APRIL 2022
Research conducted by:
Food is Medicine
in North Carolina:
Healthy Food Prescriptions
Now, and in the Future
About the Authors
Dr. Linden Thayer is Director of Research & Innovation
at Food Insight Group (FIG), a B Corporation dedicated
to building just, equitable, and resilient food systems.
FIG supports regional food systems redesign through
evaluation, research, technical assistance, program
implementation, and policy work. Dr. Thayer specializes
in the role that institutions – such schools, hospitals,
and local governments – play in nurturing thriving
people, communities, and environments.
LaShauna Austria is the founder of Seeds of
Change Consulting (SOC). She is a community
organizer, farmer, and ordained faith leader. SOC
has deep experience working with rural communities,
including community-led organizations and leaders.
Primary areas of focus include offering support,
expertise, lived experience, racial equity consulting,
and collective organizing with food practitioners,
Black farmers, and other land stewards. SOC is rooted
in liberation and dismantling white supremacy.
About the Foundation
The Blue Cross and Blue Shield of North Carolina
Foundation is a private, charitable foundation
established as an independent entity by Blue Cross
and Blue Shield of North Carolina in 2000. Over the
past two decades, the organization has worked
with - and supported - nonprofit organizations,
government entities, and community partnerships
across the state, investing $178 million into North
Carolina through more than 1,200 grants. Within
its focus areas of early childhood, healthy
communities, healthy food, and oral health,
the Foundation strives to address the key drivers
of health, taking a flexible approach designed to
meet identified needs in partnership with the
community. Learn more at bcbsncfoundation.org.
CONTENTS
Introduction ............................................................. 1
Research Methods ................................................... 4
Findings .................................................................... 4
• Types of Food Provided
• Food Access Points
• Eligibility Criteria
• Funding
• Food Sourcing
• Accommodations for Individual
Food Needs and Preferences
• Tracking and Evaluation
• Strengths and Opportunities
• Build community
• Improve health
• Support local communities
• Alternative ways to address food security
• Challenges
• Funding and policy support
• Reach
• Marketing support
• Addressing root causes of poor health
• Additional comments
Sustaining, Scaling, and Spreading
Food is Medicine in North Carolina ....................... 11
Conclusion ................................................................ 12
Limitations ............................................................... 13
Glossary of Terms ..................................................... 13
Participating Food is Medicine Programs .............. 14
Endnotes .................................................................. 22
The views and opinions expressed in this publication are those of the authors and research participants and do not necessarily reflect the positions of
the Blue Cross and Blue Shield of North Carolina Foundation. Blue Cross and Blue Shield of North Carolina Foundation is an independent licensee of the
Blue Cross and Blue Shield Association (BCBSA) ® Registered Marks of the BCBSA.
How we collectively approach health and health care
in North Carolina is changing. Health care payers are
increasingly entering into value-based arrangements
where providers are paid for patient outcomes, not
just for interactions and services provided. Social
determinants of health (SDOH), such as food, housing,
transportation, violence, racism, and income have
become increasingly salient as providers seek to
achieve better patient outcomes. Community-based
organizations (CBOs) have a vital part to play in these
efforts, due to their deep roots and long history of
action to address social determinants of health (albeit
by different names). CBOs can help health care design
upstream interventions to achieve several goals, including:
• Centering participants in planning, programs,
and policy.
• Connecting participants to a range of
wrap-around services.
• Streamlining identification and enrollment into
beneficial health care and safety net programs.
• Adapting programs to the communities’ needs
and assets.
• Connecting to local service providers to
maximize positive community benefit.
CBOs can help health care navigate a wide range
of opportunities related to social determinants of
health; in this report we highlight current (as of 2021)
CBO and health care interventions focused specifically
on food.
Food is many things: it is sustenance, culture, divisive,
uniting, livelihoods, sensory, and much more. Access
to nourishing food is a human right, but nourishing
food is not universally accessible. One in seven North
Carolina households were food insecure prior to the
COVID-19 pandemic; that number is rising as the pan-
demic stretches on.
1,2,3
Food insecurity is defined by the
USDA as either, “reports of reduced quality, variety,
or desirability of diet; little or no indication of reduced
food intake” (low food security) or, “reports of multiple
indications of disrupted eating patterns and reduced
food intake” (very low food security).
4
Food insecurity
can also be defined as a lack of consistent access to
enough healthy food for an active, healthy lifestyle.
5
And research confirms food insecurity is linked to
decreased healthy food consumption, increased risk
for diet-related chronic disease, and increased health
care costs.
6,7,8
Food is Medicine (FiM) in practice has been around for
thousands of years; the earliest humans used foods to
treat acute and chronic illness. Instinctively, we under-
stand that foods have a broad range of effects on our
physical and mental well-being. Community-based
organizations, foundations, thought leaders, health care
providers, and insurers are now paying more attention
to FiM because food and food security are recognized
as social determinants of health.
For the purposes of this report, we define Food is
Medicine as: “An individual patient is assessed by
a health professional for diet-related disease and/or
food insecurity, and then prescribed a food-based
intervention (not just nutrition education) paid for
by a health care provider.”
FiM can take many forms, but at its core a FiM
program engages health care professionals to screen
and prescribe food for a patient identified as high risk.
The risk could be food insecurity itself, a diet-related
health condition, such as diabetes or hypertension,
or both. The food prescribed can take a variety of
forms, including produce-only; a fresh food box
including items such as produce, proteins, and grains;
a shelf-stable food box; a combination fresh and stable
food box; a medically tailored food box; or medically
tailored meals. Notably, in this report FiM is not what
happens when an individual or family self-identifies as
food insecure to a food pantry and receives a box or
bag of food.
