Enhancing Chronic-Disease Education through Integrated Medical and Social Care: Exploring the Beneficial Role of a Community Teaching Kitchen in Oregon

Teaching kitchens (TKs) are rapidly being utilized as models to integrate culinary education and chronic-disease education into healthcare settings. Our observational study details the structure and organizational processes (e.g., referral, services, medical and social care integration) of the Community TK at Providence Milwaukie Hospital in Portland, OR. We utilize electronic medical-record data from engaged TK participants (n = 3077) to evaluate between the association of engagement and clinical outcomes (e.g., HbA1c, blood pressure, weight and cholesterol). Mean baseline HbA1c of Highly Engaged TK patients with diabetes (n = 88) reduced from 9.8% to 8.6% at 6 months (p < 0.0001) and sustained significant reductions at 12, 18, 24, 30, and 36 months (p < 0.05). Highly Engaged patients with hypertension (n = 152) had significant, sustained reductions in blood pressure (p < 0.0001). Engaged patients in the same high-risk groups also had significant improvements in HbA1c and blood pressure. Both engagement subgroups had moderate improvements in weight change and cholesterol. This study shows promising associations of TK services that promote chronic-disease self-management with improved clinical outcomes among higher risk patients (e.g., high blood pressure, high HbA1c, high low-density lipoprotein) with different medical issues (e.g., diabetes, obesity) and social barriers (e.g., food insecurity).

Improving Diabetes Care Through Population Health Innovations and Payments: Lessons from Western Maryland

BACKGROUND

Global budgets might incentivize healthcare systems to develop population health programs to prevent costly hospitalizations. In response to Maryland's all-payer global budget financing system, University of Pittsburgh Medical Center (UPMC) Western Maryland developed an outpatient care management center called the Center for Clinical Resources (CCR) to support high-risk patients with chronic disease.

OBJECTIVE

Evaluate the impact of the CCR on patient-reported, clinical, and resource utilization outcomes for high-risk rural patients with diabetes.

DESIGN

Observational cohort study.

PARTICIPANTS

One hundred forty-one adult patients with uncontrolled diabetes (HbA1c > 7%) and one or more social needs who were enrolled between 2018 and 2021.

INTERVENTIONS

Team-based interventions that provided interdisciplinary care coordination (e.g., diabetes care coordinators), social needs support (e.g., food delivery, benefits assistance), and patient education (e.g., nutritional counseling, peer support).

MAIN MEASURES

Patient-reported (e.g., quality of life, self-efficacy), clinical (e.g., HbA1c), and utilization outcomes (e.g., emergency department visits, hospitalizations).

KEY RESULTS

Patient-reported outcomes improved significantly at 12 months, including confidence in self-management, quality of life, and patient experience (56% response rate). No significant demographic differences were detected between patients with or without the 12-month survey response. Baseline mean HbA1c was 10.0% and decreased on average by 1.2 percentage points at 6 months, 1.4 points at 12 months, 1.5 points at 18 months, and 0.9 points at 24 and 30 months (P<0.001 at all timepoints). No significant changes were observed in blood pressure, low-density lipoprotein cholesterol, or weight. The annual all-cause hospitalization rate decreased by 11 percentage points (34 to 23%, P=0.01) and diabetes-related emergency department visits also decreased by 11 percentage points (14 to 3%, P=0.002) at 12 months.

CONCLUSIONS

CCR participation was associated with improved patient-reported outcomes, glycemic control, and hospital utilization for high-risk patients with diabetes. Payment arrangements like global budgets can support the development and sustainability of innovative diabetes care models.

Hospital-Based, Community Teaching Kitchen Integrates Diabetes Education, Culinary Medicine, and Food Assistance: Case Study During the COVID-19 Pandemic

BACKGROUND

Recent USDA Economic Research Service Population Survey cites a stabilization of food insecurity overall in the USA between 2019 and 2020, but Black, Hispanic, and all households with children cited increases - underscoring that the COVID-19 pandemic caused severe disruptions to food insecurity for historically disenfranchised populations.

