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Fresh Food Program Makes a Difference in Type 2 Diabetes Patients see drops in HbA1c, reductions in medication by Joyce Frieden,News Editor, MedPage Today
WASHINGTON -- Giving patients with type 2 diabetes access to healthy food at no charge can result in large improvements in their disease and overall quality of life, Allison Hess said here.
"We're seeing on average a two-point reduction [in HbA1c] across the board -- and we don't have any side effects," Hess, who is associate vice president for health and wellness at Geisinger Health System, in Benton, Pennsylvania, said at the World Health Care Congress. "And in fact we have people coming off of their medications."
Geisinger's journey with food as medicine began after the health system looked at its results for treating type 2 diabetes patients. "Despite all the resources and all the effort, we still didn't feel like we were moving the needle quite as much as we had hoped," said Hess. "We also looked at the cost and we were concerned with our growing spend" on these patients.
So the health system began looking at social determinants of health as a possible reason for why so little progress was being made; they zeroed in on diet and exercise, particularly diet. To find out whether patients were food insecure, the plan embedded two food insecurity statements into their type 2 patients' medical record to get patients' responses while they were being roomed:
Within the past 12 months, we worried whether our food would run out before we got money to buy more (Yes or No)
Within the past 12 months, the food bought just didn't last and we didn't have money to get more (Yes or No)
If any patient answered "yes" to either question and met other criteria, they were referred to a Geisinger program called "Fresh Food Farmacy." The program, which began in July 2016, provides patients with two meals' worth of food per day, 5 days per week, to the entire household for as long as is needed. The food is available at a 3,000-square-foot facility on a Geisinger hospital campus in Coal Township, Pennsylvania. The Farmacy, which looks much like a supermarket, also includes a food warehouse and a classroom for offering nutrition classes.
At the beginning of the program, participants are limited mostly to food that allows them to prepare certain specific healthy recipes, but after a while they can have free choice among the foods offered, Hess said. The selection mostly includes "diabetes appropriate" food such as fresh fruits and vegetables; "we try to limit canned food." Almost all of the foods are sourced from local food banks, and those that aren't come from "vendor partners" of the health system.
The partnership with the food banks makes the food very inexpensive -- the cost is about $1,200 per year to feed a family of four, said Hess. "We couldn't do it without them as our partner."
Criteria for being referred to the program include:
Diagnosis of type 2 diabetes
HbA1c of ≥8%
Patient of Geisinger specialty or primary care
Patients who express interest in the program are encouraged to come to a "welcome class" at which they also meet their care team: an RN health manager, a pharmacist, a dietitian, a wellness associate, and a community health associate. "What's interesting is all of the care team members were already available, but because we put it into a program and added a food component, all of a sudden they're taking advantage of things they always had access to but may not have realized," said Hess. Patients who decide to enroll must meet again with the care team and enroll in a diabetes self-management class.
Each team member plays a specific role in taking care of the patient's needs, she continued. For example, the community health worker can address transportation and other non-medical needs. "We found out there were other social determinants of health -- [some people] had housing issues, and there were also people struggling to pay their heating bill in the winter."
"We're catching people at the point where they're kind of giving up," she added. "They have very high A1cs -- 10%, 11%, 12%, 13% -- and they're frustrated. Every time they go to the doctor, they [hear] they need to [change their diet] but they can't afford it." One patient in the program actually cuts up fruits and vegetables at his regular job, but he couldn't afford to buy them.
The program, which is currently funded through foundation grants, is also saving money for the health system. Rita, age 55, is one of the patients in the program. She is raising three grandchildren, and caring for a husband on dialysis. She weighed 181 lbs and had an HbA1c of 13.8%. When she came into the program in January 2017, she had "given up on herself completely," said Hess.
Nine months later, her HbA1c stood at 5.8% and her weight was down to 155; she is now a champion of the program. With Geisinger experiencing an average $8,000-$12,000 cost savings for each percentage point reduction in HbA1c, there were "huge" cost savings in Rita's case, Hess said.
Another patient who joined the program started with costs of more than $200,000 annually; that cost is now down to $40,000, according to Hess. In addition to the blood glucose changes, patients frequently experience decreases in cholesterol and blood pressure, and some early results are also showing decreases in emergency department visits, she added.
Geisinger doesn't promote its program as being for weight loss. "We do that very intentionally," said Hess. "We wanted this to be a nutrition program. [But] the byproduct is that they ask, 'What do you have for weight loss?' So we have put other programs in place that now have people continuing to lose weight."
In the woods and the shadows, street medicine treats the nation’s homeless November 22, 2017
Nurse Laura LaCroix was meeting with one of her many homeless patients in a downtown Dunkin’ Donuts when he mentioned that a buddy was lying in agony in the nearby woods.
“You should check on him,” said Pappy, as the older man is known. “But don’t worry, I put him on a tarp, so if he dies, you can just roll him into a hole.”
