Introduction

Hey, all! Welcome back to Here’s the Problem Podcast. I’m your host, Kelly Nagle. In today’s episode, we’re digging deep into an interesting aspect of healthcare – agriculture!

I know agriculture isn’t the first thing that comes to mind when we’re talking about health equity and healthcare policy, but I promise you this is a fascinating topic. To explore the intersection of agriculture and healthcare. I’m talking to Helen Labun. Helen is the program manager of the Food Access and Healthcare Consortium, which works to integrate food and healthcare in Vermont. Helen’s background spans economics, public policy, and even the restaurant industry. And with all of this experience, Helen highlights how food access and agriculture integrate with healthcare, the challenges of rural access to care, and how access to healthy foods isn’t just the responsibility of the healthcare industry. Enjoy.

Kelly Nagle

Helen, welcome to Here’s the Problem Podcast. Thank you so much for joining me today.

Helen Labun

Oh, thank you for inviting me to be on your podcast.

Kelly

I’m really excited about our conversation because we’re talking about food and agriculture and healthcare, and I am curious to understand how all that works together. And it’s something that I don’t think we really talk a lot about. So, I’m excited for our students and our listeners to get a little bit better of an idea. But before we jump in, your background is so interesting. I’d love to learn a little bit more about your path into healthcare and where you are now and what Bi-State [Primary Care Association] is as well.

Helen

Sure. I can answer all of those things. Maybe I’ll start with what Bi-State is. So, I work for Bi-State Primary Care Association, and we can parse that title. So, the two states in the Bi-State are Vermont and New Hampshire, and I’m on the Vermont team there. And then for the primary care association, every state has a primary care association. And that’s tied into federal funding and goals that everyone should have access to comprehensive quality primary care, regardless of insurance status or ability to pay. And what that means is that the federal government will support federally qualified health centers in areas that require additional support for access. And the primary care associations in each state help facilitate the work of those, we call them FQHCs, or sometimes they’re called community health centers, as well as working on say, policies that will, will overall help everyone access primary care.

And I think an important distinction to make when we think about this is that when they’re talking about primary care, they’re not talking about point in time care – you visit a free clinic because you have an issue or you go to an urgent care for an issue. What they’re really talking about is a patient-centered primary care medical home. So providers and staff who will work with you throughout your life or as long as you’re in that area on having good health. And I was previously the state policy director for Bi-State, for Vermont State Public Policy. And recently switched to focus full-time on this intersection of food access and healthcare. So that’s my current role at Bi-State. Prior to working in healthcare, I had a lot of different jobs. All could be summarized as being rural policy, the focus on economic policy some more policy-like than others. I also did things like run a restaurant for a year that was not so much with the policy…

Kelly

But still food. So, I see the connection, but still…

Helen

It’s related. I am a very good home cook. I’m a terrible restaurant chef as it turns out. But a good home cook, and worked in a variety of roles around Vermont, looking at different aspects of the, of rural economic development and rural community development. So I worked in creative economy, I worked in food and agriculture, I worked on digital divide issues and eventually made my way into healthcare as many people do since it is a huge percentage of our economy.

Kelly

Mm-Hmm.  Yeah. You mentioned rural a lot and, and it’s something that I, I’m in New Jersey, I don’t hear that a lot, but New Jersey and Vermont are, are very different. So I’m wondering like, what is rural healthcare, rural economy?

Helen

It depends on what part of the country you’re in. So rural is always going to be defined by having not that many people per square mile. It looks different in different parts of the US though.  Out West you may have a couple of large towns and large swaths of space in between them with either some very sparsely populated towns or no populated towns.  In Vermont it’s less that and more, simply, that no one place is all that big. Right, so we have a city, Burlington, that is our largest, and – I haven’t looked at the census recently – the Burlington metropolitan areas around 55,000 people. I think that Burlington might be 38, 35. So we’re not, we’re not talking Manhattan here.  And then there’s a pretty quick drop off after that. So, for example, I live in the capital and we have about 8,000 people.

