Keystone First Joins Crozer Health, MANNA in New Health Care Model to Tackle Food Insecurity and Poor Nutrition

New value-based agreement designed to align traditional providers with community-based organizations to improve health outcomes for Medicaid members

March 23, 2023 - Philadelphia, Pa.

Keystone First, the largest Medicaid health plan in southeastern Pennsylvania, has started an innovative program with health care provider, Crozer Health, and local nutrition services provider MANNA (Metropolitan Area Neighborhood Nutrition Alliance), to address health emergencies that have been exacerbated by poor nutrition, often caused by food insecurity.

This collaboration, called Caring Communities, is a new health care model that provides coordinated high-quality care to improve outcomes for members with nutrition and food security needs.

The Caring Communities program is designed to work as a virtual Accountable Care Organization (ACO). Traditionally, an ACO is a group of health care providers that are accountable for quality and efficiency for assigned patients.  Keystone First’s new “virtual” ACO approach promotes collaboration between traditional providers and community-based organizations (CBOs) to focus on shared goals. The Caring Communities program aligns providers and CBOs so they can better connect members with appropriate community services with the goal of improving their overall health.

“We are committed to identifying innovative new ways to enhance the delivery of care and improve the health outcomes of people in underserved communities,” said Keystone First Market President Joanne McFall. “We believe strongly in the power of strategic partnerships with health care providers and community-based organizations to address the social determinants of life and help fill the gaps in access to the basic resources essential to achieving wellness and resilience.”

Crozer Health and MANNA are the first organizations to collaborate with Keystone First in this model that follows the principles of value-based care. This payment model focuses on the socioeconomic factors that contribute to poor health outcomes for Medicaid members with the goal of reducing emergency department visits and inpatient admissions.

Referrals have been made for 134 Keystone First members who have received meals from MANNA since the program began last year.

“We are proud to partner with Keystone First and MANNA to enhance the quality of care for those most in need,” said Anthony “Tony” Esposito, CEO of Crozer Health. “Our goal is to provide population health services in an effort to prevent unnecessary visits to the emergency department.”

Under the Caring Communities program, Keystone First members are engaged through Crozer’s Care Management team. After initial treatment and diagnosis, if Crozer Health identifies a nutrition counseling or food security need related to a patient’s health crisis or to support chronic disease management, a referral is sent to MANNA. Next, MANNA prepares and delivers medically tailored meals to members and provide nutrition counseling services until their health improves.

“MANNA has been providing delicious and nourishing medically tailored meals to individuals and families across our region, the majority of whom are below the poverty line, for more than 30 years,” said MANNA CEO Sue Daugherty, RDN, LDN. “Access to and advocacy for appropriate nutrition can exponentially improve health outcomes and reduce healthcare costs so we are proud to be a part of this program which will shine a light on the role that diet plays in the prevention and treatment of serious health issues.”

According to data from the U.S. Burden of Disease Collaborators, poor diet is the leading preventable risk factor for poor health and disease. It is associated with more than half a million deaths per year . Nutrition is even more critical to those suffering from chronic diseases. Healthy eating can help people manage the associated conditions and reduce the potential for complications. These issues affect individuals in underserved populations even more significantly2.

Following the referral to MANNA, the health plan notifies the member’s primary care physician (PCP) and facilitate follow up appointment. Additionally, the health plan will gather and analyze data – from diagnosis to treatment – to determine the effectiveness of the program on the health outcomes of members.

MANNA, a non-profit organization, has been providing medically tailored meals for Keystone First members since 2016, with the goal of improving health outcomes and reducing hospital admission rates.

An evaluation of the program in 2018 produced encouraging results related to a reduction in overall medical costs, a reduction in inpatient admissions, and a decrease in the number of emergency room visits.

Based on these positive results, Keystone First developed the new value-based program to support collaboration between Crozer and Manna.

“A more strategic and proactive approach to health care will not only raise the quality of care, but also  help reduce overall health care costs,” McFall explained. “Our health plans across different states are realizing the benefits of leveraging these relationships to improve the health of both our members and their communities.”

1The US Burden of Disease Collaborators. The State of US Health, 1990-2016: Burden of Diseases, Injuries, and Risk Factors Among US States. JAMA. 2018; 319(14):1444–1472. doi:10.1001/jama.2018.0158

2The Journal of Nutrition, Volume 150, Issue 4, April 2020, Pages 873–883,