Introduction
1
The Centers for Medicare & Medicaid Services
(CMS) have been studying the impact of a variety of
programs that address social determinants of health.
9
Likewise, the Harvard Center for Health Law & Policy
Innovation, the Rockefeller Foundation, and ChangeLab
Solutions, among others, have all published recent
reports exploring the known and potential impacts
of FiM programs.
10,11,12,13,14,15
Positive outcomes for
patients have been documented in a wide variety
of FiM programs, including reductions in household
food insecurity, increased fruit and vegetable
consumption, and decreased hemoglobin A1C
levels.
16,17,18,19,20
However, sustainable funding for
these programs remains a challenge.
In North Carolina, some CBOs and health care
providers have been collaborating for several years
to develop, implement, and evaluate FiM programs
in a variety of settings. This report reviews those
known programs in further detail, acknowledging that
this is not an exhaustive list. North Carolina FiM
work is also happening in the context of the Healthy
Opportunities Pilots (HOPs), a statewide Medicaid-
funded initiative “to test evidence-based, non-medical
interventions designed to reduce costs and improve the
health of Medicaid beneficiaries.”
21
HOPs are managed
by the North Carolina Department of Health and Human
Services, and are being implemented in three regions
across the state beginning in 2022. Priority programs
within the HOPs rollout include housing, transportation,
interpersonal violence, and food, meaning that FiM-
style programs will feature prominently in these pilot
projects. The work done in preparation for this report,
and in the lead up to HOPs, represents the first efforts in
North Carolina to foster collective engagement around
the topic of Food is Medicine.
Social determinants of health are defined by the
US Department of Health and Human Services as
the “conditions in the environments where people
are born, live, learn, work, play, worship, and age
that affect a wide range of health, function, and
quality-of-life outcomes and risks.” Examples of
social determinants of health include safe housing,
transportation, and neighborhoods; racism,
discrimination, and violence; education, job
opportunities, and income; access to nutritious
foods and physical activity opportunities; polluted
air and water; and language and literacy skills.
2
The purpose of this report is to lift up the FiM programs and partnerships between community-based organizations
and health care providers that are already being implemented in North Carolina including:
• Describing the research methods
• Identifying current North Carolina FiM models and the state of FiM in North Carolina
• Identifying opportunities and challenges in the current North Carolina FiM landscape
• Reporting on what current practitioners feel is needed to sustain, grow, and spread FiM in North Carolina
Health care payers, providers, and community organizations may benefit from reviewing this document and
supporting materials to understand what is happening – as well as barriers and opportunities – to help catalyze
and support CBOs in becoming the preferred choice for partnership with health care entities to address food
insecurity and diet-related illness.
Food Insight Group and Seeds of Change Consulting developed this report, based on research conducted in the
Fall of 2021, with the support of funding provided by the Blue Cross and Blue Shield of North Carolina Foundation.
3
Research Methods
The research team developed and piloted surveys,
as well as interview guides for CBOs, health care
practitioners, and key informants, in June and July,
2021. All surveys and interview guides were tested
internally with the research team, and then with
representative FiM practitioners prior to use. CBO
and health care providers engaging in FiM were
identified first through the research teams’ contacts,
and then via snowball sampling as the team connected
with current FIM practitioners and their allies.
Surveys were distributed August – October 2021,
and participants who self-identified as interested
in further engagement were invited to participate
in an interview to round out the picture of their FiM
program(s). Key informants with knowledge of the
FiM space in North Carolina, but who are not
delivering programs themselves, were also invited
to complete an interview to provide additional
context and perspective for the report.
Data cleaning, summary, and analysis was conducted
October – November 2021, alongside the creation of
case study reports to highlight a variety of approaches
to FiM work in North Carolina. A summary outline of the
data and report was provided to all CBO and health care
participants for review in November 2021, followed by
a virtual focus group and additional survey in December
2021 to groundtruth the findings. This provided additional
practitioner insight prior to finalizing and publishing the
report. The first version of the final report was published
in April 2022.
Findings
Overarching finding: There is not one model of
FiM in North Carolina. Each program is working
to meet the needs of its participants, and using the
resources available, in a highly localized context.
Community-based organizations are integral
partners for health care systems seeking to
maximize health benefits for individual patients
and the broader community.
The research for this report includes findings from 18
completed initial surveys (11 CBOs, 7 health care), 22
completed interviews (10 CBOs, 6 health care, 6 key
informants), 12 focus group participants (9 CBOs, 3
health care), and 8 follow-up surveys (6 CBOs, 2 health
care). Together these data represent perspectives from
12 CBOs and 8 health care providers, and 14 different
FIM partnerships. Each FiM program outlined here
includes a partnership between at least one CBO and
one health care organization, with prescriptions written
by a health care provider for patients identified as food
insecure, with a diet-related chronic disease, or both.
Programs are noted by their CBO partner in the text;
additional information about the CBO and health care
partners can be found in the Appendix.
The partnerships detailed in this report represent
a range of programs and wealth of approaches for
FiM in North Carolina. Despite their differences, and
their tailored approaches to unique settings, the most
common characteristics of FiM programs in North
Carolina include:
• The delivery of combination fresh/stable food boxes
or produce-only prescriptions.
• Access to food through a community pick-up site
or home delivery.
• Funding through grants and donations.
• A procurement partnership with local farmers,
particularly for fresh produce.
• Some accommodation for client food needs and
preferences (allergies, taste, religious restrictions, etc.).
4
FiM programs come in many shapes and sizes.
The Harvard Chan School of Public Health identifies
six broad categories of FiM programs :
24
• Combination fresh and stable food box
(Four interviewed for this report).
• Produce only: minimally processed fruits and
vegetables (Four interviewed for this report).