And that has different, just simply lack of people. So when you’re looking at healthcare and you are looking at say, access to specialty care, if you’re living in a rural place without that many people, that means that not that many people are going to be developing the condition for which you might need a specialist. So you would have to look elsewhere to get that support or find some other way to deliver that healthcare. And so there’s a lot of discussion of workforce, or telehealth is access, or crossing state lines to seek your healthcare access. Because we are a very small state geographically and it introduces those issues. And then often the economics situation of a rural state might be shaped by natural resource economies, either currently or historically. So in Vermont, that has been a lot of agriculture. If you’re going to do policy in Vermont, you should have an opinion about supply side management for dairy pricing systems, for example. And so that would be the other way that I think it really manifests itself in having different considerations if you’re going to be in the policy field.

Kelly

Yeah. Wow. The topics that I don’t hear in New Jersey where the healthcare is everywhere: massive healthcare systems, multiple massive healthcare systems, specialists everywhere. It’s hard for me to wrap my head around the idea of crossing state lines just to access a specialist versus crossing state lines to access the top of the specialists that out of the pool that you have available.

Helen

Yes. And nor do we have many pharmaceutical companies, unlike say, New Jersey, right? So, there’s also add-ons to that healthcare is a, an industry that’s not just the care that’s being provided to you, but there’s a whole nexus of work involved in that. And if you’re in a place that’s very rich in that industry, you have a lot of add-ons as well. Clearly not, not so in Vermont.

Kelly

Yeah. It’s hard for me to fathom, but that’s a reality for not just Vermont. Right. Many, many other states in the country, I think don’t actually have the benefit of any specialist that, that they would need within a 25 mile or 50 mile radius.

Helen

Sure. And we have it pretty okay in Vermont;  Boston is not that far from many areas of Vermont if you’re in a non-emergency situation. Right. So we have proximity that other rural regions may not have, but with that comes a different set of issues like interstate licensure, for example. So there are different access issues depending on where you are, but, when you look at, say the primary care association and the FQHCs that we serve, about a third of Vermonters get their primary care from one of our members, which is a little bit broader than the FQHCs, but it’s a sizeable percentage of the population. And one of the reasons for that is that when you live in a place that doesn’t have a lot of people, you don’t have the business case necessarily to set up a comprehensive high quality primary care center without additional assistance from the government to subsidize that opportunity.

And so we are fortunate in that we do have a very strong system of FQHCs and primary care providers. It’s not like you have a lot of choice, right. When I was growing up, I did not know that there was such thing as choice in who your primary care doctor was. I thought it was like a school district. You’re just assigned to this community health center and that’s where you go. I now know differently, before anyone’s worried about my policy credentials here. I have since learned that that is not true. It never occurred to me that this would be something that worked differently when I was a kid in rural Vermont.

Kelly

Yeah. Amazing. A really great different perspective to healthcare and access to care. I’m excited to get into this idea of agriculture and healthcare. How does this intersect? Why is this a topic? And, and what do you do in that space?

Helen

When we think about how this intersects, there’s two extremes that I try to avoid, but are useful for illustrating this intersection. So on one hand we can be reductionist in terms of tying everything back to health. Like there are very few, at least in the policy world, issues that don’t connect in some way to health and food, and agriculture is clearly going to be one of those. If you live off of nothing but potato chips in soda pop, the health outcomes are not going to be good. Right. It’s self-evident that there is a connection there. But also we can’t be that quite that reductionist when we’re looking at policy. We have to find some middle ground beyond just drawing everything back to your, to our eventual health.

On the other end of the spectrum, we do get into the world in nutrition of miracle foods. You know, eat a handful of blueberries and you’ll cure Alzheimer’s. Dr. Oz would be a primary example of the advice that folks get that where taking food is the equivalent of taking a pill, it’s going to cure whatever might ail you. That’s probably also a little bit extreme in most cases although everyone should have B12 supplements if they’re having a vegan diet, for example. So there are issues where it is in fact that straightforward that you need to have those foods.

