Lakewood Health System

Location: Staples, MN
Coverage Area:
State of West Virginia. Program started in a clinic in Wheeling, WV, and has since expanded to Tyler, Marshall and Wetzel counties.
Founded in: 2015

Lakewood Health food is located in a federally designated food desert. Its access initiatives were started and cultivated as a result of their community health needs assessment that found the three top areas to work with as obesity, mental health and food insecurity. The food access programming started with a pilot project in 2015 that integrated food into their pediatric practice. Ten patients screened as food insecure where given CSA shares. Now, they have four different food initiatives:


  1. 1. Food pharmacy with meals at discharge program, with two tracks. 
  2. 2. Meals at discharge program for 55 and older population with food insecurity. Patients are given a one month supply of ready made freezer meals. Eligibility is based on health condition, healing process, and ability to cook and access food. 
  3. 3. Fresh deliver: fresh food is delivered to seven low income and senior living apartment buildings within their service area that have transportation barriers to accessing grocery stores. Cooking classes and education are provided onsite. 203 served.


To provide quality personalized healthcare for a lifetime, to improve the health and wellbeing of our patients, not just through a clinical lens, but through a whole person, whole family and whole community health focus. 

Number of patients served

about 2,000 individuals


The CDC quality of life measurement tool has consistently shown the same or improved quality of life for patients, with 75% reporting a greater level of physically and mentally well days. Patients are more able to triage care to the appropriate places at the appropriate times, and have increased their clinical care and diabetic education visits. Have also seen a reduction in BMI. New data is currently being analyzed. 

Anecdotal: “We’re able to develop deeper relationships with patients and we’re able to navigate the complexities of some of their medical journeys in a more intentional and connected way”

“Family that had been identified as high risk for  homelessness that was avoided with her three children. So you think of long term implications on having three kids not go through the trauma of being homeless. How do you put a measurement around that? That’s not going to show up in an EHR record. It’s not going to show up on a BMI scale, but thinking of all the work and the pieces that implicate childhood trauma and not only were they not homeless, but they were attending cooking class with mom and we’re excited to come and try the new healthy recipes at the food pharmacy (…) It’s significant for that family and I think it will show significance over time for that entire cohort.”

Argument in favor of food farmacies

Changing patient diet is an important preventative measure to both treat and prevent diet related diseases. Paying attention to patient lifestyle can lead to overall cost savings. 


“One of the greatest arguments is that we can sit and try to fix all of these downstream chronic conditions and barriers, but until we get to that full root cause analysis, to figure out what’s causing some of these complications and health outcomes, we’re never going to move past the spinning wheel in the downstream area. So we have to go up there.”


“We had one food pharmacy participant that it was challenging to get them to take medication. The medication adherence was awful and it was causing problems. They were inpatient to get corrected and then sent home, and then back inpatient. Long story short, it was figured out they weren’t taking their medication because it needed to be taken with food three times a day and this person really only had food allocations enough to eat once a day. And so here we are trying to fix an issue with clinical methods that weren’t actually the problem. The problem was the ability to have adequate sources of food to maintain their condition.”

Cost of service

Funding from the Bush foundation innovation award provided seed money for the program. Other funding comes from philanthropy funding and grants. UCare pays for the acute care packs from Second Harvest Heartland. Integrated health partnership program (IHP) in Minnesota offers health systems incentives for improving quality and outcomes for Medicaid population, and last year the Minnesota Department of Health added health equity requirements to the incentive payment model. This provides incentive payments for their food insecurity work. 

Any and all partnerships with healthcare providers

Lakewood Health System and their five clinic sites. The nonprofits The Food Group and Second Harvest Heartland provide food, and UCare funds Second Harvest Heartland food boxes.

Screening and eligibility

The referral process for the food pharmacy is done by nurses during rooming. Nurses screen for food insecurity with the Hunger Vital Sign within the EPIC system (having it in the EMR allows them to do data extraction and patient monitoring). If a patient screens positive – either sometimes or often true, the nurse asks them if they are currently experiencing a food emergency at home. If they are, they are given a shelf stable food box, provided by Second Harvest Heartland, to take home. For all patients screened positive, a referral is made to the community health team who then follows up with the family and walks them through the benefit survey tool to ensure that they are connected to available programs and support systems, such as SNAP and WIC. The patient or family is then either enrolled or put onto the waiting list for one of two food pharmacy tracks:


Track 1: More intensive track for high risk patients. Patients need a physician referral and must be struggling with multiple chronic conditions, or with higher needs, such as getting their A1C under control or getting approved for bariatric surgery. These patients meet one on one with a community health coordinator in the hospital every other week for educational sessions, and go home with 4-5 recipes and ingredients to cook those recipes, as well as additional food from the food pantry. 20 patients at a time in this track. 


Track 2: Lower dose intervention. Families attend food distribution events once a month and get 7-10 lbs frozen lean meat and 12-15 lbs fresh produce. In the summer, these events are at a farmers market, where employees also get matching funds to shop (300 employees participate monthly). Cooking classes, budgeting classes, grocery store and farmers market tours are also offered, and 85% of families have completed a class. 100-110 families served monthly.

Greatest challenges overcome

Figuring out sourcing for fresh produce, especially with seasonal climate. Figuring out how to measure long term outcomes for patients.

Greatest challenges yet to overcome

The need for this service is greater than they are able to meet. They are learning how to scale to meet this need, and figuring out how to sustain and fund the costs of operating the program long term?

Perceptions as to what will be needed for food pantries to be paid for by third parties

More data on return on investment and the specifics of food interventions needed for patients. 


“When we think of the cost of one cardiac event or the cost of long term treatment of diabetes or the cost of any of these significant chronic conditions that are diet related in nature, we’re talking about drops of sand in the bucket to have a preventative approach on ensuring there is adequate access to healthy foods. One avoidable event can probably cover my entire budget.”

“The wait for this more intensive body of evidence, that’s great. Lakewood is not willing to wait. We’re here and we’re investing in, we’re testing models, we don’t know what intervention is most successful – is that later intervention really all that’s necessary to move the needle or is the more intensive option needed? What level of dosing per day is necessary? I don’t have any answers to that, but I think we’re not going to wait to figure it out. Having payers at the table will help ensure entire populations are able to be served and provide sustainability in the foundation for a health system to embed this as part of standards of care.”

Data on patient outcomes

They utilize process pieces, behavioral pieces and the healthy days measurement tool to measure outcomes. Also measuring some clinical measurements.  

Most impressive metric gathered thus far

Significant A1C and weight reductions “Some of the more heartwarming ones: the reduction in families eating out and the increase of sitting around the dinner table together, having dinner together, the increase in kids cooking with their parents.”