• Fresh food box: minimally processed items such
as grains, fruits, vegetables, legumes, dairy, meats,
seafood, etc. (Two interviewed for this report).
• Shelf stable food box: shelf-stable items such as
canned goods, dry goods, and other non-perishable
items (Three interviewed for this report).
• Medically tailored food box: combination of fresh,
frozen, and/or shelf-stable single-ingredient items
selected to fit particular dietary needs of the client,
such as high fiber, low added sugar, high protein,
etc. (Two interviewed for this report).
• Medically tailored meals: hot, cold, or frozen meals
prepared to fit particular dietary needs of the client,
such as high fiber, low added sugar, high protein,
etc. (Two interviewed for this report).
Type of Food Provided
Types of foods
being offered
Combination
fresh/stable
food box
Produce
only
Fresh
food box
Shelf stable
food box
Medically
tailored food
box
Medically
tailored meals
(hot/cold/
frozen)
Number of
FIM Programs
(N=13)
4 4 2
3 2 2
TYPES OF FOOD PROVIDED
5
FOOD ACCESS POINTS
Food prescribed by a health care provider in a FiM program can be accessed by the client in a variety of ways. The
most common way for clients to access food in North Carolina is through a community pick up site, such as a food
pantry, church, or other community-based organization. Home delivery of foods is the next most common way to
connect clients to food, followed by vouchers used at food retail locations (grocery or farmers market) where clients
shop for approved food items themselves. A few North Carolina FiM programs have a pantry or other program onsite
at the health care facility where clients can fill the food prescription before leaving the health care appointment.
Food Access Points
Eligibility Criteria
Where clients
get the food
Community
pick-up site
Delivery
Clinic/health
care center
Voucher for food
retail location
Automatic
electronic
benefit for food
retail location
Number of
FIM Programs
(N=12)
9
8 4 3 1
Eligibility
criteria
Food insecure
Diet-related disease
Number of
FIM Programs
(N=12)
11
6
ELIGIBILITY CRITERIA
All FiM programs that participated in our surveys or interviews indicated the health care provider was, at a minimum,
screening for food insecurity among a subset of patients. Most programs rely on a brief food security screening tool
used by the provider during a health care visit. The most popular food security screening tool is the Hunger Vital
Sign
TM
.
25
About a quarter of programs required the health care provider to identify a patient as both food insecure and
managing a diet-related chronic disease (such as renal disease, diabetes, or hypertension) to qualify for FiM services.
One current FiM program also serves clients that are identified as managing a diet-related chronic disease, regardless
of food security status; the health care provider offers medically tailored meals to that specific population. Several FiM
programs have a provider prescription program, and also provide food to clients who self-identify without a health
care provider referral.
6
Current
funding
sources
Foundation
grant
Individual
donation
Business
donation
Charitable
hospital
foundation
Non-charitable
health care
dollars
Federal
grant
State
legislative
support
Number
of FIM
Programs
(N=13)
13 8
8 6 4 2 1
FUNDING
Current North Carolina-based FiM practitioners are paying for FiM programs in a variety of ways, including:
The most common funding sources include foundation grants, business donations, and individual donations. There
is great interest in federal, state, and insurer policy changes that would cover FiM as a benefit. At the time of publication,
one FIM program included in this study is providing FIM though a vendor arrangement with a North Carolina health insurer
to a particular segment as a supplemental service.
Funding
• Foundation grants
• Federal grants
• State legislative support
• Charitable hospital foundation dollars
• Non-charitable health care dollars
• Business donations
• Individual donations
Sources
of food
Direct
from local
farms
Food
donation
Local
aggregator/
food hub
National
broadline
distributor
Food bank
Regional
broadline
distributor
Local
caterer/
restaurant
National
frozen
meal co.
Number
of FIM
Programs
(N=11)
8
6
4
4 4 3 3 2
Sourcing
FOOD SOURCING
Food in North Carolina FiM programs is most commonly sourced directly from local farms and food donations.
Other sources of food include local food aggregators, food banks, local caterers/restaurants, and national frozen meal
producers, as well as national and regional broadline distributors, which offer a mix of food, paper goods, cleaning
agents, office supplies, and other items to a wide variety of customers (as opposed to, for example, produce distributors
that only handle fresh produce). Within the context of local procurement, some organizations specifically source products
(in descending order) from small farms, BIPOC-owned (Black, Indigenous, and People of Color) farms, and women-owned
farms. A few CBOs produce meals in-house using some combination of local and non-local items.
7
Accommodations for individual food needs and preferences
ACCOMMODATIONS FOR INDIVIDUAL FOOD NEEDS AND PREFERENCES
Nine of 11 responding partnerships indicated their FiM program does accommodate client needs and preferences in
some way. This includes programs that modify food offerings based on allergies, medical needs, dietary preferences,
religious preferences, or taste preferences. FiM programs that do offer choice point to the need to honor client dignity
and be inclusive through cultural competency (providing food and using ingredients that reflect clients’ own food
cultures). Choice is offered through a menu of available options for food that is picked up or delivered, providing
a shopping experience where clients select items within the CBO’s space, and through voucher programs that
allow clients to make choices in the context of a retail location (grocery, farmers market). Those programs that
do not accommodate client choice report being limited by funding mechanisms or current infrastructure.
Program
accommodations
Dietary
preferences
(e.g., vegan)
Medical
need
Taste preference
(e.g., dislikes)
Allergies
Religious
preference
(e.g., Kosher)
Number of FIM
Programs (N=11)
12 11 10 9 7
Sourcing spotlight: Local aggregation
Sources of
local product
Direct from
local farmers
Local aggregator/
food hub
Direct from local
BIPOC farmers
Direct from
small farms
Direct from local
women farmers
Number of FIM
Programs (N=11)
8 4 6 6 3
8
Build community
• FiM collaborations between CBOs and health care
break down silos between institutions, community,
and local economies, opening opportunities for
collaboration with more community partners,
including local agricultural producers.
