Public health organizations, including the Academy of Nutrition and Dietetics and the American Hospital Association, recognize the importance of achieving food and nutrition security to improve health outcomes, reduce healthcare costs, and advance health equity. In response, federal, state, and private agencies are increasingly seeking to fund healthcare-based interventions to address food insecurity among patients. Simultaneously, nutrition-based interventions targeting chronic diseases have grown across the United States as part of the broader “Food is Medicine” movement. Few studies have examined the successes, challenges, and limitations of such efforts. As Food is Medicine programs continue to expand, identifying common approaches, metrics, and outcomes will be imperative for ensuring program success, replicability, and sustainability. Beginning in 2020, the Food as Medicine (FAM) program, a multipronged, collaborative intervention at Grady Health System has sought to combat food insecurity and improve patient health by leveraging community resources, expertise, and existing partnerships. Using this program as a case study, we (1) outline the collaborative development of the FAM program; (2) describe and characterize patient engagement in the initial 2 years; and (3) summarize strengths and lessons learned for future hospital-based food and nutrition programming. As this case study illustrates, the Food as Medicine program provides a novel model for building health equity through food within healthcare organizations.

The Affordable Care Act (2010) and Medicare Access and CHIP Reauthorization Act (2015) ushered in a new era of Medicare value-based payment programs. Five major mandatory pay-for-performance programs have been implemented since 2012 with increasing positive and negative payment adjustments over time. A growing body of evidence indicates that these programs are inequitable and financially penalize safety-net systems and systems that care for a higher proportion of racial and ethnic minority patients. Payments from penalized systems are often redistributed to those with higher performance scores, which are predominantly better-financed, large, urban systems that serve less vulnerable patient populations — a “Reverse Robin Hood” effect. This inequity may be diminished by adjusting for social risk factors in payment policy. In this position statement, we review the literature evaluating equity across Medicare value-based payment programs, major policy reports evaluating the use of social risk data, and provide recommendations on behalf of the Society of General Internal Medicine regarding how to address social risk and unmet health-related social needs in these programs. Immediate recommendations include implementing peer grouping (stratification of healthcare systems by proportion of dual eligible Medicare/Medicaid patients served, and evaluation of performance and subsequent payment adjustments within strata) until optimal methods for accounting for social risk are defined. Short-term recommendations include using census-based, area-level indices to account for neighborhood-level social risk, and developing standardized approaches to collecting individual socioeconomic data in a robust but sensitive way. Long-term recommendations include implementing a research agenda to evaluate best practices for accounting for social risk, developing validated health equity specific measures of care, and creating policies to better integrate healthcare and social services.

Background Some American households experience food insecurity, where access to adequate food is limited by lack of money and other resources. As such, we implemented a free 6-month Fruit and Vegetable Prescription Program within a large urban safety-net hospital. Methods 32 participants completed a baseline and postintervention qualitative evaluation about food-related behaviour 6 months after study completion. Deductive codes were developed based on the key topics addressed in the interviews; inductive codes were identified from analytically reading the transcripts. Transcripts were coded in MAXQDA V.12 (Release 12.3.2). Results The information collected in the qualitative interviews highlights the many factors that affect dietary habits, including the environmental and individual influences that play a role in food choices people make. Participants expressed very positive sentiments overall about their programme participation. Conclusions A multifaceted intervention that targets individual behaviour change, enhances nutritional knowledge and skills, and reduces socioeconomic barriers to accessing fresh produce may enhance participant knowledge and self-efficacy around healthy eating. However, socioeconomic factors remain as continual barriers to sustaining healthy eating over the long term. Ongoing efforts that address social determinants of health may be necessary to promote sustainability of behaviour change.

Introduction: Half of the U.S. population has chronic illness. Many disparities exist in health care for management of chronic disease among poorer individuals, including decreased access to healthy foods, homelessness, and difficulty navigating large hospital systems due to low health literacy. A survey of resident physicians found significant gaps in preparedness to provide cross-cultural care. Education is needed to promote consideration of patients' social and cultural barriers in managing disease and navigating the health care system. This module was created as an introduction to social determinants of health, and highlights disparities in access to healthy food, water, shelter, and medical care in a sample of the residents' own continuity clinic patient panel. Methods: We designed this experiential module to help internal medicine residents at an urban institution better understand how social constructs might hinder patient health. Activities were chosen by learners from a list of options, and carried out in small groups during a half day of protected time. We used reflective writing exercises to elicit resident thoughts about the module. Results: Thirty-nine second-year residents participated in the module. Following the course, 41% of residents submitted reflective statements about their experience. Reflective responses suggest an enhanced appreciation for social determinants of health, a sense of empowerment to advocate for better patient resources, and an appreciation for systems-level factors that play a role in social determinants of health. Discussion: Our results demonstrate that a short, experience-based module can impact resident attitudes about social determinants and improve advocacy around identifying community resources.