So we are looking at the middle ground there of how do we shape the food environment that we all experience, although I’m caring about Vermont, so that people in Vermont experience, to facilitate good health throughout your lifetime starting even pre-birth to be sure that everyone has the ability to have that healthy diet and promote good health in a prevention and maintenance sense.

And also, you know, going towards that other end, you can also say that there should be more targeted clinical applications of food that uses specialized knowledge of medical professionals. So there are plenty of examples. You know, some that maybe folks don’t always think about are, say a patient is going through chemotherapy and that is going to have an impact on their tastes or on their appetite. And how do you design a diet that facilitates good health and healing during that time period? Or actually a timely example, we talk about long-term covid symptoms. If you’ve lost your sense of smell, that has a very direct impact on appetite and your diet and what you eat. So it often has some specialized work with that. Or you can look at common diets where there are strict parameters, allergens dealing with allergies, looking at serious gluten issues.  Advanced kidney disease has specific dietary requirements. So that’s something more than me recognizing that I need to eat more dark leafy greens in my diet and avoid sugar sweetened beverages. Right. It takes a slightly more specialized approach. And so we are looking at interventions in that range from the prevention of the food environment through to working directly with clinical staff to shape a diet that promotes health and often treatment for disease for individual patients.

Kelly

So, is it imperative to raise awareness for citizens and patients about the importance of healthy diet? Or is it working through policy or with agricultural industries or food providers to align their products more with health?  Or make them more accessible? Or is it all of the above and more?

Helen

So, for my particular job, it is more on the policy and provider side. I would say though that the public awareness, at least in Vermont, which is its own culture, so I am not going to speak for the rest of the nation, I don’t think there’s a lot of people who are confused about the fact that less pizza, more salad is going to create better health outcomes.  So there is a baseline awareness there. Getting from generally recognizing that to acting on it in a useful way is more difficult. So we do not have the same task of raising baseline awareness that might be true in other places, but we certainly do have a lot to do in terms of, well, how do you then act on that and what’s the appropriate way to act on that? In terms of the policy work that I do or the provider work that I do, there’s a lot of technical detail and that’s what I’m more focused on. Partially not because that’s necessarily the most important thing to do, but because that’s where the gap was. So I work on where the gaps are. So examples of those types of gaps would be reimbursement systems for food as a colored health expense. Anytime you get into payment systems and healthcare, that’s fairly specialized and somewhat tedious and not that many people want to do.

So we’ll work on that. Or had you set up clinical work workflows that facilitate that. What are the HIPAA rules around coordinating with community organizations on providing food? What are the inducements laws that govern whether or not healthcare entities can spend public dollars on providing food to patients? What if you look at individual, you know, are individual insurance plans paying for food? If that became available and in some, and in some instances, it is available, that requires a fair amount of work on the practice side to link through food insecurity screening, referral systems, dietary change, clinical outcomes, there’s a lot of points of connection that have to happen to make it be a legitimate medical expense. So I look at those sorts of technical issues.

Kelly

So, I’m wondering the food insecurity point was interesting because I was already thinking like, is this for a patient who is socioeconomically challenged and they’d have to go to a food bank, say, and have to get specific food for their health condition? Then is it really only looking at that socioeconomic group or how do you do it for someone where finances aren’t a challenge, they just need, I mean, need specialized food that they’d be looking for insurance to reimburse them on because they have to go out and avoid things with vitamin K, say if they, they had a stroke or you have to eat, you know, how high alkaline foods or, or what have you if you’re going through chemo? Is it just for one demographic or is there a way to make this universal regardless of socioeconomic status?