• FiM programs can be community-driven, designed
by participants in collaboration with trusted CBO
partners, who will keep community at the core of
FiM efforts, and their health care allies.
• FiM offers revenue-generating opportunities for
food-focused CBOs, which could reduce reliance on
grant and donation-based operations in the future.
• FiM can be a model of collaboration between
CBOs and health care organizations, not just for
addressing food insecurity, but other programs
related to social determinants of health as well
(e.g., transportation, housing).
Improve health
• FiM can be a model (or models) for addressing
food insecurity and health disparities by providing
access to quality healthy foods to those who do
not have access.
• FiM can make healthy, culturally appropriate foods
available to a wider audience.
• Evidence suggests addressing upstream factors
of poor health will (a) more likely result in positive
outcomes for the patient, and (b) reduce the
need for expensive and invasive health services,
ultimately reducing health care costs. These
positive outcomes for patients are documented
in the literature, although we are waiting on direct
evidence from these models.
• The provider screening tool is easy and successful
at identifying potential clients.
Support local economies
• FiM offers opportunities to support local agriculture
and local economies through sustainable, reliable
markets; FiM can provide fair market outlets for
local producers, especially small farms, BIPOC-owned
farms, and women-owned farms; ripple effects
will support community-based resilience. Many
respondents see FiM as a natural evolution of
health care, mimicking current partnerships
between health care and pharmaceuticals, except
the pharmaceuticals/pharmaceutical companies
are replaced by food/farmers.
Alternative ways to address food security
• FiM is an alternative/supplement to SNAP and
WIC benefits that can be inaccessible to some
(because they do not quite qualify, because they
are undocumented, etc.), restrictive to others (WIC
benefits come with specific size, weight, and quality
mandates), and generally do not provide enough
funds to support a healthy, well-balanced diet.
• Data from FiM programs can influence policy at
organizational, local, state, and federal levels.
TRACKING AND EVALUATION
Six out of 13 FiM programs track what and how much clients are eating during their participation in FiM programming
(e.g., how many servings of fruits and vegetables per day); this is more than tracking what is prescribed or purchased
by the client. Without consistent and shared measures across FiM programs it is difficult to compare client impact and
comparative return on investment. No long-term health information was gathered from North Carolina FiM programs
interviewed for this report, although researchers are working in partnership with several participating organizations to
better understand program costs, implementation, and client impact. And four programs did indicate that they track
client health impacts and health care utilization during FiM program participation, following participation, or both.
STRENGTHS AND OPPORTUNITIES
With a variety of FiM models in North Carolina, we can begin to understand promising practices and opportunities to
increase impact for individuals, for health care, and for local communities.
We asked FiM practitioners what they saw as the strengths of FiM and the opportunities for FiM in
North Carolina. Responses included:
9
Funding and policy support
• Lack of funding specifically for transportation of food
to people (drivers, gas, benefits, etc.) because home
delivery is a necessity for many individual clients and
programs that want to reach the most vulnerable
populations. Transportation to access health care
is also a concern, especially in rural communities.
• Limited support from statewide organizations, state
and federal agencies, state and federal policies, and
health care providers to implement FiM programs.
• Some programs felt their offerings were limited
because they do not currently accommodate client
choice or preferences, making the program feel
more like a handout than a supportive, client-driven
service. Accommodations were not offered because
of CBO’s limited funding and staffing capacity.
• Although North Carolina is an agricultural state,
there are not yet many supports or incentives offered
to farmers to engage in conversations about FiM.
Reach
• From an equity perspective, FiM programming only
reaches individuals seeking health care services.
• Ongoing silos (between different CBOs, and
between health care organizations and
CBOs) limit their ability to increase efficiency,
effectiveness, and reach.
• Some CBOs find it challenging to identify and
connect with health care partners to expand the
reach of FiM programs.
• Four of 13 respondents confirmed they could only
provide services for the individual seen by the
health care provider, not the whole family, even
though food insecurity inevitably impacts every
individual in a household. Funding and program
design currently prevents some FiM programs from
reaching all family members through one patient
referral – likely perpetuating negative outcomes
for some or all family members in the home.
Marketing support
• There needs to be a more coordinated approach to
outreach (to clients and to health care entities) with
science-based healthy food choice information;
respondents also want better ways to disseminate
information to potential partners and clients.
Addressing root causes of poor health
• Some believe FiM does address root causes of
poor health, some did not, and some think FiM
addressed the tip of the iceberg but did not go
deeper. As health care becomes more involved
in addressing the social drivers of health, interest
and focus on the root causes of poor health –
including poverty, racism, sexism, and other
forms of oppression that result in inequities –
could grow. There are certainly examples of this
in other states where value-based payment for
care is more prevalent.
• Although health care plays a critical role in the FiM
process, the community needs greater power and
agency in program design, implementation, and
benefits to insure the greatest impact.
Additional comments
• Some respondents want differentiated programs
for maximum effect and impact (FiM programs
for children, seniors, etc.). FiM are typically
treatment programs, but FiM prevention programs,
especially for children, are needed to prevent
chronic disease and the associated human,
economic, and cultural toll.
Not enough is known about the clients’ perspectives
to speak to their perceptions and experiences of FiM
programs at this time.
CHALLENGES
We asked FiM practitioners what they saw as the challenges and areas for growth for
FiM in North Carolina.
