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Anne Thorndike, MD, MPH, a physician-investigator in the division of General Internal Medicine at Massachusetts General Hospital and an associate professor of Medicine at Harvard Medical School, is the senior author of a recent study published in Jama Health Forum, Assessment of the Massachusetts Flexible Services Program to Address Food and Housing Insecurity in a Medicaid Accountable Care Organization.

What was the question you set out to answer with this study?

The Massachusetts Flexible Services program  is a 3-year pilot program to address food insecurity and housing insecurity by connecting Medicaid accountable care organization (ACO) enrollees to community resources.

The main question we were investigating was what were the initial implementation challenges and solutions for a Medicaid accountable care organization participating in the Massachusetts Flexible Services program?

What methods or approach did you use?

We used a mixed methods study design that analyzed quantitative electronic health record data of all MGB Medicaid ACO enrollees and qualitative interview data collected from ACO staff and Flexible Services enrollees.

To evaluate the implementation of the Flexible Services program in the ACO during the first 17 months of the program (March 2020-July 2021), we assessed the program’s reach, perceived efficacy, adoption, and implementation, as well as the external and internal contextual factors that influenced the roll-out and uptake of the program at MGB.

What Did You Find?

Our results showed that among the 67,098 MGB Medicaid enrollees:
-- 57% completed at least one social needs screening between March 2018 and July 2021;
-- 16% screened positive for food insecurity,
-- 11% screened positive for housing insecurity.

There were 658 (1.6%) adults and 173 (0.7%) children (<21 years) enrolled in Flexible Services; of these,:
--  74% were female,
--  53% were Hispanic/Latinx, and
-- 21% were Black.

Most Flex enrollees received the intended nutrition or housing services, such as food vouchers, medically tailored meals, or assistance with housing applications.

Implementation challenges identified by staff interviewed included:

  • Administrative burden
  • Coordination with community organizations
  • Data and information sharing between MGB and community organizations
  • COVID-19 factors (e.g., reduced clinical visits).

Implementation facilitators included:

  • Administrative funding for enrollment staff
  • Structured communication and contact with community partners
  • Bidirectional data sharing platform for the health system and community organizations
  • Adaptive strategies to identify eligible patients
  • Raising clinician awareness of Flexible Services.

In Flexible Services enrollee interviews, those receiving nutrition services reported increased healthy eating and food security; they also reported higher program satisfaction than Flexible Services enrollees receiving housing services. Enrollees who received nutrition services that allowed for selecting food based on preferences reported higher satisfaction than those not able to select food.

What are the Implications?

For optimal reach, adoption, and implementation of  programs addressing food and housing needs in low-income populations, states and health systems should provide funding to address administrative burden, design effective data sharing platforms, tailor support programs to patient preferences, and assess implementation outcomes during program delivery.

What are the next steps?

The next steps in this research are to evaluate program implementation from the perspective of the community-based organizations and to determine the effectiveness of the Flexible Services program on improving diet, stress, and health outcomes of participants.


Listen to the accompanying author interview with Anne Thorndike, MD, MPH, featured on the JAMA Health Forum podcast: “Challenges of Addressing Food and Housing Insecurity in a Medicaid Context” 

Paper cited:

McCurley, J. L., Fung, V., Levy, D. E., McGovern, S., Vogeli, C., Clark, C. R., Bartels, S., & Thorndike, A. N. (2023). Assessment of the Massachusetts Flexible Services Program to Address Food and Housing Insecurity in a Medicaid Accountable Care Organization. JAMA health forum4(6), e231191. https://doi.org/10.1001/jamahealthforum.2023.1191

About the Massachusetts General Hospital

Massachusetts General Hospital, founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The Mass General Research Institute conducts the largest hospital-based research program in the nation, with annual research operations of more than $1 billion and comprises more than 9,500 researchers working across more than 30 institutes, centers and departments. In July 2022, Mass General was named #8 in the U.S. News & World Report list of "America’s Best Hospitals." MGH is a founding member of the Mass General Brigham healthcare system.