Helen

Is not just for one demographic, but it depends on what you’re doing and what you are paying for. So, for example, if someone had no barriers to either acquiring the foods they need for whatever their condition may be and no barrier to preparing those foods, then you would say, ‘well that is not a problem that healthcare needs to solve’, but they may have a barrier to knowing what to do. Right. So, if it were me and I had, and five different conditions that materialized out of nowhere, I’m a pretty good cook – there was that restaurant incident we mentioned before, you know. 

In terms of people with home cooking skills, mine are pretty high up there, but I’m still not a registered dietician. I’m not going to know the details of how to design a menu.  After someone’s walked me through that and helped me understand that, yes, then I may be good to go, but I’m going to need that specialized counseling ahead of time. So that would be the covered service in that scenario – is that assistance for understanding. So, we’re not only looking at a basic healthy diet, as I mentioned before, we’re looking at professional input into how to design a diet whatever your current health situation might be. I would also say that when we look at food insecurity as a concept, there is a definition for that and there are validated screens for doing that. The U.S.D.A. set of definition, and then there were screens developed for clinical applications that were validated against the U.S.D.A. definition, which is a, a, it is, well, US Department of Agriculture, so it’s not a clinical definition and then also validated against clinical outcomes.

So, we know how to do that, we know how to screen for that. But just because you are at one point in time, okay, on the basic food insecurity screen, it doesn’t mean that circumstances don’t change, right? You get a medical diagnosis, suddenly the systems that you had in place for accessing the food that worked for a diet previously don’t work anymore. And you have the additional stress in your life of dealing with whatever this medical issue might be as one example. So your food security in a clinical sense has now just gone down, right? And, we need to deal with that. And then there’s also the ongoing question of does everyone in our community have abundant access to healthy food? And that’s just a, that’s a baseline question. It affects healthcare, but it affects everything else as well. So that would be the most fundamental level.

Kelly

So my takeaways are there are a lot of different variables to consider, whether some, like you said, someone might be fine with a diet they were on, no issues to access to food or food insecurity, and then you get a diagnosis and all that goes out the window versus maybe someone who is already dealing with food insecurity and now has to take into consideration they need very specific foods that might not be available in food banks or in their own areas. I mean, we talk a lot about food deserts, particularly in New Jersey and, and there’s just not the availability of fresh produce, you know, healthy foods. It’s all very fast food based, you know, cheaper, cheaper options, which might work economically for some people, but it’s not working in the healthcare sense. How do you account for all these different variables and situations that can be very fluid when you’re creating a policy? And then a step beyond that, just practically executing that? Like, it seems like a big undertaking. But, I’m not an expert here, so tell me if I’m wrong!

Helen

It, it is a big undertaking. I think that an important point inherent in what you’re describing is that it’s not all on healthcare, right? We we’re not looking for healthcare to solve all the policy issues that might present themselves in our lives. Healthcare is expensive enough.  We don’t need to put everything on top of it. So, part of it is working in collaboration with other organizations and some amount of ‘all right, you have this lane, I have this other lane, that person has this third lane and they’re going to come together in the end, but we don’t need to jump lanes and try and rewrite dairy pricing systems from the perspective of a hospital’, right?  So there is a fair amount of choosing what you’re going to focus on and knowing why and knowing how that fits in with the bigger picture.

It’s not like we’re writing policy from scratch. It has occurred to people before now that food and nutrition is an important part of our lives. So we are building from an existing framework, and the question becomes ‘what elements do we want to target for evolution, you know, in this next iteration’? Policy gets rewritten every year, so what are we going to look at this year to begin to build toward our, our final goal? The positive side of this being such a big and complicated system is that there’s always something to work on. It’s not like we’re sitting around saying, ‘gosh, what could we work on next’? And some of it is simply aligning ‘right now there’s interest in this issue and there’s momentum on this, so this is what we’re going for’. And some other things may need to wait a couple of years and that’s okay because everything’s at least moving in the right direction.

Kelly

Hmm. So who are the players involved in these conversations and merging healthcare and agriculture together?