The primary concern voiced by CBOs, health care providers, and key informants was secure and stable funding
for FiM programs. Every program described in this report relies on a combination of funding sources that are not
sustainable (e.g., grants, donations). Additional challenges for CBO and health care partners include:
10
Sustainable financing of FiM programs is the biggest
concern for those interviewed in this report. Funding
is needed for staffing, storage space, screening clients,
tracking client data and program outcomes, and food
procurement. Practitioners are busy doing the work;
key federal policy partners (including policy-focused
nonprofits, researchers, etc.) must be engaged to
advocate for the necessary changes, especially
reimbursement through Medicare/Medicaid, to make
FiM truly sustainable. We asked FiM practitioners what
they needed in order to sustain, scale, and spread FiM
in North Carolina. The most common requests were
for insurance reimbursement (changes in policy so
that FiM can be a billable service, like pharmaceuticals
and diagnostic tests), and state-level policy change
(to facilitate FiM funding, and to require local
food purchasing).
Additional supports identified by respondents
to sustain, scale, and spread FiM in North
Carolina, beginning with those most frequently
reported, include:
• Technical assistance (teaching CBOs how to manage
reimbursable prescription food programs, how to
engage health care organizations in the work, etc.);
see below for more details.
• Facilitating connections between CBOs and
health care providers.
• National-level policy change (to allow for
reimbursement, and to facilitate program
development and scaling).
• Facilitating connections between CBOs and
potential clients, so that patients know to ask
health care providers for available services.
• Physical infrastructure (storage and transportation
for all types of food, but especially perishable, cold,
and frozen items); see below for more details.
• Facilitating connections between CBOs and local
food retailers, local food producers, and local meal
producers to expand their offerings.
FiM practitioners requesting technical assistance
were interested in:
• How to set up a CBO to be able to manage
reimbursement-based FiM programs (insurance
requirements, secure technology support and
operations, data management, etc.).
• Best practices for FiM programs in rural or
urban settings.
• Accessing a community-of-practice resource hub.
• Measuring, analyzing, and acting on data related
to program operations and client outcomes.
• How to increase local farmer capacity to serve
FiM-type programs, including food safety
requirements, product forecasting, and contract
negotiations, etc.
• How to generate a list of resources (other
social determinants of health resources, such as
transportation and housing) to share with clients.
Additional comments
• One respondent was unsure if current health care
and CBO operations are compatible at all without
disruptive systems change, including universal
health care, major investment in regional food
systems infrastructure, and funding mechanisms
for health and agriculture.
• Another respondent had mixed feelings about
allowing free-market, for-profit companies to
enter the FiM food provision space, in direct
competition with CBOs: on the one hand,
competition could lead to more effective and
efficient solutions; on the other, competition
could lead to greater disparities and gaps
where large for-profit companies cannot reach.
SUSTAINING, SCALING, AND SPREADING
FOOD IS MEDICINE IN NORTH CAROLINA
11
Conclusion
Food is Medicine programs have the potential to
positively impact individual lives, improve health care
outcomes, support local agriculture, and grow local
economies. They also serve as a tool to help health
care stakeholders think and act on upstream factors
affecting health and health outcomes, such as food,
transportation, health care, and interpersonal violence.
North Carolina has a number of FiM program models to
study, learn from, and potentially adapt across the state.
And CBOs play an integral role in understanding how to
maximize benefits offered through these programs for
individuals, local agriculture, and local communities.
How FiM programs develop and grow in North
Carolina is still unfolding, and this report does not
delve into return on investment of each type of FiM
opportunity. Immediate next steps may include
statewide convening and connection between
current and future FiM practitioners; advocacy and
policy work around changes to federal and state
reimbursement for social determinants of health;
research to understand everything from client
perspective to return on investment; and a more
coordinated funding approach.
What is known is that health care providers and
organizations stepping into the world of Food is
Medicine programs will gain a deeper understanding
of how best to support their community, and how best
to engage in FiM programs holistically, if they connect
to local CBOs to begin conversations. New and adaptive
programs will take a number of different forms as these
partnerships continue to evolve programming to meet
need, demand, and funding. While challenges to
sustaining, scaling, and spreading FiM programs
remain, partners across community-based organizations,
health care providers, and other interested parties
remain dedicated to lifting up and advancing the
work of FiM programs to improve lives for many
North Carolinians.
12
Limitations
This report is a first step in understanding Food is Medicine programs in North Carolina – opportunities, challenges,
and what is needed to advance this movement forward. We acknowledge many limitations, including:
• We only interviewed or surveyed those agencies
brought to our attention as engaging in FiM work;
there are undoubtedly other groups that were not
included and should be included in future updates
to this report and ongoing work.
• We did not speak with FiM clients/recipients to
understand their perspective (e.g., Are these
programs addressing their basic needs and
concerns? How would they like to receive items?
What works or does not work? What is needed
instead or in addition? What happens when
these programs – often grant-funded or time-
limited – end? What is the long-term impact of
temporary food assistance? etc.).
• We did not consider for-profit partners that are
engaged in FiM operations (largely in other states
currently, but beginning to appear in North Carolina).
• We only spoke with known CBO and health care
partners involved in current FiM operations. We did
not speak with those who tried – and ended – FiM
programs for their perspective on why they stopped
or why the program failed. Nor did we speak with
CBOs and health care providers not engaged in FiM.
• Health care providers especially were limited in
their capacity to participate in early information
gathering because of the strain of COVID on
hospital personnel’s time and attention.
• We do not describe impact; we did not measure
what the impact of current FiM programs is on
individual lives, health care operations, local
economies, etc.
• Most people we spoke with are not those directly
interacting with the recipients, so there was
sometimes limited knowledge of the personal
or individual impact.