AIM

Describe lessons learned, considerations, and recommendations from the experience of a community teaching kitchen (CTK) in addressing food insecurity and chronic disease management among patients during the COVID-19 pandemic.

SETTING

The Providence CTK is co-located at Providence Milwaukie Hospital in Portland, Oregon.

PARTICIPANTS

Providence CTK serves patients who report a higher prevalence of food insecurity and multiple chronic conditions.

PROGRAM DESCRIPTION

Providence CTK has five components: chronic disease self-management education, culinary nutrition education, patient navigation, a medical referral-based food pantry (Family Market), and an immersive training environment.

PROGRAM EVALUATION

CTK staff highlight that they provided food and education support when it was needed most, leveraged existing partnerships and staffing to sustain operations and Family Market accessibility, shifted delivery of educational services based-on billing and virtual service considerations, and repurposed roles to support evolving needs.

DISCUSSION

The Providence CTK case study provides a blueprint for how healthcare organizations could design a model of culinary nutrition education that is immersive, empowering, and inclusive.

New Frontiers in Diabetes Care: Quality Improvement Study of a Population Health Team in Rural Critical Access Hospitals

BACKGROUND

Rural populations are older, have higher diabetes prevalence, and have less improvement in diabetes-related mortality rates compared to urban counterparts. Rural communities have limited access to diabetes education and social support services.

OBJECTIVE

Determine if an innovative population health program that integrates medical and social care models improves clinical outcomes for patients with type 2 diabetes in a resource-constrained, frontier area.

DESIGN/PARTICIPANTS

Quality improvement cohort study of 1764 patients with diabetes (September 2017-December 2021) at St. Mary's Health and Clearwater Valley Health (SMHCVH), an integrated health care delivery system in frontier Idaho. The United States Department of Agriculture's Office of Rural Health defines frontier as sparsely populated areas that are geographically isolated from population centers and services.

INTERVENTION

SMHCVH integrated medical and social care through a population health team (PHT), where staff assess medical, behavioral, and social needs with annual health risk assessments and provide core interventions including diabetes self-management education, chronic care management, integrated behavioral health, medical nutritional therapy, and community health worker navigation. We categorized patients with diabetes into three groups: patients with two or more PHT encounters during the study (PHT intervention), one PHT encounter (minimal PHT), and no PHT encounters (no PHT).

MAIN MEASURES

HbA1c, blood pressure, and LDL over time for each study group.

KEY RESULTS

Of the 1764 patients with diabetes, mean age was 68.3 years, 57% were male, 98% were white, 33% had three or more chronic conditions, and 9% had at least one unmet social need. PHT intervention patients had more chronic conditions and higher medical complexity. Mean HbA1c of PHT intervention patients significantly decreased from baseline to 12 months (7.9 to 7.6%, p < 0.01) and sustained reductions at 18 months, 24 months, 30 months, and 36 months. Minimal PHT patients decreased HbA1c from baseline to 12 months (7.7 to 7.3%, p < 0.05).

CONCLUSION

The SMHCVH PHT model was associated with improved hemoglobin A1c among less well-controlled patients with diabetes.

Barriers and Strategies to Operationalize Medicaid Reimbursement for CHW Services in the State of Minnesota: a Case Study

Integrated medical and social care via community health worker (CHW) services is a growing area of interest, particularly among health care organizations that offer care for underserved populations. Establishing Medicaid reimbursement for CHW services is only one step to improve access to CHW services. Minnesota is one of 21 states that authorize Medicaid payment for CHW services. Despite available Medicaid reimbursement for CHW services since 2007, the actual experience of many Minnesota health care organizations in obtaining reimbursement for CHW services has been challenging due to barriers at multiple levels (e.g., clarifying and operationalizing regulation, navigating complexity of billing, building organizational capacity to reach key stakeholders at state agencies and health plans). This paper provides an overview of the barriers and strategies to operationalize Medicaid reimbursement for CHW services in the state of Minnesota, through the experience of a CHW service and technical assistance provider. Based on lessons learned in Minnesota, recommendations are made to other states, payers, and organizations as they navigate processes to operationalize Medicaid payment for CHW services.

