Success! The Final Report from Year 1 of the Food and Nutrition Services Bundle
We are thrilled to announce the results of the first year of our joint Delivery System Reform Incentive Payment model (DSRIP) Innovation Award project through OneCity Health, the NYC Health + Hospitals Performing Provider System.
The Food and Nutrition Services Bundle (FNS Bundle) program offered screening for and navigation to the community food and nutrition resources that are available for food insecure Bronx patients at NYC Health + Hospitals/Jacobi and NYC Health + Hospitals/Lincoln. Public Health Solutions (PHS) led the project with God’s Love We Deliver, BronxWorks, the Food Bank for New York City, Healthfirst and Unite Us as partners.
The project grew out of our joint experience as community-based organizations (CBOs) participating in DSRIP. We realized that while many community-based services exist to improve food security and nutritional health, there was confusion about how to get patients the services they require. When providers are unsure of where to refer their food insecure patients, fewer patients receive the care that they need, and community-based organizations receive improper referrals that drain capacity, because patients are referred to services for which they are ineligible. The FNS Bundle was designed to eliminate these frustrations by creating a risk-stratified assessment for eligibility for nutrition services – a process led by God’s Love – and then embedding the assessment in a closed-loop referral system, Unite Us, that ensured that patients actually got the services to which they were referred.
In the 10-month period beginning in November 2018, the FNS Bundle registered 871 families for food and nutrition programs. Nearly 60 percent of the participants screened enrolled in one or more of the food and nutrition services, such as Supplemental Nutrition Assistance Program (SNAP), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and our very own medically tailored meals. Through these services, access to emergency food resources to families in need rose from 6% to 56%. Based on research estimates of healthcare savings, the average estimated savings associated with SNAP enrollment is about $1,400 for each participant per year, and $9,036 per person/per year associated with medically tailored home-delivered meals.
"When providers are unsure of where to refer their food insecure patients, fewer patients receive the care that they need, and community-based organization receive improper referrals that drain capacity, because patients are referred to services for which they are ineligible."
This project succeeded in many of the areas that have been consistently identified as challenging throughout the DSRIP experience:
- Accurate Referral and Assessment for Social Determinants of Health Services: We answered a deep need to create a durable nutrition assessment that got patients to the right services for their need and eligibility.
- Consent-based Service Tracking: By embedding the assessment and navigation in a consent-driven, trackable data system, the project received vital information about service completion, previously unavailable to both providers and CBOs. This is key to evaluation.
- Funding: Thanks to PHS and their unique contracting process, the project leveraged a diverse funding structure, where resources were applied strategically based on existing funding, available incentive funds and anticipated increases in volume of services provided by the network.
We are thrilled by the first phase of this project and excited to implement phase two, which will include a more embedded presence on the inpatient side to bring this service to a more acute patient population.
Thank you to OneCity Health for believing in the FNS Bundle vision, to Public Health Solutions for their incredible leadership of the project, to Unite Us for their ability to work within the strictures of this unique provider/community partnership and to all our partners for being such a wonderful team.