LaCroix called her boss, Brett Feldman, a physician assistant who heads the “street medicine” program at Lehigh Valley Health Network. He rushed out of a meeting, and together the two hiked into the woods. They found Jeff Gibson in a fetal position, vomiting green bile and crying out in pain from being punched in the stomach by another man days earlier.
Feldman told him he had to go to the hospital.
“Maybe tomorrow,” Gibson replied.
“Tomorrow you’ll be dead,” Feldman responded.
Months later, the 43-year-old Gibson is still in the woods, but this time showing off the six-inch scar — for a perforated intestine and peritonitis — that is evidence of surgical intervention. He greets Feldman warmly. “You’re the only person who could have gotten me to the hospital,” he says. “You’re the only person I trust.”
Pappy and Gibson are “rough sleepers,” part of a small army of homeless people across the country who cannot or will not stay in shelters and instead live outside. And LaCroix and Feldman are part of a burgeoning effort to locate and take care of them no matter where they are — whether under bridges, in alleyways or on door stoops.
“We believe that everybody matters,” Feldman says, “and that it’s our duty to go out and find them.”
Most of the time, members of his team provide basic primary care to people who live in dozens of encampments throughout eastern Pennsylvania’s Lehigh Valley. During their street rounds, they apply antibiotic ointment to cuts, wrap up sprains and treat chronic conditions such as blood pressure and diabetes.
But they also help people sign up for Medicaid, apply for Social Security disability benefits and find housing. Three or four times a month, they deal with individuals threatening to commit suicide. After heavy rains, they bail out “the Homeless Hilton,” a campsite under an old railroad tunnel that frequently floods — and where two rough sleepers once drowned.Many days, they simply listen to their patients, trying also to relieve emotional pain.
Street medicine was pioneered in this country in the 1980s and 1990s by homeless advocates Jim O’Connell in Boston and Jim Withers in Pittsburgh. Yet only in the past five years has it caught fire, with a few dozen programs becoming more than 60 nationwide. A recent conference on the topic in Allentown drew 500 doctors, nurses, medical students and others from 85 cities, including London, Prague and New Delhi. Most programs are started by nonprofit organizations or medical students.
Even as it comes of age, street medicine faces new challenges. A younger set of leaders is less interested in cultivating a bleeding-heart image than in establishing the approach as a legitimate way to deliver health care not only to the homeless — whose average life expectancy is about 50 — but also to other underserved people. Backers say street medicine should be considered a subspecialty, much like palliative care is, because of the unique circumstances of treating its target population.
Proponents also are pressing for much more financial support from hospitals, which can benefit greatly when homeless individuals receive care that helps keep them out of emergency rooms. Feldman’s program — which includes the street team, medical clinics in eight shelters and soup kitchens, and a hospital consultation service — has slashed unnecessary emergency room visits and admissions among its clientele. The result, to the surprise of Lehigh Valley Health Network officials, was a $3.7 million boost to the bottom line in fiscal 2017.
Perhaps the biggest issue facing street medicine, however, is figuring out how to provide more mental-health services. About one-third of homeless people are severely mentally ill, and two-thirds have substance-use disorders. Long waiting times for psychiatric evaluations delay needed medications and, in some cases, opportunities to get housing.
Psychiatrist Sheryl Fleisch is working on that problem. In 2014, she founded Vanderbilt University Medical Center’s street psychiatry program, one of a few such initiatives in the country. Every Wednesday morning, Fleisch and several medical residents visit camps in Nashville, handing out shirts, blankets — anything that can build trust.
Then they split up to talk one-on-one with people waiting on park benches, at bus stops and in fast-food restaurants, providing a week’s worth of prescriptions as needed. Fleisch says these homeless patients seldom miss an appointment.
Many “have been thrown out of other programs or are too anxious to go to regular office sessions,” she said. “We have some patients who will get up and sit down 15 times during our appointments. We don’t give up on them.”
On a muggy fall morning, Feldman’s team makes its way from the Hamilton Street Bridge in downtown Allentown to a swath of mosquito-infested woods between the railroad tracks and the Lehigh River. A few blocks away, an extensive redevelopment project, complete with a luxury hotel and arena for the minor-league Phantoms hockey team, is revitalizing parts of the long-depressed area.
Bob Rapp Jr., who has worked extensively with homeless veterans and knows the location of many campsites, is the advance man. “Good morning! Street medicine!” he calls out.
Feldman carries a backpack full of medicines. LaCroix uses her “Mary Poppins bag” to try to coax people out of their tents: “We’ve got supplies — socks, toilet paper, tampons!”
A thin woman with striking blue eyes pops out of a tiny tent, pulling at her wildly askew blonde hair as she glances in a mirror propped against a tree. Her toenails are painted gold. A Phillies cap and a Dean Koontz book, “Innocence,” sit on one of her two chairs.
“Tampons!” exclaims the woman, who identifies herself only as Duckie. “I just turned 60. I don’t think I need tampons!” She hugs LaCroix, with whom she bonded after the nurse helped her get new clothes and emergency treatment for a virulent, highly contagious skin infestation called Norwegian scabies.