Helen

It depends on what level you’re looking at. Federally, the Department of Agriculture is the steward of nutritional policy. However, Health and Human Services cares as well. So there is a…always challenging at the federal level and really any level to get two different fields to work together, right?  So a common example of that would be, say you get a grant from the U.S.D.A. for a food and health initiative, they are going to measure success primarily in the pounds of food moved. So if they’re trying to move more pounds of, I’m just going to keep using the example of kale because Vermont’s into kale…

Kelly

I love kale, I’m good with that! 

Helen

We’re a cold weather state, kale grows well! So we know in a general sense from healthcare that more kale getting into the system is an incremental win of some sort.  And so it’s not like the two aren’t aligned in that sense, but if that same grant would’ve been given by a healthcare organization, then success would be measured on whether people are eating that kale, whether the kale displaced french fries in your diet. and whether say your A1C levels shifted away from, you know, to better control of Type 2 diabetes; it would be a different set of measures. So, we are working at the federal level to combine different goals that are, that are broadly aligned, but not necessarily specifically aligned. 

At the state level, in Vermont, there are a lot of players. We are a very agriculture enthusiastic state…

Kelly

I love that phrase!

Helen

…which is odd given our growing climate and our very rocky and not very flat soil, but we are enthusiasts! So, we don’t have that much trouble bringing to the table the agency of agriculture. The land grant and agricultural colleges, the food banking system, the charitable food system, the healthcare providers, and I should say that, that that there is a professional distinction of people who are working on community health or population health – so the health outcomes of the entire state, or the entire town, or the entire community, and then the people who are dealing one-on-one with patients. So those are two different groups that we also bring together at the table.

And then we also look at where there currently is in healthcare a lot of preexisting infrastructure for combining food and health. So you would look at, say, the lifestyle medicine trained doctors who have a high focus on that, or nutritionists and dieticians are an obvious example, or working on ongoing collaboration with the area agencies on aging who tend to have the Meals on Wheels contracts and have nutrition for older Vermonters, for example, or visiting nurses, people who are providing home services, which again, traditionally in healthcare has had funding for food elements. So we also work on integrating those.

Kelly

Is there a willingness by all parties and, and health insurance companies are standing out, since we’re talking about reimbursement, is there a willingness to bring this to life or are there barriers or challenges that one player, I’ll put in quotes, “have to overcome” or, or the collective group that you just talked about has to “overcome”?

Helen

I would say both. There is both interest and barriers. So, when we look at…I’m just going to focus on the reimbursement barriers. I am not a clinician. I am trained in economics. So I, let me recognize that the barriers I’m about to list are a subset of the barriers out there. But to give a non-three hour answer, I will just give some reimbursement examples. So, if you look at payers, either a Medicaid payer or a commercial plan payer, you can imagine other kinds of payers, but for those examples, let’s say traditional barriers include, you don’t want a cost shift, right, so we already talked about that: you don’t want the entire budget of the US Department of Agriculture to shift over to healthcare, and you don’t want any gradation down of that, right? So, we don’t want to create new costs for healthcare by shifting somebody else’s responsibility onto them.

We want to make some sort of, not dividing line, but just an understanding of what we’re investing in – I made that distinction before of community and population health versus an individual patients prevention treatment plan. So that needs to be sorted out: which goes in which, which bucket? And then you also in healthcare, if you want to do something that’s new, that hasn’t previously been covered, there are many barriers to that. Many of which for good reason, right? We don’t want to be spending money on treatments that don’t work. That’s bad from a cost perspective, it’s bad from a patient outcome perspective, it’s bad from many, many perspectives. So there is a relatively high burden on getting new services, treatments, prevention measures into the system. And some of that comes down to just fundamentally how are you going to get flexibility?

