, indicated by low network density. Agencies in a network were decentralized rather than centralized around a few influential agencies, indicated by low centralization. There was evidence regarding homophily in a network, indicated by some significant correlations within agencies of the same type. Agencies connected in any one network were considerably more likely to be connected in all the other networks as well. In conclusion, promoting healthy eating and lifestyles among populations with limited resources warrants strong partnership between agencies in communities. Network analysis serves as a useful tool to evaluate community partnerships and facilitate coalition building.