Food Insecurity & Care Navigation
2023 Cohort Findings
The 2023 social determinants of health application had six opportunity areas for organizations to choose from in their response to how their solutions would address health-related social needs. Solutions were expected to focus on one or more aspects of the social needs challenges within this opportunity.
The first 2023 showcase highlighted solutions that address at least one of the following four focus areas:
Food and Nutrition Security
Housing Affordability and Quality
Economic Stability through Education and Employment
Navigating and Coordinating Care, Resources, and Services
Challenges and Opportunities
Many individuals do not have enough food each month and must make the tough choice between buying groceries and other living expenses. Even when they do have enough, families often struggle with getting the “right” food on the table. It is often difficult to access the kinds of healthy foods they would want. While SNAP and WIC provide essential assistance, there is often a stigma associated with accessing these programs, or food supplies are not always enough to meet the full need.
Solutions should provide individuals and families with supplemental food, including flexibility in how and when users can access foods. Solutions should also increase access to healthy food options, including vegetables and fruits as well as a greater variety of foods. Solutions may incorporate nutritional education, recipes, and/or cooking lessons as part of their offering. A best-fit solution would provide people with options for both pre-made meals and healthy ingredients that they can use to prepare meals themselves, including medically-tailored meals or ingredients. It would also be connected with or integrated into local settings (grocery stores, food pantries) and provide culturally-appropriate options based on user-indicated preferences.
Individuals and families are concerned with the rising cost of living, and surging rent prices are a major stressor when it comes to their overall financial security. Limited affordable housing options are extremely challenging in both urban and rural settings. Many individuals do not feel completely stable in their current housing situations and worry their circumstances could change at any moment. People struggle with navigating governmental housing assistance and other programs to support safe and affordable housing. Additionally, even those in stable situations have concerns about the quality of their housing or keeping utilities paid. They could use assistance with seasonal preparations, pest control, facility repairs, and improvements where landlords fall short.
Solutions should provide individuals and families with assistance to navigate programs for affordable housing and supportive services. Solutions could support households in paying utilities and security deposits, weatherizing their homes, or ensuring housing is safe and accessible with a focus on home improvements.
In the case of a crisis event, once the adolescent is stabilized with the appropriate interventions, solutions should be able to provide support services to aid in recovery and future crisis prevention.
Solutions may also engage with adolescents more generally to aid the complicated transition into teenage years, with programmatic components to introduce and assist with mental health and substance use.
Access to and support for consistent income is core to addressing many of the social needs experienced by Medicaid beneficiaries. For those able to work, people want access to jobs that allow them to support themselves and their families; they desire to be self-sufficient without requiring assistance for things like food, transportation, or housing. Many people are currently participating in the gig economy or seasonal jobs, which are not providing them with stability, and many supplement their incomes with cash-paying side jobs. Being un- or underemployed and unable to navigate finding high quality jobs to support themselves and their families can foster a sense of shame. Some would like the opportunity to learn new skills or professions but are not sure where to find the tools or financial resources to get started.
Solutions should help individuals navigate resources for educational or employment assistance. These solutions could help them identify job opportunities appropriate to their training and experience or support them in strengthening their resumes and interviewing skills. Solutions could support people in accessing training and education to transition into better paying jobs that strengthen their financial stability long term. Solutions could also help individuals navigate the benefits cliff associated with increasing household income, which is a concern for many.
Resources, and Services
Too often, individuals and families do not know what services are available to them nor how to access those services. Medicaid enrollees have difficulty understanding the complexities of eligibility for services, coverage through health insurance, or knowing how to access particular providers or services in a timely manner. Furthermore, individuals aren’t comfortable discussing their social needs with just anyone. While there isn’t a big difference in preferences around the type of role (e.g., physician) they share with, what is important is that they have a trusted relationship with the person asking questions, that they are approached with empathy, and that they have context as to why they are being engaged on social needs. Individuals are also more comfortable when they perceive the person or organization as having expertise in the subject matter.