Implementing the Partnership Assessment Tool for Health to Assess and Strengthen Cross-sector Partnerships: Lessons from a Federally Qualified Health Center

La Clínica del Pueblo (LCDP), a federally qualified health center that serves the low-income, Latino/a/x community in D.C., used the Partnership Assessment Tool for Health (PATH) to assess two cross-sector partnerships: a medical-legal partnership with a legal services agency and a five-year partnership with FRESHFARM focused on alleviating food insecurity.

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.

β-Cryptoxanthin-Biofortified Hen Eggs Enhance Vitamin A Status When Fed to Male Mongolian Gerbils

Background

Consumption of provitamin A carotenoid biofortified crops, such as maize, supports vitamin A (VA) status in animals and humans. Laying hens that consume β-cryptoxanthin-biofortified maize deposit β-cryptoxanthin into egg yolk.

Objective

We investigated whether β-cryptoxanthin-biofortified egg consumption would affect VA status of male Mongolian gerbils (Meriones unguiculatus) compared with white-yolked eggs.

Methods

β-Cryptoxanthin-biofortified egg yolk, produced in hens fed biofortified orange maize or tangerine-fortified maize feeds, was freeze-dried and fed to gerbils. White-yolked eggs were produced by feeding white maize to hens. Gerbils (n = 57) were fed VA-deficient feed for 28 d. After baseline (n = 7), treatments (n = 10/group) included oil control (VA-); 16.7% orange maize-biofortified, tangerine-fortified, or white-yolk egg feeds; or retinyl acetate as positive control (VA+) matched to daily preformed retinol intake from the eggs for 30 d. Preformed retinol did not differ between the egg yolks. Gerbil liver retinol, lipid, fatty acids, and cholesterol were determined.

Results

Liver retinol concentration (0.13 ± 0.03 µmol/g) and total hepatic VA (0.52 ± 0.12 µmol) were higher in gerbils fed orange maize-biofortified eggs than in all other groups. The VA- group was severely VA deficient (0.018 ±0.010 µmol/g; P < 0.05). Liver retinol was similar among VA+, tangerine-egg-, and white-egg-fed gerbils, but retinol reserves were higher in tangerine-egg-fed gerbils (0.35 ± 0.11 μmol) than in VA+ or VA- gerbils or at baseline (P < 0.05). Liver fat was 3.6 times (P < 0.0001) and cholesterol was 2.1 times (P < 0.004) higher in egg-fed groups that experienced hepatosteatosis. Liver fatty acid profiles reflected feed, but retinyl ester fatty acids did not.

Conclusions

The preformed retinol in the eggs enhanced gerbil VA status, and the β-cryptoxanthin-biofortified eggs from hens fed orange maize prevented deficiency. Biofortified maize can enhance VA status when consumed directly or through products from livestock fed orange maize.

Serum retinol concentrations demonstrate high specificity after correcting for inflammation but questionable sensitivity compared with liver stores calculated from isotope dilution in determining vitamin A deficiency in Thai and Zambian children

BACKGROUND

The WHO estimates that 190 million preschool children have vitamin A deficiency (VAD). Serum retinol (SR) concentration is a common indicator of vitamin A (VA) status, but SR is homeostatically controlled and suppressed during inflammation, which may lead to misdiagnosis.

OBJECTIVE

The sensitivity and specificity of SR compared with VA total liver reserves (TLRs) were evaluated for VAD in children from Thailand (n = 37) and Zambia (n = 128). SR was adjusted for inflammation in the Zambian children.

DESIGN

Each child was classified as VA-deficient or not based on cutoffs of <0.1 μmol VA/g liver with the use of retinol isotope dilution and <0.7 μmol/L for SR concentrations. Four categories of infection status in the Zambian children were based on elevated C-reactive protein (CRP) and α1-acid glycoprotein (AGP). Sensitivity and specificity were calculated with the use of unadjusted and inflammation marker-adjusted SR cutoffs.

