Michigan Offers Fresh Rx Program to Patients with Hypertension

Submission Date: May 2024

State/Territory Submitted on the Behalf of: Michigan

States/Territories Involved: Michigan

Funding Source: CDC

CDC Funding:

Yes

CDC Funding (Specified):

Other CDC Funding

Grant Number:

DP18-1815: Strategies for Improving the Health of Americans Through Prevention and Management of Diabetes, Heart Disease, and Stroke

Other Federal Funding:

N/A

Other Funding:

Other

Domain Addressed:

Community-Clinical Linkages, Health Promotion

Public Health Issue:

In 2021, cardiovascular disease (CVD) was in the top leading causes of death among Michigan (MI) residents living in the City of Detroit. Heart disease and stroke accounted for approximately 30% of deaths. Approximately one in seven MI adults living in Detroit had CVD based on 2021 data from the Michigan Behavioral Risk Factor Surveillance System (MiBRFSS). Over one-third of adults aged 75 years or older had CVD (MiBRFSS, 2017-2021 combined). The estimated age-adjusted CVD prevalence among adults with a household income less than $20,000 (16%) was higher than among adults with a household income of at least $20,000 (8%), and adults with an education up to high school had a higher CVD prevalence than adults with a college degree or higher (14% vs. 8%). High blood pressure and high blood cholesterol are modifiable risk factors for CVD. Approximately 80% of adults with CVD also had hypertension (MiBRFSS, 2017, 2019, and 2021 combined). By increasing access to fresh fruits and vegetables and managing high blood pressure, it is possible to improve health outcomes for those disproportionately impacted by chronic disease and food insecurity.

Project Objectives:

The Michigan Department of Health & Human Services’ (MDHHS) Heart Disease and Stroke Prevention Unit (HDSP) aims to reduce health disparities by implementing interventions for populations disproportionately affected by CVD. To help populations with high CVD in Detroit, we partnered with clinical and community agencies to establish a system of enrolling patients in The Fresh Prescription (Fresh Rx) program and evidence-based lifestyle change programs. This has improved access to higher cost and perishable foods and provides an evidence-based framework to self-manage one of CVD’s most impactful modifiable risk factors.

Fresh Rx is a fruit and vegetable prescription program that was developed in 2013. Since 2018, Eastern Market in Detroit has led this program and convenes a Fresh Rx Network. The Fresh Rx Network brings together healthcare and local food systems to foster innovative relationships that have helped to build this sustainable, healthy food system in Detroit. The Fresh Rx program is a promising approach that connects patients living with chronic disease to fresh locally grown produce while providing direct economic benefits to small and midsize farmers.

The Healthy Heart Ambassador Blood Pressure Self-Monitoring Program (HHAP) partners with Eastern Market to increase referrals to and participation in the Fresh Rx program, as well as additional evidence-based lifestyle change programs such as the HHAP, Diabetes Prevention Program (DPP), and SNAP Ed. As a result of our partnership, participants who qualify for multiple programs are given the opportunity to attend as many programs as they need, as long as they only participate in one program at a time.

Program Action:

Fresh Rx network members, GenesisHOPE (a community-based agency) and Authority Health’s Popoff Family Health Center, worked together to align the Fresh Rx and the HHAP programs. Patients at risk of CVD who are seen at the Popoff health center receive a “prescription” to eat more fruits and vegetables and are referred to Genesis Hope (https://www.genesishope.org/) for a nutrition consultation. Eligible participants also receive an offer to attend the HHAP Self-Monitoring Program before or after participation in the Fresh Rx program.

Community Health Workers (CHWs) trained by the Michigan Community Health Worker Alliance serve as facilitators for the HHAP. Facilitators provide one-on-one support for self-monitoring of blood pressure and support for identifying and controlling factors that can impact blood pressure, adopting healthier eating habits, and encouraging physical activity. CHWs often share ethnicity, language, socioeconomic status, and life experiences with the community members they serve, which can help participants better navigate challenges and barriers to behavior change.