So if you take Medicaid as an example, even though that is a state administered program it is matched at the federal level. So anything they need, they want to do that’s out of the ordinary, they have to negotiate with the federal payer as well. So even just to get to the starting line in terms of flexibility is a fairly there’s intense federal negotiation that needs to happen. So those are some of the classic examples and then if you’re going to really go down the rabbit hole of opening the doors, you need to prevent fraud and abuse so you have to have a coding system and a well-defined service, and how are you going to monitor that this service was actually provided and it was providing the value that we’re paying for? So there’s a lot that goes into developing a system to pay for food as part of healthcare. And like I said at the outset, that’s just one piece of the puzzle.

Kelly

Yeah. Well, that, that’s a lot that would take up, you know, hours of podcast. How long have you, and I say you as I guess Vermont and Bi-State and the other entities been working on this, and how close to the finish line are you? That’s a loaded question!

Helen

This is not just a marathon, this is an ultra-marathon!

Kelly

Ok, that puts it in perspective. I feel that.

Helen

I mean, we’ve been trying to solve the problem of hunger since agriculture was invented. We’re talking millennia here. So there is no finish line!

I would say though that in terms of starting work, so at Bi-State my position working on this full-time is a new position, but I’m building on work that has happened in Vermont before now. So it’s been a continuous evolution. We can also look to models in other states and, for example, I was explaining about how with Medicaid you need to have that negotiation with the federal government. Well in North Carolina they had that negotiation and they went big on investing in the healthy opportunities pilot, which has a lot of food involved in it. This is an intense and very long and probably imperfect – because this is really hard and it was interrupted by Covid 19 – project the North Carolina has been doing, but it’s being done in the public domain, right?

I can look at what happened in North Carolina, I can look at how they defined the services. I can look at the stakeholder process they used to define those services. I can see how much the services cost using the formulas that North Carolina used. I can see what their agreement with the federal government looks like. That’s all available to me. And we can see how that pilot turned out. Ditto in other states. Massachusetts has a big state ‘food as medicine plan’ that you can look at for that. Medically tailored meals programs are building models of how those get reimbursed. So there’s lots and lots of models out there to look at. Maybe not lots and lots, maybe just lots. There are models out there to look at. So, no one is starting from scratch. We are all learning from each other and building off of what has happened before.

Similarly, there’s the clinical evidence base, there’s study on cost savings so there is a lot of information out there that any given state can work with to put together the answer that’s right for them. So, it definitely does not feel like I’m at the bottom of any mountain here. It’s been going on, this work has been going on probably forever. And it just evolves each year and there’s more information available each year, and we’ve learned from the year before.

Kelly

Hmm. I was going to ask you, are there other states that are doing this same thing and you beat me to the punch with your answer.  But, I mean, as a political scientist, I know why we’re doing this state by state, by state, you know, the whole, you know, tension between states rights and federalism and all of that. But is there any sort of coordinated effort instead of doing this state by state by state and, you know, watching what others have done and then try to implement it. Is there any way to coordinate across the country that this is working in some states, let’s all 50 of us come together and instead of you having to have the local and federal Medicaid conversation, and that’s repeated in each state, is there a way to coordinate and make this sort of a countrywide – mandates the wrong word – but countrywide initiative without getting into the state’s rights issues?

Helen

Sure. You can have a National health service, so that would be one solution….

Kelly

That’s a whole other conversation.

Helen

We know that…

Kelly

I just know that a can of worms, I’m sorry.

Helen

…we know that there is an option. Setting that one aside is unlikely.  It would be valid to say that, I’m going to say in healthcare, but I think this is true not in healthcare as well, there is a tendency towards lots and lots of pilots that are pitched as being something from which you can build programs that are applicable other places, but that never get to that program that’s applicable other places stage, right? That’s just an inherent issue that is systemic and should be resolved. So I’m sure that there are many a PhD student working on the theoretical basis for why that happens and how we can change it.  I’m not one of those people. So, recognizing that inherent problem, there are structures in place that we know are more advantageous versus less advantageous if you want to do this food and healthcare integration. So for example, I, if we move down the pathway in Vermont, well, we are moving down this pathway.