• We were not able to compare and contrast the
relative costs and benefits of specific FiM programs
in North Carolina; we can only see the prevalence
of certain model components.
13
Appendix
PARTICIPATING FOOD IS MEDICINE PROGRAMS
Appalachian Regional Healthcare System works in partnership with Hunger and Health Coalition (see below) to pro-
vide food to patients identified as food insecure by their health care provider. Ongoing food and nutrition support is
available to patients prescribed food for pick-up at Hunger and Health community sites, as well as through their food
and meal delivery programs. Additional partners in these FiM efforts include Appalachian State University and Watau-
ga County Schools.
Organization
Appalachian Regional Healthcare System
Service area
Ashe, Avery, Watauga Counties
Type of food provided
Combination fresh and stable food box
Food access points
Community pick-up site, delivery
Eligibility criteria
Food insecure
Current FiM funding
Foundation grant, hospital foundation, business donation, individual donation
Sources of food
Regional broadline distributor, local aggregator/food hub, direct from local farms, local
BIPOC farms, local small farms, local women-owned farms, food donation, food bank,
local caterer/restaurant
Accommodations
Allergies, medical need, dietary preferences
Organization
Appalachian Sustainable Agriculture Project
Service area
Buncombe County; expanding next to Alleghany, Ashe, Avery, Burke, Caldwell,
Cherokee, Clay, Graham, Haywood, Henderson, Jackson, Macon, Madison, McDowell,
Mitchell, Polk, Rutherford, Swain, Transylvania, Watauga, Wilkes, Yancey Counties
Type of food provided
Produce only
Food access points
Voucher for local food retail
Eligibility criteria
Food insecure, dependent on having or being at risk of developing a diet related disease
Current FiM funding
Federal grant, foundation grant, individual donation
Sources of food
Local aggregator/food hub, direct from local farms, local BIPOC farms, local small
farms, local women-owned farms
Accommodations
Allergies, medical need, dietary preferences, religious preferences, taste preferences
Appalachian Sustainable Agriculture Project (ASAP) seeks to “help local farms thrive, link farmers to markets and
supporters, and build healthy communities through connections to local food.” ASAP has a myriad of food and farming
programs that support strong communities. Through their FiM program, Farm Fresh Produce Prescription program,
participating health care providers write a prescription for fresh produce for patients identified as food insecure.
Produce prescriptions can be filled at farmers markets, roadside stands, or through community supported agriculture
(CSA) opportunities. Current funding restrictions require the patient to participate in Medicaid, SNAP, or other federally
qualifying program as a proxy identifier for elevated risk of food insecurity.
14
Atrium Health Wake Forest Baptist is an academic health system based in Winston-Salem, North Carolina, and a
part of Atrium Health Enterprise. Atrium Health Wake Forest Baptist addresses food insecurity in a number of ways,
including screening for food insecurity at every visit, and screening for WIC/SNAP enrollment at well child visits.
Positive screens for food insecurity are followed by a care navigator meeting; an on-site food pantry bag with recipes
and QR code-linked cooking videos; backpack program and/or meal or fresh produce delivery; and/or produce voucher
to a farmers’ market. Patients also have access to a mobile produce market on site at the hospital every Tuesday
afternoon, gift cards for emergency food needs, and WIC/SNAP referrals.
Organization
Atrium Health Wake Forest Baptist
Service area
Davidson, Davie, Forsyth, and Guilford Counties
Type of food provided
Fresh produce, combination fresh/stable food boxes, shelf stable food boxes,
medically tailored meals
Food access points
Clinic-based pantry, community pick up, voucher for food retail location, delivery
Eligibility criteria
Food insecure
Current FiM funding
Foundation grant
Sources of food
National broadline distributor, regional broadline distributor, food donation,
direct from local farms
Accommodations
Information unavailable
Carolinas Collaborative (in partnership with the American Academy of Pediatrics and funded by The Duke
Endowment) “brings together academic pediatric programs and their host health care systems across the Carolinas.
The goal of this collaborative is to create an environment that empowers action through access to data, comparative
analytics, and technical expertise, uplifting all residents of the Carolinas.” In addition to important work on addressing
toxic stress, the Carolinas Collaborative is focusing on food insecurity in children. All participating pediatric programs
screen children for food insecurity, and then offer wrap-around services through partnerships with WIC/SNAP enrollment
offices, Johnson & Wales, local food pantries and food share programs, and other community-based organizations to
provide culturally relevant food and meals (as needed) for food insecure children. Program specifics vary by location.
Organization
Carolinas Collaborative
Service area
Durham, Forsyth, Mecklenburg, Orange, Pitt Counties
Type of food provided
Produce only, fresh food box, shelf stable food box, combination fresh/stable food box
Food access points
Clinic/health care center, community pick-up site
Eligibility criteria
Food insecure or identifying desire for referral or resource without being food insecure
Current FiM funding
Foundation grant, charitable hospital foundation, non-charitable hospital dollars,
business donation
Sources of food
National distributor, local aggregator/distributor, local farms, local BIPOC farms,
food donation, food bank
Accommodations
Medical need, dietary preferences, taste preferences
15
Cone Health is a not-for-profit network of health care providers, and engages in a long list of community-based
outreach efforts. Their FiM programs include medically tailored frozen meals for patients managing diabetes and
renal patients (created by Sodexo food service providers that manage all hospital food production). Cone Health is
in the process of opening a new Food Market (pantry) in a women’s medical center to support patients and their
families who struggle with access to healthy food and nutrition education, in partnership with Food Lion and the local
food bank. Providers will prescribe food to patients, who will be able to shop on-site before leaving the clinic; food
prescriptions can also be filled at other community and food retail locations. Additional partners include ‘Message
in a Meal,’ Out of the Garden Project, among others.