Feldman kneels in front of Duckie with his stethoscope to check her lungs; the last time he saw her, the longtime smoker had bronchitis. No breathing problems this time, but Feldman tells her he wants a psychiatric evaluation. If the doctor confirms that she has bipolar disorder, depression or post-traumatic stress disorder — all diagnoses Duckie says she has heard over the years — she will be able to get the drugs she needs and perhaps transitional housing.
“I self-medicate,” she shrugs. But she likes the idea of moving inside with winter coming.
“It stinks out here,” she says. “It’s cold. I have to watch out for rats and raccoons and people.” She agrees to see a psychiatrist — a volunteer who comes out once a month — at her tent the following week.
Later in the day, the team goes to see a favorite patient. When the group approaches his plastic-covered hut in the woods, Mark Mathews frantically orders them to stop. “I don’t want to be caught with my pants down!” he yells from within.
Moments later, khakis on, the 57-year-old emerges. The son of a successful Allentown actor, the grey-bearded Mathews spent years playing Santa Claus in malls. He also worked for a high school theater department and in the 1980s was part of a local cable comedy show, “Sturdy Beggars.”
He became homeless after having a falling out with his sister four years ago. “The money ran out, and I couldn’t get another job,” he says.
LaCroix takes his blood pressure. The reading is high, something Mathews blames on not having taken his blood-pressure medicine that morning. The team will be back in two days to do a recheck, which is fine with him. “I enjoy their company,” he says.
Once, LaCroix carried a mattress across an old railroad trestle and up a steep hill to deliver it to his hut. Like other patients out here, Mathews has the team’s cellphone numbers. He frequently texts LaCroix to tell her jokes or alert her to someone’s possible health problem.
Mathews is sure his life has purpose. “I try to help other people,” he says. “I lend people phones if they don’t have them. I help them get to their appointments. I should be nominated for sainthood.”
About 550,000 people in the United States were homeless in 2016 on a given night — according to the most recent estimate by the Department of Housing and Urban Development — and about a third of them were sleeping outside, in abandoned houses or in other “unsheltered” places not meant for human habitation. In Santa Barbara, Calif., so many people live in their cars that the local street medicine team provides care in automobiles.
Federal and regional estimates for the number of homeless people in the Lehigh Valley — which includes the cities of Allentown, Bethlehem and Easton — range from more than 700 to almost twice that number. But that’s likely a big undercount.
A research study of people who sought care at three area emergency rooms during the summer of 2015 and the following winter identified 7 percent as homeless. Feldman, who led the study, said the finding suggested that more than 9,200 of the health system’s emergency room patients were homeless sometime during the year — in communities with no permanent emergency beds for couples and fewer than two dozen for women.
The LVHN Street Medicine program, which he founded, takes care of about 1,500 people a year. Since 2015, it has pursued its mission relentlessly, taking laptops into the woods to get homeless patients insured, usually through Medicaid; today, 74 percent have coverage. Over the same period, emergency room visits by the program’s patients have fallen by about three-quarters and admissions by roughly two-thirds.
It has taken Feldman years to get to this point. In high school, he began lifting weights after getting into a car accident and fracturing three vertebrae. In 2000, as a freshman at Pennsylvania State University, he won the National Physique Committee teen championship.
“It gave me laser focus, but I was the only person who was helped,” he said. “It was very unfulfilling, and I decided that whatever I did after that would be different.”
His close collaborator is his wife, Corinne Feldman, a physician assistant who is an assistant professor at DeSales University. When they first moved to the Lehigh Valley in 2005, the couple wanted to work with the homeless but couldn’t find them — until realizing they were in campsites in the woods. These days, one encampment is even in the shadow of a defunct Bethlehem Steel facility.
The Feldmans started by setting up free clinics in shelters where they worked without pay. But a 2013 Boston conference on street medicine sharpened their focus. They would go to wherever the homeless were.
“We thought, ‘This is all we want to do with our lives,’ ” he recounted.
By then a physician assistant at Lehigh Valley Hospital, Brett Feldman got a grant from a local philanthropy, the Dorothy Rider Pool Health Care Trust, that allowed him to do street medicine one day a week. Over time, he received more grants, as well as backing from the health system to set up a full-time street medicine program. It launched in 2014.
There have been numerous disappointments and heartbreaks: Two patients at an encampment in Bethlehem froze to death. A man with third-degree burns from sleeping on a heating vent fled rather than have his badly infected lower leg amputated. And before the psychiatrist could come out, Duckie disappeared.
At the same time, there have been poignant victories. When a 50-year-old man, living in a drainage pipe, was given a diagnosis of advanced colon cancer, he declined treatment but eventually was able to move into an apartment, where the street-medicine team provided him palliative care. When his symptoms worsened and Feldman said it was time to go to hospice, the man replied, “First, I have to clean up the apartment because the landlord was so nice.”
The team helped him do the cleaning and then took him to hospice, where he died a peaceful death.