Project Background

In 2020 - 2022, Bi-State Primary Care Association (Bi-State) led the Vermont Food Access in Health Care Consortium (FAHC) through strategic planning funded by grants from the Federal Office or Rural Health Policy and the Northern Border Region Commission. These network planning grants supported the following vision and strategic purpose:

Vision:  All Vermonters have access to the diet needed to achieve their health goals, alongside access to health services that can support them in setting and reaching those goals.    

Strategic Purpose: We support the integration of food and diet at all stages of creating good health, from prevention to treatment, through building capacity in both rural Vermont health care systems and community-based food organizations to implement evidence-based models for food in medicine. 

The strategic planning reviewed national models for Food As Medicine work, evaluated rural Vermont system capacity for implementation, and suggested priorities for increasing capacity for implementation. The planning also reviewed organizational questions around whether a dedicated Consortium effort was needed to achieve identified priorities and, if so, what structure that Consortium should take. 

Helen Labun led the initial planning as Special Projects Manager at Bi-State. Kristen Bigelow-Talbert is continuing this work and can be reached at kbigelow@bistatepca.org. 

FAHC Participating Members (2022):

Network Partners:

Bi-State Primary Care Association (Project Director)

Vermont Foodbank

Hunger Free Vermont

Northeast Organic Farmers Association NOFA-VT

Vermont Association of Hospitals & Health Systems

Advisory Group: Vermont Farm to Plate, Vermont Department of Health, Agency of Agriculture, Blueprint, OneCare, and Vermont Program for Quality in Health Care (VPQHC)

FQHC Pilot Participants: Lamoille Health Partners, Little Rivers Health Care, Northern Tier Center for Health (NOTCH)

Project Contractor: Vermont Farm to Plate (Transportation & Food Insecurity strategic planning)

Framework for Analysis:

In the 2020-2022 planning period for the Vermont Food Access and Health Care Consortium, the group reviewed current literature, evidence base, and model programs that integrated food across the continuum of patient care. Programs were mapped across three overlapping domains that described how health care practices interact with food and food access. We found that rural Vermont programs clustered in food security and the food security / community health domains with fewer in the Individual Health Care section. Tailored health care services integrating food were more common in the urban region of the state.

Successful food access integration blends all of these domains, but individual projects or funding sources generally do not have such a broad reach. For this reason, comprehensive food as medicine initiatives often have a “braided” funding strategy that brings together multiple sources of sustainable support. Many coalitions use variations on a pyramid model to reflect individual program designs that move from broad population-wide goals to progressively more targeted interventions.

The FAHC strategic planning combined local capacity review for evidence-based programs at different levels of this pyramid with funding & policy analysis in the three overlapping focus areas described perviously. From this assessment, we identified 4 key elements for a successful statewide approach to food access in health care integration:

Data Collection & Information Flows that track patients from screening through referral and participation in food-related services, which encompass both social care and medical care workflows, and that are analyzed both at the community health level and against individual patients’ health goals.

Patient Engagement in Nutrition Services, including clinical services from Registered Dietitians when appropriate. 

Medication Management / Integration in Treatment, accommodating a combination of lifestyle change and medications to manage conditions as best meets patient needs, not separating the two approaches.

Availability of Multiple Food Programs to Match with Dietary Needs. This goal returns us to the first bullet point of tracking patient pathways to identify gaps and missing resources.

Organizational Structures:

In 2022, VT FAHC worked with the Center for Health Law and Policy Innovation to review structures of other Food Is Medicine networks nationally. We concluded that three network focus areas were not a strong match: advocacy / lobbying; research; technical assistance tied to a particular grant type (for example, preparing food programs to apply for USDA Produce Prescription funding).

The closest match was an Integrator Organization structure, generally defined as navigating the interface between health care system, community non-profits, and other social services. These organizations perform different functions, including:

Data Integration - For example the "closed loop" between health care and community organizations.

Billing and Reimbursement Integration - Not usually as their only function, but to create an administrative pathway for community organizations to interface with the health care payer system.

Establishing Navigation Services for Patients - This can include screening for social risks, working with patients to identify their priorities for assistance, connecting them to those resources.

Strategic Network Development - Implicit in these models is that the organization isn't passively screening and referring, they're also providing strategic insights into what is missing, where there is overlap / duplication, and what to prioritize for community investment to improve health.

Bi-State Primary Care Association applied for a Federal Office of Rural Health Policy Network Development Grant in late 2022, for FY2023, that could support creation of this type of consortium. For information on this grant, please contact Kristen Bigelow-Talbert at kbigelow@bistatepca.org. 

Next Steps:

In addition to FAHC sustainability planning, we also identified immediate next steps related to key program areas addressed by organizations participating in FAHC. These steps are listed on each of the resource pages found on this website.

Project Funding:

Creation of this website was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $189,892.00 with 0 percentage financed with non governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government.