Organization
Cone Health
Service area
Alamance, Forsyth, Guilford, Randolph, Rockingham Counties.
Type of food provided
Produce only, shelf stable food box, combination fresh/stable food box,
medically tailored food box, medically tailored meals
Food access points
Clinic/health care center, community pick-up site, voucher for food retail location, delivery
Eligibility criteria
Food insecure and/or diet-related disease
Current FiM funding
Foundation grant, charitable hospital foundation, non-charitable health care dollars,
business donation, individual donation
Sources of food
Direct from local farms, local BIPOC farms, local small farms, food donation, food bank,
local caterer/restaurant, national frozen meal company
Accommodations
Dietary preferences, taste preferences
Organization
Conetoe Family Life Center
Service area
Edgecombe and Nash Counties
Type of food provided
Fresh food box
Food access points
Clinic/health care center, community pick-up site, delivery
Eligibility criteria
Food insecure and/or diet-related disease
Current FiM funding
Foundation grant, business donation, individual donation
Sources of food
Direct from local farms, direct from local BIPOC farms, food donation, food bank
Accommodations
None
Conetoe Family Life Center’s (CFLC) mission is to improve the health of the youth and community by increasing
access to healthy foods, increasing physical activities, and providing access to health services. The goal is to disrupt
the poverty cycle in families by improving the resources available, specifically to children. CFLC operates a farm and
beekeeping operation, youth development programs, and food security efforts. They partner with Vidant Health and
Nash UNC Health Care to provide fresh produce to patients and staff. Current CFLC FiM operations include delivery
of fresh food boxes (with produce, proteins, grains, etc.) to hospital sites for distribution, directly from the farm, and
direct to patients’ homes.
16
Feast Down East “strengthens the farming communities in and around the Wilmington area by providing resources,
education, and distribution opportunities to farmers while addressing equitable food access in communities with the
greatest need.” Feast Down East works in partnership with local medical providers, the local housing authority, and
community partners around New Hanover, Brunswick, and Pender Counties to fulfill fresh food prescriptions for
individuals identified as food insecure by health care providers. The fresh food items come from (often small or
midsize) local, traditionally disadvantaged farmers seeking new outlets for their products.
Organization
Feast Down East
Service area
Brunswick, New Hanover, Pender Counties
Type of food provided
Fresh food box
Food access points
Community pick-up site
Eligibility criteria
Food insecure
Current FiM funding
Foundation grant, charitable hospital foundation, non-charitable hospital dollars,
business donation, individual donation
Sources of food
Local aggregator/food hub, direct from local farms, direct from local BIPOC farms,
local small farms, local women-owned farms
Accommodations
Allergies, medical need, dietary preferences, taste preferences
Green Rural Redevelopment Organization (GRRO) was founded to address poverty, food insecurity, and chronic
diseases in rural North Carolina. What began as a grassroots effort to revitalize rural communities through
micro-market farming and food-base entrepreneurship has grown into a systems approach to addressing acute and
upstream causes of hunger and poverty. GRRO’s FiM operations include a food prescription program in which local
health care providers write a prescription for patients identified as food insecure and/or managing diet-related disease,
and GRRO connects the patient to fresh produce and other food items. GRRO also provides nutrition and lifestyle
support and connection to wrap-around services for the patient. GRRO is moving toward the production and delivery
of medically tailored meals in one of the Healthy Opportunity Pilot regions in North Carolina in 2022.
Organization
Green Rural Redevelopment Organization
Service area
Franklin, Granville, Person, Vance, Warren Counties
Type of food provided
Combination fresh and shelf stable food box
Food access points
Community pick-up site, delivery
Eligibility criteria
Food insecure and/or diet-related disease
Current FiM funding
Foundation grant, hospital foundation, business donation, individual donation
Sources of food
Information unavailable
Accommodations
Allergies, medical need, dietary preferences
17
Organization
Healthy Highland
Service area
Gaston County
Type of food provided
Combination fresh and stable food box
Food access points
Community pick-up site, delivery
Eligibility criteria
Food insecure
Current FiM funding
Foundation grant
Sources of food
Information unavailable
Accommodations
Allergies, medical need, dietary preferences, religious preferences, taste preferences
Healthy Highland is a grassroots effort located in a historically Black community in western North Carolina, which aims
to support health and well-being for all people in Gastonia. Originally started to address acute hunger needs
in a community identified as a food desert, Healthy Highland has expanded services and programs to better serve
the community. A new addition to their programming includes an FiM-style opportunity where providers in local
community health centers can prescribe Healthy Highland food certificates to patients requesting support in
accessing healthy meals or a healthier food lifestyle. These certificates can be redeemed for prepared meals at
Healthy Highland’s central kitchen, called ”RAMS Kitchen” which is located in the Highland Community, or the
meals can be delivered. Meals include healthy adaptations of culturally relevant foods, prepared by community
members familiar with the needs and preferences of their neighbors.
Hunger and Health Coalition is dedicated to “empowering neighbors in need through healthy, nutritious food and
life-saving medications.” Hunger and Health Coalition provides a wide range of food and medication services. They
provide FiM programming in partnership with all local health care providers in Watauga County, including the
Appalachian Regional Health Care System. Medical professionals screen patients for food insecurity and diet-related
disease, and then use a Hunger and Health prescription pad to refer patients to ongoing care: Hunger and Health
provides nutrition education for the whole family, medically tailored food boxes, and delivery services for individuals
with transportation challenges.
