Frontline clinical teams can support patient success in FIM programs by identifying eligibility, communicating program options and potential benefits, making referrals to other clinical staff or external vendors, monitoring progress, and scheduling follow-up appointments to reassess continued eligibility and reenrollment.
The case example below demonstrates how FIM may look in practice, with the following underlying assumptions met:
- The clinic has an established partnership with an external MTG vendor.
- The MTG vendor receives direct referrals from the clinic through an established referral portal.
- The MTG vendor communicates directly with the patient and provides a debit card to their home address.
- The debit card is configured with eligible purchases based on an approved product list.
- The cost of the program is covered or partially covered by the patient’s health plan.
- The patient must be reassessed every three months to reaffirm eligibility and continued enrollment.
- The clinician is aware of this program.
Screening & Eligibility
The clinician reviews the patient’s chart and takes note of the electronic health record (EHR) best practice alert (BPA) that the patient is eligible for the MTG program based on their diagnosis of diabetes and food insecurity.
Example: Best Practice Alerts ▶
Engagement & Referral
The clinician explains to the patient that they are eligible for a FIM program. If the patient consents to being referred into the program, the clinician makes the referral in the EHR. The clinician may also ask the patient if they are interested in receiving a referral to an RDN for nutrition education and counseling support. See how this conversation may flow in a clinical setting.
Small doses of additional nutrition training may support clinicians in recognizing the value of screening and referring eligible patients to FIM programs. See here for four examples of continuing education resources.
Enrollment & Delivery
The patient receives the debit card in the mail and participates in the FIM program for three months. The patient may receive nutrition counseling from an RDN or participate in group-based diabetes classes. The patient provides feedback through the patient portal at their own will.
Clinical staff may support the patient by providing nutrition education materials through the patient portal, email, or text messaging. See here for examples of patient-facing nutrition education resources.
Care Coordination & Monitoring
At three months, the clinician takes note of the EHR BPA and evaluates changes in the patient’s health status. Using a shared decision-making approach with the patient, the clinician renews the referral to the MTG program, refers the patient to a community health worker or social worker for continued food access support, refers the patient to an MNT program, or discontinues the prescription.
Feedback & Integration
At the three-month follow-up visit, the clinician solicits feedback from the patient on their experience in the program and shares any health gains and their implications with the patient. This is an important time to review medications and make adjustments, noting where FIM has assisted the patient in reducing medication reliance, as may be true for diet-sensitive conditions that can go into remission with careful management.
Success will not look the same for all patients. Even small gains should be noted and celebrated. At the same time, it is important to discuss and acknowledge barriers that may have prevented a patient from fully benefiting from a FIM program, and in doing so, help the patient adjust their participation and set new goals. The clinician documents care plan modifications based on the discussion with the patient during the visit.
Collecting feedback at the end of the enrollment period supports program improvement and adjustments to the patient’s care plan. There are also opportunities to monitor engagement throughout. Clinical support staff can monitor feedback channels to identify patients at risk of disengagement, schedule proactive follow-up appointments, and raise implementation challenges to health system managers and leaders.
The following chapters describe how health systems can organize the processes, personnel, and enabling technology to launch FIM programs so that clinicians can successfully follow this workflow and begin referring patients.
Sample Script:
Referring a Patient to a FIM Program
Provider: “Nutrition can play an important role in helping manage your diabetes, and I see in your chart that you often have difficulty accessing healthy food. We have a program that connects people with diabetes with healthy foods and nutrition support. Is this something you would be interested in learning more about?”
Patient: “Yes, tell me more.”
Provider: “It’s called a Food Is Medicine program. It can help make it easier for you to get the right foods to support your health. If you’re interested, I can make a referral, and a program coordinator will reach out to help you get started.”
Patient: “That sounds great. I’d love to join that program.”
Provider: “Great! Would you like me to make a referral to a registered dietitian as well? They can help with individualized nutrition and lifestyle recommendations to support you as you receive the Food is Medicine program.”
Patient: “No, thank you. I don’t have time to come to the clinic for those visits.”
Provider: “That’s understandable. They offer virtual sessions if that’s something you’re interested in. We also have monthly diabetes support group classes. You can sign up for those any time using your patient portal or by calling the clinic. ”
Patient: “I’d like to try the FIM program on my own first, then I will let you know if I want additional support.”
Provider: “That sounds like a good plan. I will make this referral to the Food is Medicine program for you. My medical assistant will help schedule us a quick follow-up appointment in three months to see how the program is going. What other questions do you have about this program or managing your diabetes through food?”
Patient: “None, thank you. I’m excited to try this new program.”
FIM Within the Clinical Workflow ▶