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Many Americans take good nutrition for granted. They shouldn’t. Hunger is a growing problem in the U.S. In 2019, more than 1 in every 10 American households suffered from food insecurity, meaning that they lacked access to enough food for an active, healthy life for all household members.

The Covid-19 pandemic made things worse. The need for food assistance increased as millions of families — according to one estimate, nearly 1 in 4 U.S. households across the country — experienced food insecurity, the result of pandemic-related factors such as job loss. Quarantines and social distancing made it harder to get to affordable grocery stores and for food relief organizations to provide food safely.

These challenges underscore the urgent need for health care and food relief organizations to find creative ways to work together to address food insecurity in the U.S. Poor nutrition can cause serious disease and makes it even more challenging for individuals living with chronic illnesses like diabetes or high blood pressure to manage their conditions.

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As is sadly the case for so many health and social problems in the U.S., food insecurity reflects the social inequities that exist in many American communities. Before the pandemic emerged, nearly 16% of Latinx people, more than 19% of Black people, and 23.5% of Native American people lived in food-insecure households compared to 8% of white people.

The problem is national, but the path forward is at the state and local levels. As states begin making investments in alleviating food insecurity, there are enormous opportunities for health care organizations to partner with social service organizations, strategically supporting communities to improve residents’ ability to make healthy choices. The path to collaboration, however, is not always smooth.

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Health care professionals who diagnose and treat illness — and who may prescribe food assistance — prefer standard, scalable workflows and procedures. Those in community-based organizations working to overcome social challenges prefer developing long-term, intuitive relationships, and tailoring services to meet clients’ needs. Health care and community-based organizations see the world differently, so coming together to help people requires that they find a common vision.

In 2019, our organizations — Community Care Cooperative (C3), a Massachusetts accountable care organization, and Project Bread, Massachusetts’ statewide anti-hunger organization, began working together to create a food security intervention under the auspices of a state Medicaid program (MassHealth) initiative. Known as Flexible Services, the initiative funds the provision of food and related social services to people with complex health conditions who are experiencing food insecurity.

Playing to our organizations’ strengths, C3 and its 18 health centers identified patients with complex health needs who were experiencing food insecurity. Project Bread then assessed each patient’s household food situation and provided tailored support to address barriers that those individuals and families were experiencing. It also connected people to the federal Supplemental Nutrition Assistance Program (SNAP, known as food stamps), food vouchers, and referrals to home-delivered meals from partner organizations Community Servings and Elder Services of Worcester Area to ensure access to healthy food, as well as offered nutrition education and cooking supplies.

Our original plan was to launch the Flexible Services program in June 2020, but the pandemic spurred us to act more quickly. While food insecurity grew in every state across the U.S., Massachusetts saw a sizable increase, with 19.6% of households reporting food insecurity at the onset of the pandemic compared to 8.2% before it began.

To address the growing need for food, we launched a streamlined program two months early, in April 2020. Over the next six months, we added more staff to increase the capacity of the program to serve more people, and expanded the services offered to reflect the original plan. At the end of the program’s first year, it had helped more than 2,000 Massachusetts residents (four times more than the original plan) with expanded access to healthy food and enrollment in federal nutrition programs, providing them with the cooking equipment and nutrition education needed to make healthy food choices. Nearly everyone who received food assistance through the program reported that their health was better as a result of the support.

What we did and learned can serve as a guide for other organizations aiming to collaborate to address social determinants of health.

The five “co-s.” Leverage collaboration, co-design, co-creation, communication, and consistency as guiding principles for shared missions to find common ground and create durability to weather unexpected challenges. This strong foundation allowed us to pivot rapidly to a new service delivery model as soon as the pandemic’s extent became clear.

Dialogue and data sharing. Jointly develop mechanisms, workflows, and a technology system to foster dialogue and allow data sharing across organizations. C3 updated Project Bread staff about health information to inform nutrition education, while Project Bread shared program evaluation data, identifying needs for additional services.

Equal voices in planning. Each organization had an equal voice in strategy, decision-making, and day-to-day operations.

Feedback for improvement. Our organizations met regularly to collect and deploy feedback. Information from Project Bread nutrition coordinators highlighted opportunities to improve C3’s training and communication with health center staff in order to set expectations with patients and improve the success of referrals, while C3 provided more details about patients’ health conditions so Project Bread staff were better equipped to help them meet their health and nutrition goals.

Build trust. Creating strong relationships across organizations led to an enhanced level of trust, allowing each organization to focus on what it does best without stepping on each other’s toes, resulting in increased efficiency and better care for those we serve.

The Flexible Services program continues to grow and serve the people who need it. We anticipate referring another 2,500 people to the program in 2021, and 3,000 in 2022, while also adding support for transportation and more disease-specific nutrition education and wellness coaching.

This program certainly isn’t the only one helping address food insecurity. Using state funding and Delivery System Reform Incentive Payment waivers to Medicaid, Massachusetts, Oregon, North Carolina, California, and other states have launched programs to support healthy food access and alleviate food insecurity as a root cause of poor health.

An ongoing pilot program in California, launched in 2018, has successfully met the needs of 1,400 Medicaid beneficiaries living with congestive heart failure by providing them with home-delivered, medically tailored meals for three months at a time. A Medicaid waiver in Oregon created a health-related services program allowing Medicaid programs to offer medically tailored food through vouchers or meal delivery. The North Carolina Healthy Opportunities program, set to launch in the spring of 2022, will test interventions focused on food security, housing, transportation, and interpersonal safety for Medicaid enrollees.

As we reflect on the past 18 months and look to the future, we are confident that our organizations have developed a strong partnership that will support the continued evolution of our food assistance program. While the guiding principles on which it is based are simple, they can provide guidance for other organizations or groups coalescing to solve complex social and health problems like addressing food insecurity and improving nutrition for people with chronic medical issues.

Christina Severin is the president and CEO of Community Care Cooperative (C3), a 501(c)(3) accountable care organization made up of 18 health centers across Massachusetts. Erin McAleer is the CEO of Project Bread, a 501(c)(3) organization that addresses food insecurity in Massachusetts.

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