When Leora Porter’s doctor told her she was pre-diabetic a couple of years ago, she said she didn’t take it too seriously at first.
At the time, she was out of a job and focused on how she would support her two children.
“I had so many other things going on,” said Porter, a Cleveland Heights resident. “You know, I wanted to make sure that we still had a house to go to. I needed a job.”
But Porter was open to a program that a nurse at her doctor’s office told her about: Because she was at risk of developing diabetes, she could receive coupons to shop for free fruits and vegetables at produce and farmers markets around Cleveland. The goal was to help prevent diabetes by eating healthier foods.
Not only did it work – Porter said her blood sugar levels dropped – but the program gave her an opportunity to enjoy shopping with her kids and more knowledge around preparing produce. The vendors at the West Side Market, where she took her coupons weekly, gave her cooking tips. Like, try making guacamole with lemons, not limes, so kids like it better.
“It just made me feel — it made me feel confident,” Porter said. “Knowing that, OK, what I’m eating can make or break me.”
Health professionals in Northeast Ohio are working to grow more programs like Porter’s and looking for ways to sustain them long-term, in the hope that they can provide health benefits to more residents. Researchers at Case Western Reserve University’s Center for Environmental Health, alongside a doctor who leads a regional medical quality improvement hub, took advantage of extra funding made available last summer to pilot another free produce program, one that was slightly different from Porter’s. Patients at clinics and hospitals in Northeast Ohio were offered $100 in coupons to spend at farmers markets on produce in May and June.
The one-time program also helped them test out a new strategy – targeting patients based on insurance status instead of a health diagnosis. But it operated for just around six weeks, an example of what one expert called a “hodge-podge” of efforts to connect patients with free produce in the last decade. The hope is that these pop-up programs can help build relationships between medical and food systems that can be scaled up if, or when, funding is in place to do so.
“Over a decade, there’s been several prescription programs, but they kind of come and go, come and go,” said Darcy Freedman, the director of the Mary Ann Swetland Center for Environmental Health at Case Western Reserve University. She said the center wants to determine “how do you create that sustainable infrastructure so that it can keep going?”
A new produce prescription program in Northeast Ohio
The environmental health center receives a grant from the Cuyahoga County Board of Health to increase the number of clinics and hospitals prescribing produce and the number of residents receiving the benefits.
Leaders there jumped at an opportunity last year from the Northeast Ohio Quality Improvement Hub, which is led by doctors from Case Western Reserve and Northeast Ohio Medical University. The hub had learned there was extra funding from the Ohio Department of Medicaid that needed to be used quickly.
For the past two years, the hub focused on lowering blood sugar levels for those living with diabetes in Northeast Ohio. Health care providers in the region often saw patients struggle because they lacked healthy food, especially if they ran out of food stamps at the end of the month.
Dr. Shari Bolen, a leader of the quality improvement hub and a professor of medicine at Case Western Reserve University, wanted to see if she could use the money to help those patients, rapidly. The environmental health center had connections with local farmers markets and an app that patients could use to find what food items would be available. Last summer, the health care hub and the Center for Environmental Health joined forces to start handing out coupons for free produce to patients last summer.
Testing a larger program with fewer barriers
The new program tested out a few different approaches to prescribing produce.
One was pushing a larger-scale effort. Bolen said that different health systems in Northeast Ohio have “food as medicine” programs. But the new coupon program stretched across three major local hospital systems — MetroHealth, University Hospitals and Cleveland Clinic — as well as federally qualified health centers.
“I wanted something more at scale to reach more people,” Bolen said.
The program reached 431 patients in Cleveland, Akron and several smaller cities in the region.
Another aspect: Unlike Porter’s program, patients didn’t need to have a pre-diabetes diagnosis to get the coupons. Instead, they had to be enrolled in a public insurance program such as Medicare or Medicaid or be uninsured.
Leaders hoped lowering the requirements to get in the door could make it easier for residents to enroll and put less work on medical staff’s plate.
“How do you build the system for that to work easily and not become another 24 hours of work added to anybody’s existing, already-overloaded system?” Freedman said.
To recruit, the program set up booths within the health clinics that patients could visit on their way in or out of a doctor’s visit. Though participants weren’t required to have a chronic health condition, the program targeted clinics that served a high volume of Medicaid patients, who are more likely to be food insecure.
Produce prescription results
Out of more than 400 people who received coupons, most were Black or African-American, and 70% were receiving Medicaid.
Throughout the six weeks the program was open, a little over half of the participants redeemed at least $10 of their $100 in coupons at a local farmers market. About a third of participants visited two farmers markets.
That’s within the range of what most programs have seen when passing out coupons for fruits and vegetables from doctors’ offices, said Owusua Yamoah, a co-lead of the project and a research scientist at the Swetland Center.
“There is room to really think about, like, how do we increase redemption of these programs?” Yamoah said.
Patients with the coupons reported eating more fruits and vegetables, though the program didn’t measure their health outcomes because of the time limit it dealt with.
The produce prescription program also gave a hand up to the farmers markets where patients shopped. In total, participants spent around $17,800 in the weeks the program operated.
Three of the North Union Farmers Market locations in Cleveland participated in last summer’s produce prescription program. It’s not the first time North Union has partnered with a health care system to make fresh fruits and veggies accessible to patients, said Emma Visnic, the director of marketing and communications for the market.
“Any of these programs, you know, is a great way to be introduced to new customers who might be already eligible for some of our other programs,” Visnic said. That includes SNAP benefits, which can be spent at the market all year long.
Next steps for produce programs
Freedman said the center has two goals to improve the long-term sustainability of produce prescriptions.
One is making sure there’s enough locally grown food for residents with free produce coupons. Not many local farmers have the capacity to grow enough food for every patient who might participate. Freedman said there needs to be more work on how to combine produce from different farmers into one place.
“Right now, there isn’t a way to really bring together food from multiple local growers into a [produce prescription] program,” Freedman said.
The other challenge is funding. Freedman hopes to see Medicaid ultimately reimburse patients for produce prescriptions. Other states, like North Carolina, have successfully received approval from the federal government to use Medicaid to cover at least some costs of healthy foods for patients.
“I don’t think it’s going to happen in Ohio immediately, but potentially over time,” Freedman said.
Freedman said there are other ways to get Medicaid, Medicare and insurance companies to cover the cost of produce – and she sees an appetite amongst those organizations to get involved.
Porter hopes to see long-term funding
Without sustainable funding, produce prescription programs can come and go. The grant that funded Porter’s coupons, which was from the U.S. Department of Agriculture, ended last September.
That’s hard on patients. Porter said she never got notice that the program ended. She just stopped receiving coupons.
Losing the program felt like losing a sense of control over her health, she said.
Porter now works as a community housing coordinator for a local nonprofit that assists veterans. She said she still tries to incorporate fresh fruits and vegetables into her diet. But her paycheck just can’t cover everything she wants.
“It’s like, do I pay a gas bill, or do I put fresh fruits and vegetables?” Porter said. “I’m gonna pay the gas bill.”
The tough part is that she’s seen her blood sugar levels go back up. At a doctor’s appointment in December, she found out that she was pre-diabetic, once again.
It was proof, she said: for her, food really was medicine.