Solutions should be able to create a unified way for individuals to find out what resources and services are available to them and what they are eligible to access. Solutions should provide up-to-date resources and the ability to get answers to questions about how to access local services to address their social needs. Solutions should help people navigate to high quality services and may take advantage of support from community health workers or navigators. Solutions should improve access to culturally-competent care, bridge the digital divide, and build trust in the community. Solutions which include social needs screening should employ strategies to build trust with users, considering a balance of empathy and expertise. Best-fit solutions would offer a one-stop-shop for enrollees to be screened for eligibility, understand options, and streamline benefit applications.
Showcase: Food Insecurity & Care Navigation
Solutions Selected to Present
With criteria based on the findings from community discovery, members of the Selection Committee nominated the following organizations to present their models at the Food Insecurity & Care Navigation Showcase in May 2023.
FarmboxRx is an engagement platform that partners with health insurance providers to improve member health outcomes through nutrition and health literacy. Since 2014, FarmboxRx has been providing the necessary support for individuals to attain the highest level of health by promoting self-efficacy and inspiring individuals to take a more active role in their own health. FarmboxRx delivers customizable member engagement programs via food solutions that support sustainable, scalable, and long-lasting quality outcomes for Members and Healthcare Organizations.
Free From Market is a patient-driven digital health company in the food is medicine space. Free From brings together personalized food selection, tele-nutrition, and the ability to measure outcomes in one platform.
Live Chair Health (LCH) is a tech-enabled Community Health Worker (CHW) platform that serves as a last-mile member engagement resource for health plans and systems (Health Partners). LCH partners with payors, providers and other health care entities to ensure that residents of traditionally disenfranchised communities can access Preventative, Social and Administrative care resources that focus on HEDIS gap closures and the achievement of broader STARs metrics. The Company combines its CHW ground team, call center staff, web application and network of community based organizations to target community members that are hard to reach, endure chronic conditions or are otherwise expensive to manage in order to bend the cost curve for its Health Partners.
NourishedRx is a human-centered digital health and nutrition company that combines the power of food, people, and technology to deliver comprehensive and personalized nutrition programs and experiences. NourishedRx exists to nourish the most vulnerable, build connections, and bend the healthcare cost curve while addressing health equity. NourishedRx's programs engage participants with clinically appropriate, culturally relevant, high-quality food and then work with members longitudinally to educate and support self-agency and skills to transform the trajectory of their dietary path. NourishedRx's solutions delight members, promote connection, and enable staff to glean actionable insights regarding gaps in care and health-related social needs. NourishedRx's omnichannel communications (digital and phone) ensure broadly accessible engagement.
Pair Team connects underserved communities to high quality care with their tech-enabled care teams. They partner with safety-net primary care providers and act as extension of the clinical staff to provide comprehensive clinical and mental health care while addressing the many social barriers to achieving a high quality of life such as access to housing, food, or transportation. Their community-led, virtual care model is powered by their intelligent care delivery platform.
Samaritan is a support platform that empowers people without a stable home to reach life goals. Health and human services deploy Samaritan to engage last-mile populations into the financial & social support needed to meet critical SDOH needs. Samaritan enters communities with frontline partners to reach targeted individuals with a Samaritan Membership. Members get a smart wallet, then share goals, immediate needs, and desired action steps. From here, Members gain social & financial support to meet needs and enable action steps towards goals.
Waymark is a physician-led public benefit company dedicated to improving access and quality of care for people receiving Medicaid. Waymark partners with health plans and primary care providers to deliver technology-enabled, community-based care in neighborhoods across the country. Waymark's local teams of community health workers, pharmacists, and therapists partner with PCPs to increase their capacity, build relationships with hard-to-engage patients, and improve outcomes through evidence-based care pathways. Waymark's flagship products — Lighthouse and Signal — use proprietary data science and machine learning models to help community-based teams identify patients early in their disease course and match them to the right clinical and community interventions.
Welfie puts community health workers in K-12 schools to provide health education, care coordination and address social determinants of health issues for children and families on Medicaid/CHIP. Welfie's CHWs are able to enroll eligible members in Medicaid, help with redetermination, complete health assessments, gather SDOH/Health Equity data, close care gaps and improve quality of care metrics (HEDIS, CAHPS etc.) which are reported via a population health analytics and data dashboard that will soon support the new NCQA digital measures.