The HHAP program was also implemented at Hope Village Revitalization (https://hopevillagecdc.org/) as a result of the partnership with the Fresh Rx Network. Although Hope Village is not a current Fresh Rx program site, both sites have promoted the HHAP program and other program offerings at community events, health fairs, and onsite farmers markets. The Popoff health center has hired a CHW who has been beneficial to maintaining knowledge of the program(s) and assisting with bi-directional referrals to these programs.

Data/Other Information Collected:

The Fresh Rx program has been successful in reaching populations disproportionally affected by CVD. Seven sites are participating in the Fresh Rx program, with approximately 400 people having participated in the program in 2020. Of those, 37% have an income below $25,000. The demographic breakdown of participants is as follows: African American or Black (72%), Hispanic Latino (14%), American Indian or Alaskan Native (7%), White (7%), other races (1%). This year alone, 45 referrals have been made to both the Fresh Rx program and HHAP by the Popoff clinic. While recruitment and retention in evidenced based programs can be challenging, between the two HHAP sites, Genesis Hope and Hope Village, there were at least 25 participants enrolled into the program; seven of these participants were recruited as a result of providing the program onsite at a local library. HDSP will continue to support these sites to expand capacity and reach of this program in the next few years.

Impact/Accomplishments:

Both HHAP and the Fresh Rx program have demonstrated improvements in participants’ health behaviors which in turn have been proven to improve cardiovascular health. At the beginning of the Fresh Rx program, 80% reported consuming less than the daily recommended servings of fruit and 91% reported consuming less than the daily recommended servings of vegetables. Participants have increased consumption of fruits and vegetables, with 58% reporting an increase in fruit and 46% reporting an increase in vegetable consumption. Participants also reported a decrease in consumption of unhealthy foods and beverages, with 27% reporting a reduction in unhealthy food consumption and 26% reporting a decrease in unhealthy beverage consumption. By aligning the Fresh Rx and HHAP programs, individuals who have been diagnosed with high blood pressure and/or have been prescribed antihypertensive medications are provided with an opportunity to participate in HHAP, receive additional nutrition education resources, one-on-one support, and tools to self-monitor their blood pressure. Program sites have also found creative ways to leverage this work with other health program programing, such as walking groups, learning kitchens, and programs like SNAP Ed. Eastern Market has been instrumental in promoting the programs and have distributed over 200 copies of HHAP flyers across their welcome center, main office, and information booth. Eastern Market operates their food assistance currencies in these spaces 3 days a week in the summer and 1 day a week year-round.

Challenges/Lessons Learned:

Challenges in aligning the HHAP with the Fresh Rx program include needing additional time to orient new staff, which has resulted in referral disruption and concerns about fidelity to both programs due to participants only being allowed to attend HHAP before or after participation in the Fresh Rx program.
We have learned that communication with patients from both health centers as well as with program staff is instrumental. A lesson learned was that participants are likely to disregard recruitment calls from HHAP staff if the provider does not explain the purpose of the program to them. Additionally, to overcome a shortage in blood pressure cuffs for HHAP participants, underfunded community-based agencies offering the program identified additional funding sources to receive blood pressure cuffs.

Next Steps:

The HDSP Unit will continue to partner with Eastern Market to support and align HHAP with the Fresh Rx program and there are plans to expand the HHAP to at least one additional Fresh Rx site. Eastern Market also plans to leverage existing food purchasing agreements to provide weekly fresh fruit and vegetable boxes to support nutritional needs and/or address food insecurity among participants of HHAP. Eastern Market is actively involved in policy discussions in attempt to make the Fresh Rx a sustainable program statewide.

Program Areas:

Heart Disease and Stroke

State Contact Information:

Michigan
Karen Pratt
Michigan Department of Health and Human Services
prattk4@michigan.gov

Board President's Challenge:

No

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