Catholic Health World Articles

Representatives from those hospitals' community health and well-being departments say Food Farmacy has been a success, in large part because the program has a screening system to identify people who could most benefit from chronic disease management. It also has a behavior change model that provides participants with education and resources to promote lasting results, access to professionals to coach people and help them navigate the system, and access to multiple sources of nutrient-rich food.

Eric Stone, director of community health and well-being for St. Joseph's Health, says, "Our focus has been on the education and social care pieces."

Sheilah McCart, manager of community engagement, community health and well-being at St. Peter's Health Partners, says it is critical for health care providers to address nutritional deficiency, especially as it relates to chronic disease management. Lack of healthy food "leads to so many chronic diseases, including diabetes and hypertension. In pediatric patients, it can cause learning issues. For pregnant women, it can lead to gestational diabetes, which can lead to poor pregnancy outcomes," she says.

In both the Albany and Syracuse areas, there are neighborhoods with few or no grocery stores selling fresh, healthy foods. McCart says the cost of living has been escalating faster than many people's paychecks. This has resulted in high levels of food insecurity, she says. Many people eat cheaper, heavily processed convenience food that doesn't nourish their bodies. There is a high level of nutrition-related chronic disease in these low-income areas, she says.

In Albany, the Food Is Medicine team uses Trinity Health's patient database to identify people with type 2 diabetes, gestational diabetes, pediatric obesity or malnutrition, or hypertension who also have revealed through Trinity Health's screening tool that they have socioeconomic barriers to health. Those patients can participate in the 12-week Food Is Medicine program where they receive nutrition education from a registered dietician. They also can work with community health workers from local organizations to get help navigating socioeconomic barriers to health and to learn where they can access food.

In Syracuse, Stone says, the community health and well-being department worked closely with St. Joseph's primary care clinical network to develop its iteration of Food Is Medicine. Launched in 2021, it serves a similar patient population with similar programming to the Albany program.

The Food Farmacy program includes emergency food aid for patients, staff and community members, with some of this aid provided through partnerships with community organizations.

Through the Emergency Food Bag program in Albany, St. Peter's keeps a stock of bags of nutritious food for patients to ensure a three-day supply upon discharge. The program started in 2020 in the emergency department and behavioral health units and has since expanded throughout St. Peter's network.

Both St. Peter's and St. Joseph's have on-site food pantries in discreet locations where colleagues can get nutritious food.

McCart and Stone mention that both the Albany and Syracuse hospitals have extensive relationships with community-based organizations to ensure community members generally get access to socioeconomic screening and food aid. Community health workers at these organizations can screen local people for food needs and refer them to help. Local pantries provide groceries, including options that take into account cultural preferences.

The Mother Cabrini Foundation is a top grant source for the Trinity Health New York hospitals' programming.

Both the Albany and Syracuse teams have tracked results of Food Farmacy programming. In fiscal year 2025, the Albany and Syracuse programs together served 1,367 people, all of whom were screened for socioeconomic need. This count compares with 1,185 people served the prior fiscal year. In fiscal year 2025, the combined Food Farmacy programs provided access to 70,350 meals as compared with 49,446 the prior fiscal year.

The Food Is Medicine chronic disease management program in Albany has served more than 800 people since its 2020 inception. For a diabetes cohort of that program, participants lost an average of 10.3 pounds and had an average decrease in their A1C score of 3.10%. In the Food Is Medicine program for hypertensive and diabetic people, offered in partnership with community agencies, participants saw an overall 1.9% decrease in their A1C numbers and a decrease in blood pressure from on average 148/84 to 136/78. The Food Is Medicine Program in Syracuse has served more than 400 people since its 2021 inception.

"We've learned that we need to motivate people" to help them change, says Stone in Syracuse. "We need to give them tools and education."

To address such concerns, Trinity Health Of New England's community health and well-being department assembled a committee of community partners to study the problem and develop solutions. In conjunction with the primary care practices within Trinity Health Of New England's Medical Group, they developed Food Is Medicine. Launched in 2023, it is a six-month chronic disease management program centered on healthy eating and behavior change. Community health workers hired by Saint Francis through grant funding "tethered lifelines to participants during their time in the program," explains Carolyn Alessi, regional director of community health and well-being at Trinity Health Of New England. Saint Francis is part of Trinity Health Of New England.

Alessi says the engagement by community health workers has proven vital.

Chronic conditions linked to nutrition, including hypertension, congestive heart failure and type 2 diabetes "are huge contributors to poor health outcomes," she says.

Saint Francis and its community partners also engage in advocacy and in efforts to remove barriers to healthy eating. "We hope to change the landscape of the community," Alessi says.

She says wide swaths of Hartford — particularly the North Hartford area – have high poverty levels and a prevalence of chronic disease. There has been disinvestment from these communities, with investment going toward affluent areas, Alessi says.

In these urban neighborhoods, there are no full-service grocery stores. Alessi explains that these areas are "food swamps. There is a lot of low-quality food," with little nutritional value.

In the Greater Hartford area, the hospital's latest community health needs assessment noted, 42% of the patient population had two or more comorbidities that are uncontrolled — including hypertension, type 2 diabetes, and congestive heart failure — leading to frequent visits to the emergency department.

The Food Is Medicine program was piloted at the three Hartford-area safety net clinics then broadened to local patients served by Trinity Health Of New England's medical group. Patients identified by their providers as using the emergency department frequently for uncontrolled chronic conditions are eligible for the six-month intensive behavioral change program.

Patients who join the program receive counseling, education and resources on healthy eating and healthy lifestyle choices. They get access to cooking classes at a teaching kitchen, help with medication adherence, and help using blood pressure monitoring equipment provided by the program.

Community health workers provide intensive support to participants and help them address social needs. They assist participants in accessing healthy food, including at the Joan C. Dauber Food Pantry at Saint Francis, and ensure the participants know how to prepare it.

The chronic disease management coach role is a new one for the community health workers. Alessi says the Food Is Medicine program has trained the participating workers in the skills needed for chronic disease management.

Connecticut Health Foundation, a statewide nonprofit, granted $50,000 to Saint Francis and its partners to evaluate the effectiveness of community health workers "providing high-value services in chronic disease management," explains Alessi.

She notes that "Traditionally, community health workers screen for social care needs and facilitate closed-loop referrals to community resources."

Alessi says initial results from the safety net clinic pilot and from the rollout in the medical group show that many participants adopt healthy behaviors, including more healthful eating. She says that among other positive health impacts, participants have reduced their return visits to the emergency department and improved their control of their blood pressure.

At the local level, Saint Francis and its Hartford-area community partners advocate for greater access to healthy food. They've supported the opening of a grocery with sliding-scale pricing as well as a hydroponic farm that uses efficient methods to grow food for the community.

Trinity Health and its partners also are working with local bodegas as part of their social impact investments to include more nutrient-rich offerings in their selections.

Alessi says the work promises to achieve change on multiple levels. "We are driving policy change and clinical change," she says. "It's a great balance of both."

— JULIE MINDA