Telehealth services, specifically telemedicine audio-video and audio-only patient encounters, expanded dramatically during the COVID-19 pandemic through temporary waivers and flexibilities tied to the public health emergency. Early studies demonstrate significant potential to advance the quintuple aim (patient experience, health outcomes, cost, clinician well-being, and equity). Supported well, telemedicine can particularly improve patient satisfaction, health outcomes, and equity. Implemented poorly, telemedicine can facilitate unsafe care, worsen disparities, and waste resources. Without further action from lawmakers and agencies, payment will end for many telemedicine services currently used by millions of Americans at the end of 2024. Policymakers, health systems, clinicians, and educators must decide how to support, implement, and sustain telemedicine, and long-term studies and clinical practice guidelines are emerging to provide direction. In this position statement, we use clinical vignettes to review relevant literature and highlight where key actions are needed. These include areas where telemedicine must be expanded (e.g., to support chronic disease management) and where guidelines are needed (e.g., to prevent inequitable offering of telemedicine services and prevent unsafe or low-value care). We provide policy, clinical practice, and education recommendations for telemedicine on behalf of the Society of General Internal Medicine. Policy recommendations include ending geographic and site restrictions, expanding the definition of telemedicine to include audio-only services, establishing appropriate telemedicine service codes, and expanding broadband access to all Americans. Clinical practice recommendations include ensuring appropriate telemedicine use (for limited acute care situations or in conjunction with in-person services to extend longitudinal care relationships), that the choice of modality be done through patient-clinician shared decision-making, and that health systems design telemedicine services through community partnerships to ensure equitable implementation. Education recommendations include developing telemedicine-specific educational strategies for trainees that align with accreditation body competencies and providing educators with protected time and faculty development resources.

Background: To evaluate the impact of home-delivered, medically tailored meals and medical nutrition therapy among food-insecure patients following hospitalization for congestive heart failure by comparing clinical outcomes to a retrospectively matched cohort. Methods: Patients at high risk for readmission and food insecurity received up to three months of medically tailored meals and medical nutrition therapy after discharge. Pre-intervention and post-intervention weight, body mass index, blood pressure, and dietary intake were assessed. A combination of difference-in-difference and logistic regression models were used to compare changes between cohorts and evaluate impact attributable to the program. Results: Thirty-nine program participants were compared to a matched cohort of 117 unexposed patients. Participants experienced a marginal reduction in body mass index and an increase in systolic and diastolic blood pressure; however, these results were not statistically significant. To determine relevance to clinical cut-offs, logistic regressions were used, demonstrating that exposure to the intervention resulted in higher odds of a categorical reduction in blood pressure (OR: 1.85), though this did not reach statistical significance (95% CI: 0.67–5.32). Pre vs. post trends indicated that more-healthful foods and drinks increased numerically or remained similar to baseline, while less-healthful foods decreased numerically or remained similar to baseline. Conclusions and implications: These findings highlight the need for more longitudinal research on medically tailored meals and medical nutrition therapy interventions using clinical outcomes while setting realistic suggestions for program implementation. This study additionally illustrates the promise of integrating electronic medical record data and matched cohorts into medical nutrition program evaluation within the health sector.

As members of the Clinical Practice Committee (CPC) of the Society for General Internal Medicine (SGIM), we support practice innovation and transformation to achieve a more just system by which all people can achieve and maintain optimal health. The COVID-19 pandemic has tested the US healthcare delivery system and sharpened our national awareness of long-standing and ingrained system shortcomings. In the face of crisis, SGIM members innovated and energetically mobilized to focus on the immediate needs of our patients and communities. Reflecting on these experiences, we are called to consider what was learned from the pandemic that applies to the future of healthcare delivery. CPC members include leaders in primary care delivery, practice finance, quality of care, patient safety, hospital practice, and health policy. CPC members provide expertise in clinical practice, serving as primary care doctors, hospitalists, and patient advocates who understand the intensity of care needed for those with severe COVID-19 infections, the disproportionate impact of the pandemic on Black and Brown communities, the struggles created for those with poor access to care, and the physical and emotional impact it has placed on patients, families, and clinicians. In this consensus statement, we summarize lessons learned from the 2020-2021 pandemic and their broader implications for reform in healthcare delivery. We provide a platform for future work by identifying many interactive elements of healthcare delivery that must be simultaneously addressed in order to ensure that care is accessible, equitably provided, patient-centered, and cost-effective.