Hospitalist Tackles Chronic Disease With Food Pharmacies

Jennifer L.W. Fink, BSN

Disclosures

December 29, 2017

Before January 2017, Rita Nguyen, MD, was "pretty much like any other academic hospitalist," she says. She worked full-time at Zuckerberg San Francisco General Hospital and Trauma Center, caring for hospitalized adults. In the hospital, she could provide excellent care to patients, but once they were discharged, many didn't have the necessary resources to adopt healthier habits.

Inspired by programs in other parts of the country, Dr Nguyen worked to establish at her hospital a food pharmacy, a program that allows physicians to prescribe healthy food to patients and gives them affordable access to those foods. Today, she is a chronic disease specialist with the San Francisco Department of Public Health and a leader of the San Francisco Health Network's Food Pharmacy program. She continues to see patients as a hospitalist about 2 weeks of the year.

Medscape: How did a hospitalist end up doing public health?

Dr Nguyen: What drew me to medicine was its potential to unite the humanitarian promises of medicine with social justice. I actually did a primary care residency because I believe in the fundamentals of primary care; that's really what our country needs to create healthier people in communities.

On a clinical level, I found myself drawn to inpatient hospital medicine. I love taking care of patients in the inpatient setting, but I also recognize that so much of what we see in the hospital could be prevented. Some people are sort of surprised that I'm actually a hospitalist and a primary care doctor, but to that I say, why should hospitalists be limited by a building just because that's what we're called? Why should the scope and impact of our work be constrained by the walls of a hospital? If the ultimate goal is to keep patients in communities well, we should be reaching beyond the walls of the hospital.

Medscape: Why a food pharmacy?

Dr Nguyen: When I had a primary care clinic, I'd give my patients with hypertension and diabetes their medications and say, "You also have to eat well." Some of my patients actually said to me, "It's really stressful when you keep reminding me of that, because it's not as if I don't want to; I just can't afford it, or there's no grocery store around."

So often these patients would come back with elevated blood pressures and elevated blood sugars. It was these patients who really fueled my desire to do something. I thought, why can't we reorient the way the healthcare system operates and focus more on what people tell us that they need help with?

Medscape: How is the food pharmacy program funded?

Dr Nguyen: I really want to give a shout-out to the San Francisco Health Network. [The San Francisco Health Network is the Department of Public Health of San Francisco's integrated system of healthcare delivery.] Their priority is to deliver high-quality care, and they've identified this as a strategic priority. They wanted to address hypertension equity and hypertension quality of care for primary care patients, and they chose two interventions to focus on; one of them was the food pharmacy. So they funded a staff person to help support the scaling of the model.

One of the things that's unique about our program is that we have an entire health network that's said, "This is a priority." That's helped us scale our efforts so that patients can go to whichever clinic is most convenient for them to fill their "prescriptions" (which provide a few months' worth of healthy food at no cost to the patient). Patients can go to a place where they're already comfortable, a place they already associate with health and healthcare; that really ties together the message that food is part of healthcare. Patients receive written prescriptions once they arrive at the food pharmacy, and some of our clinics have started using the prescriptions to refer patients directly from clinic.

Our predominant model now is referral from a list of patients whom we know have poorly controlled hypertension (so they're getting phone calls and not necessarily a physical prescription). This partially has to do with the fact that this is a relatively new pilot, so we haven't done a huge education campaign among all clinic providers to start handing out prescriptions.

Major credit also goes out to the San Francisco-Marin Food Bank. There's an extensive food pantry network in San Francisco, but a lot of folks feel stigma about going to food pantries to get food. The food pantry people see this as an opportunity to leverage the medical messaging: This isn't just about a free handout, but it's about your medical care. This is part of your treatment plan, and your doctor has said that it's just as important as your pills. And you can get it where you get healthcare.

Medscape: When did the food pharmacy program kick off in San Francisco?

Dr Nguyen: Our initial attempts were as early as 2013. I worked with a number of stakeholders at the hospital, including the executive leadership and CEO, and we were able to pilot something at the hospital by 2015. We ended up having them move the food pharmacy out of the hospital and into the primary care clinics, which ended up being great. We now have food pharmacies in three of our 14 primary care clinics, and we plan to get going in two or three more by the end of the year.

Currently, our focus is patients with hypertension. Some clinics have chosen to expand who they give prescriptions to include patients with diabetes. (So you get a prescription if you have hypertension or diabetes.)

Our initial pilots that ran this calendar year had us outreaching to patients with these health conditions via phone calls inviting them to come to the food pharmacy to fill metaphorical prescriptions (rather than physical prescriptions being given by a doctor), but now that our clinics are making their pilots more permanent, we're giving out more traditional paper prescriptions to patients rather than just relying on outreach calls to a select group of patients.

Medscape: Who determines what a patient should eat?

Dr Nguyen: When patients show up, they are allowed to take whatever they like. We don't dictate what people get; we just ensure that everything is offered is appropriate. There is no junk food at our food pharmacies.

Our nutritionist works closely with the food banks to ensure that the foods being delivered from the food pantries are consistent with a heart-healthy diet. When we were targeting diabetic patients, she ensured that we were only offering food items that would be diabetic-friendly. That did not mean we excluded all carbs, though. When we received such items as potatoes, we would do education around what would be an appropriate serving size for a diabetic, so it was a teaching moment; several patients falsely thought they were forbidden to eat starchy foods. We were able to clarify the importance of portion size.

Medscape: How have patients reacted to the program?

Dr Nguyen: It's been very well received by patients. Being able to fill a prescription for food is just part of it. We also have cooking demonstrations and nutritionists, and we plug people in to other food resources, such as CalFresh (California's version of SNAP); food voucher programs; WIC; local food pantries; home-delivered meal programs, such as Meals on Wheels; congregate meal sites for seniors or people who are disabled; and summer lunch programs for families with kids when they're out of school. There really is a sense of community among those who come.

For so many people, the messaging they've gotten about nutritionists and healthy eating is negative: "Don't do this, don't do that." Now we're offering positive messaging: "Look how tasty your food could be, and here are some ways you can simply, quickly, and cheaply prepare these foods."

Medscape: Has the food pharmacy program positively affected the health of patients?

Dr Nguyen: When we ran our pilot, we collected some pre- and postdata to get a sense of the impact; we also went back and looked at chart data. Now, this is a small sample size of about 15, but of patients who had A1c measured before and after the intervention, there was a trend toward decreased A1c. I'm not going to say that's all because of the food pharmacy program; a lot of other things happened for these patients, including medication changes. Perhaps most important, 75% of the 21 patients who responded to our postpilot survey told us that the program increased their access to healthy food; 50% reported eating more or a lot more healthy foods. We hope to publish our data.

Now we're looking at hypertension and entering data and are studying them.

Medscape: What advice do you have for hospitalists who want to address health on a broader scale?

Dr Nguyen: The work should be driven by the people you want to help. If you go to patients for inspiration, look at their lives, and hear what they're saying, you may see what you should turn your attention to. For me, it was my patients expressing frustration over not being able to eat well. In the inpatient setting, I take care of a lot of patients with chronic disease who are food-insecure; I know that when they leave the hospital, they're not eating right. That's what triggered my interest and actions.

I think everyone has a capacity to make a difference in patients' lives, not just in the hospital room. Think about what happened that led them to the hospital in the first place.

Medscape: Are there other organizations throughout the country that hospitalists could contact to help establish food pharmacies?

Dr Nguyen: Unfortunately, there's no unifying entity, but Boston Medical Center is a great model. Hennepin County Medical Center in Minnesota also has something similar. There are others that are much smaller and newer, but those are two that have been around the longest.

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