Care Redesign

Food as Medicine: Meeting the Needs of Complex Medical Diets

Interview · May 18, 2018

David Waters CEO of Community Servings and Tom Lee


Thomas H. Lee, MD, interviews David B. Waters, MA, Chief Executive Officer for Community Servings.

 

Tom Lee:  This is Tom Lee from NEJM Catalyst, and I’m talking today with David Waters, who is the CEO of an organization known as Community Servings. I was interested in interviewing David in part because in my work on the board of Geisinger Health System, I got very interested and involved with people who are working on giving patients with poorly controlled diabetes free healthy food, and finding that it leads to better health and lower costs. There’s an article in NEJM Catalyst about that. When I was talking with those folks and I mentioned David Waters and Community Servings, I found out that in some circles, at least, you are rock stars — you’re heroes. But I think most of our listeners will not have heard of you.

Can you tell us what Community Servings is?

David Waters:  Sure. Thanks, Tom. It’s great to be here. Community Servings is a food and nutrition program for people who are critically and chronically ill. We deliver over 600,000 meals a year to a patient’s home, [to someone] who’s struggling with an illness where they can’t shop and cook for themselves, but equally important, they aren’t able to manage complex medical diets. We have the ability to customize their meals to fit 15 different medical diets.

Lee:  When I first heard about Community Servings, I thought you were some kind of combination of a food bank and Uber, but I was completely wrong. You’re really part of health care. Tell me, how did you begin?

Waters:  Community Servings grew out of the HIV epidemic in the late 1990s. As some of your listeners might know, in the early years of AIDS a majority of people died of what was called AIDS wasting syndrome, which is really malnutrition. There were not yet drugs, either AZT or cocktails, to care for people, and so food became the only intervention. And we like to think food is medicine.

As we’ve evolved from purely an HIV program to a program that feeds people with any illness, we see the advantages of controlling patients’ complex medical diets if they’re not able to do it on their own, both in terms of cost savings and improved outcomes.

Lee:  I’m old enough that I remember being a doctor attending on the wards during those early days of HIV care, before highly active antiretroviral therapy came along in 1994 and 1995. Doing the work I was doing in the hospital was hard, but what you were doing must’ve been so much harder. You should be proud of the work that you did back then, and proud of those roots.

Who are the patients you’re helping today, what do they have, and where do they come from? Are they all poor patients, or is the criteria mainly that they’re sick?

Waters:  Our program is not specifically an anti-hunger program; it’s about using food as a health care intervention. But 94% of our patients are living below 200% of the federal poverty level. They are hungry, they are poor, and, most importantly, they’re very isolated by their illness — unable to walk to the store, carry a bag of groceries, or stand at the stove.

Seventy percent of them are dealing with more than one illness and more than one dietary restriction, so one of the unique things about our program that we’ve evolved over the years from HIV to now cancer, kidney disease, diabetes, etc., is the ability to blend up to three different medical diets in the same meal.

All of our food is made completely from scratch using local farm produce and herbs we grow on our property. It’s beautiful food, but most relevant for your listeners is that we can manage issues like potassium, glucose, vitamin K, food allergies, etc.

Lee:  One of the questions our readers will be wondering is what happens when you do that. I know that you and your colleagues worked with Seth Berkowitz, a researcher who probably has done as good a job as anyone in studying social needs and what happens when you meet social needs. Can you tell us a little bit about the data that you guys just published?

Waters:  About 4 years ago we went to senior health care leaders in the Boston community and said, “We think that what we’re doing is health care, more so than pure anti-hunger work, and we are interested in the idea that insurance might reimburse for this.” They smartly said, “You would need to prove a return on investment.”

So with Dr. Berkowitz, who at that time was at MGH [Massachusetts General Hospital] and is now at UNC [Internal Medicine], we were able to look at cost data for patients we fed through an insurance program for dual-eligible patients and compare the insurance data to patients we hadn’t fed. What we were able to establish was a 16% savings for patients who were receiving medically tailored meals versus comparable patients who weren’t.

It was a small study. It was only about 133 of our patients, but it has led to a study we’re working on now, funded by the Robert Wood Johnson Foundation, that will be looking at 8,000 insurance records: 2,000 we fed and 6,000 we didn’t feed. The study published now is sort of a proof of concept for the larger study, but what it shows specifically is less ambulance usage, fewer ER visits, and fewer in-patient hospitalizations, which of course are tremendously expensive.

Lee:  That makes the case that this is worth considering on a scalable level. How are you guys getting funded?

Waters:  Originally, we were funded through public money for HIV, government money — what’s called Ryan White [the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act] — but [when expanding] to feed other illnesses there’s no similar government commitment to feed the sick, so we had to access philanthropic dollars to feed people. Most recently, we’ve been making the argument to health insurance and we have about six early adopters, in terms of insurance contracts, where we’re being paid to feed their patients, typically dual-eligible patients. It represents now, in only 3 years, about 20% of our income.

We expect that with the growth of ACOs, particularly here in Massachusetts under MassHealth, there will be opportunities for new contracts, whether they’re dual eligible, Medicaid, Medicare, or some of the new Medicare Advantage programs [that] are also interested in this as a potential intervention and cost savings.

Lee:  There are some encouraging signs. There are new regulations coming out for Medicare Advantage. What is your ideal vision for how this should work, and do you think we might be about to see it in the next year or two?

Waters:  I really think that we’re at that tipping point. We’re certainly getting a lot of encouragement from the health care world. What I always say to health care leaders is, “We’re not saying feed everyone; we’re saying the potential to feed people where you’re seeing poor outcomes and you know it’s tied to diet.” If the super-utilizers can’t control their diet on their own, that ends up being the spiral that puts them back in the hospital or back in the ER on a regular basis. If we can control their diet and it’s cheaper than the other services, then it makes sense.

What I would hope for, ultimately, is that we’re going to develop some kind of a diagnostic code, or a decision-making tool. Depending on your diagnosis you might receive medically tailored meals for 3 weeks or 3 months, or for some disabled patients it might be less expensive to provide medical meals forever if you’re going to keep them in their home and out of a nursing home clinical setting.

Lee:  We are grateful for the work you’ve done over decades, David, you and your organization, and we’re looking forward to seeing how it goes in the years ahead. Collecting data, as you guys are doing, is very important so that this becomes part of a strategy, not just charity, but I think you guys are well on your way to making that happen. Thanks for joining us today. We’ll be checking in some time in the future, I’m sure.

Waters:  It’s a pleasure, Tom. We appreciate it. Thank you.

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