Organization
Hunger and Health Coalition
Service area
Ashe, Avery, Watauga Counties
Type of food provided
Combination fresh and stable food box, medically tailored meal box
Food access points
Community pick-up site, delivery
Eligibility criteria
Food insecure
Current FiM funding
Foundation grant, hospital foundation, business donation, individual donation
Sources of food
Regional broadline distributor, local aggregator/food hub, direct from local farms,
local BIPOC farms, local small farms, local women-owned farms, food donation,
food bank, local caterer/restaurant
Accommodations
Allergies, medical need, dietary preferences
18
Organization
North Carolina A&T
Service area
Wayne County
Type of food provided
Fresh produce
Food access points
Community pick-up site, delivery
Eligibility criteria
Food insecure and diet-related disease
Current FiM funding
Federal grant
Sources of food
Food donation (from research farm)
Accommodations
Allergies, medical need, dietary preferences
North Carolina A&T State University is a land-grant research institution dedicated to “scholarly exchange and trans-
form[ing] society with exceptional teaching, learning, discovery, and community engagement.” NC A&T’s Dr. Chyi-lyi Liang’s
research farm supports efforts to understand how delivery of organically-grown specialty fruits and vegetables impacts the
health of residents. Specialty produce donated from Dr. Liang’s research farm provides fresh produce for participants and
limits food waste from the farm.
Novant Health New Hanover Regional Medical Center (NHRMC) provides care to a large portion of southeastern
North Carolina. NHRMC offers a Food Pharmacy to patients who are identified as food insecure by a health care
provider using the Hunger Vital Sign
TM
screening tool. Both outpatients and inpatients are referred to the program;
the food boxes provided contain about six days’ worth of canned and shelf-stable food. Food is procured in partnership
with a local Feeding the Carolinas affiliate. Currently, NHRMC distributes about 90 food boxes per month.
Organization
Novant Health New Hanover Regional Medical Center
Service area
New Hanover County
Type of food provided
Shelf stable food box, combination fresh and shelf stable food box
Food access points
Community pick-up site, clinic/health care center
Eligibility criteria
Food insecure and diet-related disease
Current FiM funding
Foundation grant, business donation
Sources of food
National broadline distributor, direct from local farms, direct from small local farms,
food donation, local caterer/restaurant
Accommodations
Medical need, dietary preferences, religious preferences, taste preferences
19
Organization
Reinvestment Partners
Service area
90 North Carolina Counties (all 500 North Carolina Food Lion stores)
Type of food provided
Produce only (fresh, frozen, canned - minimally processed)
Food access points
Automatic electronic health care benefit for food retail location
Eligibility criteria
Food insecure and/or diet-related disease
Current FiM funding
Foundation grant, federal grant, state legislative support,
non-charitable health care dollars
Sources of food
National broadline distributor, regional broadline distributor
Accommodations
Allergies, medical need, dietary preferences, religious preferences, taste preferences
Reinvestment Partners’ (RP) mission is to foster healthy and just communities by empowering people, improving
places, and influencing policy. RP addresses the problems of poverty and social injustice in the areas of food,
housing, community development, health, and financial services. Eat Well, RP’s produce prescription program,
provides $40 per month to each enrolled participant. The electronic benefit is linked to a retail grocery customer
loyalty card to facilitate access, ensure client choice, and maintain the dignity of participants. Health care partners
screen patients for low income, food insecurity, and/or diet-related disease (depending on the funding mechanism’s
requirements). Referred patients sign up by phone or online. Eat Well facilitates access to produce for individuals
with limited barriers to enrollment, and access to food in places where clients are already shopping.
SHARE Winston-Salem is a faith-based, food-focused organization, formed to serve the diverse citizens of
Winston-Salem, North Carolina. Their mission centers on providing wholesome and nutritional food to families
in and around areas designated as food deserts. SHARE Winston-Salem’s Food Pharmacy Project involves a
health care provider writing a food prescription for a patient, and then typically that patient brings the prescription
to SHARE’s Harvest Market, where a staff nutritionist helps the patient select food items that will support their
health and wellness goals. In some cases, patients can order items for delivery.
Organization
SHARE Winston-Salem
Service area
Forsyth County
Type of food provided
Fresh produce, medically tailored meals
Food access points
Voucher for food retail location (SHARE’s cooperative grocery store), delivery
Eligibility criteria
Food insecure
Current FiM funding
Foundation grant, individual donation
Sources of food
National broadline distributor, regional broadline distributor, direct from local farms,
direct from small local farms, national frozen meal company
Accommodations
Allergies, medical need, dietary preferences, religious preferences, taste preferences
20
Organization
TRACTOR Food and Farm
Service area
Avery, Buncombe, Haywood, Henderson, Madison, Mitchell, Transylvania, Yancey Counties
Type of food provided
Fresh food box
Food access points
Community pick-up site, delivery
Eligibility criteria
Food insecure
Current FiM funding
Foundation grant, charitable hospital foundation, business donation, individual donation
Sources of food
Local aggregator/food hub, direct from local farms, local BIPOC farms, local small farms,
local women-owned farms
Accommodations
Allergies, medical need, dietary preferences, religious preferences, taste preferences
TRACTOR Food and Farms is a food hub focused on “increasing access to local food by empowering producers
and consumers alike, reconnecting people with agriculture for a healthier community, environment, and economy.”
TRACTOR’s Clinical Referral Program procures and delivers locally sourced produce to individuals and families
experiencing food insecurity or diet-related illnesses. Individuals are referred to the program by local health care
providers, and CSA-style shares are available for pick-up or delivery.
Other Key Informants
• Blue Cross and Blue Shield of North Carolina Healthy Blue
• Blue Cross and Blue Shield of North Carolina
• Carolina Farm Stewardship
• Feeding the Carolinas
• Impact Health, Dogwood Health Trust
• Resourceful Communities
21
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ENDNOTES
22
