Stepped Care Model for Improved Engagement and Health Outcomes Among Medicaid Adults with Hypertension

Scope of Project Our proposal aims to develop a stepped care randomized controlled trial (RCT) among Medicaid adults with hypertension residing in high poverty rural and urban areas, recruited from three large healthcare systems across Kentucky. This large-scale proposal takes lessons learned from the current American Heart Association Health Care by Food™ grant (PI: Gustafson) related to screening, referral, enrollment, and engagement to now test a full powered RCT to determine the incremental effect of a more intensive food and nutrition support plus counseling service program. This study will be able to answer at what level of care and for whom are these services clinically meaningful and cost-effective. Lastly, the proposed study incorporates referral services after the study ends to ensure sustainability after completion of the program. The proposed aims of the future large-scale study are as follows: Aim 1) Determine effectiveness of a stepped care food is medicine intervention among Medicaid adults diagnosed hypertension on primary outcome of blood pressure (systolic and diastolic) and secondary outcomes of (hemoglobinA1C, quality of life, food security, nutrition security, and family stress (anxiety, depression, and stress). Aim 2) Examine the lived experience in the entire Health Care by Food system at key time points in screening, referral, enrollment, and engagement throughout the stepped care process to enhance scalability across multiple healthcare sectors (health departments, hospitals, federally qualified health centers, managed care organizations, and food providers). AIM 3) Evaluate the cost effectiveness of the interventions from a healthcare and societal perspective, expressing cost effectiveness as: 1) cost per percentage point reduction in systolic and diastolic blood pressure and 2) cost per quality adjusted life year gained, assessed with a generic preference-based health utility measure (PROPr). Our study takes our previous three years of experience in building a statewide food is medicine system to develop a stepped-care model with nutrition and mental health counseling including referral systems into federal nutrition programs for sustained clinical improvements. The stepped care model allows for testing the incremental effect of more intensive food, nutrition, and counseling services which can answer at what level of care and for whom are these services clinically meaningful and cost-effective. This study also balances the importance of the user experience to allow for long-term success and engagement.