If we move further down the pathway towards having value-based payment as our reimbursement model across payers, we know from other states that that provides you the flexibility that is needed in payment and also the practice change supports that are also needed on the ground to bring food more integrated into healthcare. And that is an established model. It is a framework that was put forward in the Affordable Care Act. It is a legal framework that we have access to and that would allow us to replicate in Vermont things that are happening in other states in this field. So, there are templates out there that can be applied to different states. We don’t need to reinvent the wheel each time. We simply need to implement the templates that have been set up. Similarly, you could look at federally changes that make funding available to states saying a grant form.

So one of the big issues is say that we see that there is a sustainable reimbursement pathway, whether it’s full value based or something else, and we’ve set up that sustainable reimbursement; we still need the money to cover the startup phases, right, of getting these programs into place, setting up the healthcare connections, matching the clinical best evidence models. That’s a different type of investment. So we could federally make those funds available to facilitate states, again, learning from each other and the evidence and the models that are out there and putting them into practice in their own states. So there are very immediate and practical things that can help reduce the amount of reinventing the wheel.

You’re never going to get around having to match programs to your particular state context. Like we began at the beginning of this conversation, the reality for setting up a medically tailored meals program in downtown Boston versus the Northeast Kingdom of Vermont, those are going to be two very different initiatives. You’re always going to need to tailor to the local context. You’re never going to get around that.

Kelly

Yeah, really good point. So, I mean, what does the pathway forward look like? What are you…because what are the benchmarks that you’re looking to hit to know that, okay, we’re making progress. It might not, you know, it’s that ultra marathon, you know, we might not see like perfect concept wrapped up in a bow and, and ready to go. But what are some of the goals or milestones that you’re aiming for so the agencies working on this can say, okay, hey, like, we’re making progress, we’re moving the needle, we’re providing a benefit for our communities?

Helen

There are, so my answer is not going to be very satisfactory because my program is grant funded. So within the grants I have very specific deliverables. I have very specific goals I need to hit every year and then every, you know, every end of the grant cycle. So in some senses it’s very micro in that, you know, I need to help healthcare practices implement food insecurity screening; I need to, and I’m saying I need to, because it’s in the grant, right? I want to as well, but I need to set up a system where they can refer a patient to community food program know that that referral was, we call it a close the loop on it, so they know that the patient is then participating in that program. They can have the conversations with a patient about diet change and the impacts, perceived impacts on health, and then they can also look into their electronic health record and see the clinical indications.

That’s a pretty basic progression from a healthcare clinical perspective of linking food and health outcomes. So, you know, another part of the grant is getting that structure in place and available, and that leads to other advantages down the road. So, we have for the next couple of years the work plan laid out. At the same time, it’s not like I’m being myopic here, right? So I work with a broader coalition of organizations that each have their own different angle on the food access issues and food and health issues. So there’s the staying in touch with them and coordinating our efforts and then also we do strategic planning. So for example, last year in what was no surprise to anyone, was decided that the big common barrier to the success of these food programs was transportation.

Helen

Not a lot of public transportation in Vermont – a lot of bad roads, a lot of people are living at the end of bad roads who don’t necessarily have access to a private vehicle or have a reliable enough schedule that they can say, get to a CSA pickup at a particular hour in a particular place every week, right? So we also are doing, identifying kind of those big boulder type issues and doing planning work around them. So hopefully there is a happy combination of looking at those boulders and what can we do about them and what are the next steps on that. And also implementing very specific next steps that we’ve identified from our previous strategic planning work. There is no sense of, and once this happen, my work here will be done’.

Like I can’t even say, you know, a lot of times food and healthcare integration is phrased as, ‘well as soon as healthcare will pay for food, then, then our work here is done’.  Which isn’t even a…it doesn’t even make sense as a goal in the sense that, ‘well what do you mean healthcare pays’? There are dozens and dozens and dozens of different plans and plan types and different payers within healthcare that doesn’t even specify. So, you know, I think there are no simple, ‘here’s the finish line type answers’ there. It’s only an ongoing matching of strategic planning with very particular micro implementation on the ground.