RESULTS

VAD was 65% and 0% according to TLRs and SR, respectively, in Thai children and 0% and 17%, respectively, in Zambian children. No true positive VAD cases occurred; thus, sensitivity was 0% and indeterminable, respectively; specificity was 100% and 82.8%, respectively. CRP was elevated in 26.6% of Zambian children, whereas 97.7% had elevated AGP, categorizing them as having no infection (2.3%) or in early (26.6%) or late (58.6%) convalescence. With the use of marker-adjusted SR cutoffs of 0.6 μmol/L for late convalescence and 0.5 μmol/L for early convalescence, the adjusted prevalence of SR deficiency was 2.3%, increasing specificity to 97.3%.

CONCLUSIONS

No cases of VAD were identified by both TLRs and SR (true positives) in Thai or Zambian children. Specificity of SR to evaluate VAD was high, but additional research is needed to investigate sensitivity. Adjusting SR cutoffs for inflammation improved specificity by reducing false positives. SR as a VAD indicator may depend on infection rates, which should be taken into consideration. These studies were registered at clinicaltrials.gov as NCT01061307 (for Thailand) and NCT01814891 (for Zambia).

Biofortified orange maize enhances β-cryptoxanthin concentrations in egg yolks of laying hens better than tangerine peel fortificant

The xanthophyll β-cryptoxanthin provides vitamin A and has other purported health benefits. Laying hens deposit xanthophyll carotenoids into egg yolk. Hens (n = 8/group) were fed conventional-bred high β-cryptoxanthin biofortified (orange) maize, tangerine peel-fortified white maize, lutein-fortified yellow maize, or white maize for 40 d to investigate yolk color changes using L*a*b* scales, yolk carotenoid enhancement, and hen vitamin A status. Yolks from hens fed orange maize had scores indicating a darker, orange color and mean higher β-cryptoxanthin, zeaxanthin, and β-carotene concentrations (8.43 ± 1.82, 23.1 ± 4.8, 0.16 ± 0.08 nmol/g, respectively) than other treatments (P < 0.0001). Yolk retinol concentrations (mean: 14.4 ± 3.42 nmol/g) were similar among groups and decreased with time (P < 0.0001). Hens fed orange maize had higher liver retinol (0.53 ± 0.20 μmol/g liver) than other groups (P < 0.0001). β-Cryptoxanthin-biofortified eggs could be another choice for consumers, providing enhanced color through a provitamin A carotenoid and supporting eggs' status as a functional food.

Cooking enhances but the degree of ripeness does not affect provitamin A carotenoid bioavailability from bananas in Mongolian gerbils

Banana is a staple crop in many regions where vitamin A deficiency is prevalent, making it a target for provitamin A biofortification. However, matrix effects may limit provitamin A bioavailability from bananas. The retinol bioefficacies of unripe and ripe bananas (study 1A), unripe high-provitamin A bananas (study 1B), and raw and cooked bananas (study 2) were determined in retinol-depleted Mongolian gerbils (n = 97/study) using positive and negative controls. After feeding a retinol-deficient diet for 6 and 4 wk in studies 1 and 2, respectively, customized diets containing 60, 30, or 15% banana were fed for 17 and 13 d, respectively. In study 1A, the hepatic retinol of the 60% ripe Cavendish group (0.52 ± 0.13 μmol retinol/liver) differed from baseline (0.65 ± 0.15 μmol retinol/liver) and was higher than the negative control group (0.39 ± 0.16 μmol retinol/liver; P < 0.0065). In study 1B, no groups differed from baseline (0.65 ± 0.15 μmol retinol/liver; P = 0.20). In study 2, the 60% raw Butobe group (0.68 ± 0.17 μmol retinol/liver) differed from the 60% cooked Butobe group (0.87 ± 0.24 μmol retinol/liver); neither group differed from baseline (0.80 ± 0.27 μmol retinol/liver; P < 0.0001). Total liver retinol was higher in the groups fed cooked bananas than in those fed raw (P = 0.0027). Body weights did not differ even though gerbils ate more green, ripe, and raw bananas than cooked, suggesting a greater indigestible component. In conclusion, thermal processing, but not ripening, improves the retinol bioefficacy of bananas. Food matrix modification affects carotenoid bioavailability from provitamin A biofortification targets.