Kelly

Yeah. Also fascinating. And I, I love our conversation, the entirety of it, and then what you just talked about because it’s integrating so many layers to this one issue. And like we talked about economy and socioeconomic status and challenges and impediments that that presents. And then this idea of just accessing care, like issues that being in a rural community present, that complicates, you know, the topic. If you had that finish line of ‘we figured, we’ve solved the problem, we found the perfect intersection of food and agriculture and how it’s going to be paid and how it’s going to be implemented’, but, and like, you can’t really celebrate because then on the other side of that finish line is, oh wait, but can people practically get to this solution? Is, you know, being in a rural area, another impediment? Is, you know, socioeconomic status another impediment? Is cultural beliefs another impediment?

And the more I talk, the more dejected I kind of start to, to get like, ‘oh gosh, how do we solve all this’? But one of the things we really try to reinforce in the Teen Think Tank Project is there isn’t just one quick solution. We have to dig through these complexities. We have to think of all these different impediments to then be able to clearly start to put together a plan to overcome them. And at the outset of our conversation, I didn’t think agriculture and healthcare was going to like really open up that whole conversation; but its tied together so many different topics just outside of healthcare that’s fascinating. I think they’re really going to resonate with our students in particular who have learned to kind of uncover things beneath the surface level to address these issues and create change. So, thank you. Like what a fascinating topic and what you’re doing and so relevant yet not talked about or understood well enough.

Helen

It is not a simple topic as, as you noted.

Kelly

Yeah.

Helen

And I’m not, you’ve probably caught on from the conversation. I’m not a quick sound bite kind of gal. So I’m just embracing the complexity. If you spend your life searching for silver bullets, then you’re going to spend your life chasing after things that don’t actually move the needle. It’s the incremental change and the having clear goals and having goals at different scales and working towards them and having the ability to say, ‘this is what I’m working on right now, you next to me are working on your piece of this puzzle, we’re going to work in collaboration’. We don’t need to have a solution that solves everyone’s problem at once. We need to work together, collaboratively towards a better situation a year from now and a better situation a year after that.

Kelly

Yeah.

Helen

Which is, you know, it is great to be able to be doing that – to have that incremental progress, even if it isn’t, everything gets solved within the next five years type of plan.

Kelly

Right. Which is kind of against our instant gratification culture in our society. But, I think it’s important for people to understand that there is incremental progress and that the fact that you haven’t magically reached the finish line doesn’t mean something’s not working. You know, it’s digging down beneath the surface to understand these issues and their complexities – every single one of them – and figuring out what is that progress? How do we collaborate, how do we start to move the needle, even if it’s not moving a hundred miles an hour towards the finish line?

Helen

Yeah. In healthcare, the, the danger is that instead of going a hundred miles an hour, we go one mile an hour…maybe a nice 65 would be the appropriate middle ground there.

Kelly

I love all the analogies. I can understand 65 miles an hour. I can understand ultra marathon. Like, gosh, okay, I feel that other than, you know, seeing some other metric you throw out that that would just be lost on me. So thank you for, for making this so relatable. I can physically feel the hard work that, that’s going into this and the, the progress. Helen, I love this conversation. I know people can, can follow you at VTfoodandhealth.net to see all the awesome work that you’re doing, get more information on this. I really appreciate you bringing this topic and your perspective to, to Here’s the Problem and the Teen Think Tan Project.  I’m really grateful.

Helen

Well thank, thank you for giving me a chance to talk about and for the great work that you and your Teen Think Tank participants are doing to, to change these and many other issues, now and in the future. Thank you.

Kelly

Yes. I’m sure you’ll be hearing from us again and some of our folks might even jump on board with the agriculture and healthcare policy. I think some of them will find that very fascinating. So, be well and look forward to staying connected and talking soon.

Helen

Great. Thank you.