A healthy meal may not look like health care, but for many people living with diabetes, heart disease, and other chronic conditions, access to nutritious food can be just as impactful as a prescription.

That’s the idea behind Food is Medicine (FIM), an approach that is gaining momentum in Medicaid programs across the country. States are increasingly offering services such as medically tailored meals and groceries, produce prescriptions, and nutrition counseling and education to help members manage their health and improve outcomes. A growing body of evidence shows that FIM interventions can improve health outcomes by helping prevent and manage diet-related chronic conditions while addressing food insecurity, a key driver of health.

But creating a Medicaid benefit does not, on its own, ensure that eligible members access it. As states move from policy design to implementation, they face an important question: How can Medicaid programs effectively connect members to FIM services and integrate them into broader patient care?

Primary care providers are uniquely positioned to help answer that question. For many Medicaid members, a primary care provider is the health professional they know best and see most often. Primary care practices are often where food insecurity, nutrition challenges, and diet-related chronic conditions first come to light, making them a natural connection point between Medicaid members and the community organizations that provide FIM services.

This blog post highlights three strategies states can consider to strengthen the role of primary care in connecting Medicaid members to FIM interventions through ongoing care management and supporting the community providers that deliver these services.

1. Improve Identification and Referral

While many Medicaid members could benefit from FIM services, they may never be identified or referred. Primary care can serve as a front door to FIM interventions because it provides ongoing care for patients with diet-related chronic conditions and is often where food insecurity or nutrition-related needs are first identified.

Organizations such as the American Academy of Pediatrics and the American Diabetes Association recommend screening for food insecurity and other social determinants of health, but integrating FIM into primary care involves more than adding another screening question. Providers face competing demands and limited time. Many providers may not be familiar with FIM or lack the resources to coordinate with nutrition professionals, community health workers (CHWs), and care managers who connect patients to services. Screening, education, and care coordination may not be adequately reimbursed.

To make it easier for primary care providers to identify patients and make FIM referrals a routine part of care, states can:

• Incentivize primary care practices through value-based care initiatives to screen for diet-related conditions and incorporate nutrition-related findings into chronic disease management. States can also consider alternative payment strategies that support the staff time and care coordination needed to connect patients to FIM services, such as enhanced payments for care management, per-member-per-month payments, or quality incentives tied to screening, referral, and follow-up.

• Support multidisciplinary primary care teams, including CHWs, care managers, and dietitians, who can provide food insecurity screening, connect members to FIM services and federal nutrition programs such as SNAP and WIC, and provide follow-up support.

• Provide education and implementation tools and resources to help primary care teams understand available FIM services, eligibility requirements, and referral pathways. Recent Texas legislation requires nutrition training in many medical and health professional schools and establishes continuing education requirements on nutrition and metabolic health.

• Standardize primary care screening and referral processes through managed care organization (MCO) contract requirements. These requirements can establish provider expectations for screening, documenting, and referring eligible members to FIM services, with standardized questions and referral workflows embedded in EHRs or care-management platforms.

2. Strengthen Partnerships Between Primary Care and Community-Based Organizations

Because primary care practices generally do not deliver FIM services directly, strong partnerships with community-based organizations, MCOs, and community care hubs are essential. Primary care providers need clear referral pathways and knowledge of local resources to connect patients to FIM services, while CBOs need capacity to manage increased referrals. Building stronger connections between primary care and community providers can help create the infrastructure needed to support FIM at scale.

To strengthen these partnerships, states can:

• Invest in Community Care Hubs, regional coordinating entities, and technology-enabled referral infrastructure that can connect primary care practices with CBOs and streamline referrals. New York‘s Medicaid Social Care Networks (SCNs), established through the state’s 1115 waiver, provide a model for this approach. Regional SCNs coordinate screening, navigation, and referrals to CBOs for services including nutrition.

• Encourage MCOs to engage their contracted primary care practices to ensure they understand which CBOs offer FIM interventions in their areas, member eligibility requirements, and established referral and follow-up processes.

• Build sustainable financing models that support health care-CBO partnerships and demonstrate their return on investment. Massachusetts’ 1115 waiver evaluation found that nutrition supports resulted in fewer hospital visits and an average of $2,502 in health care cost savings per participant.

• Support communications and outreach to increase awareness of available FIM services among providers, Medicaid members, and CBOs.

3. Support Coordinated Care and Data Exchange Between Primary Care and CBOs

A referral should not be the end of the connection between primary care and a community organization. FIM works best when primary care providers and CBOs have closed-loop referral processes that integrate FIM into ongoing care rather than treating it as a one-time referral. For example, a CHW or care manager may refer a patient with diabetes to a produce prescription program. Knowing whether the patient enrolled, participated, or encountered barriers can help the care team determine the intervention’s effectiveness and improve future referrals.

These connections can be difficult to establish. Health care organizations and CBOs may use different data systems that do not communicate with one another and may not share the same quality measures. Information sharing can also create administrative burdens for organizations with limited capacity.

To support coordinated care, states can:

• Invest in closed-loop referral technology that enables providers to track whether referrals resulted in successful connections to services.

• Create shared approaches to measuring referral and service outcomes to assess whether referral pathways are working and if FIM services improve health outcomes and reduce health care utilization.

• Foster partnerships through learning collaboratives and technical assistance, helping primary care and community organizations to develop shared workflows, learn from one another, and support CBOs that are new to Medicaid with contracting, billing, data reporting, and compliance.

Key Considerations for Rural Primary Care

The strategies described above may be particularly important in rural communities, where health care providers and community organizations are more dispersed and coordination can be more challenging. At the same time, rural primary care providers may have longstanding relationships with patients and other community organizations that can provide a strong foundation for FIM interventions.

States can support rural implementation through approaches such as regional referral hubs, shared CHWs or dietitians, telehealth and virtual care coordination, partnerships with local food banks, farmers, and other CBOs, and mobile food delivery models that help address transportation barriers.

Because rural providers and community organizations may already have strong community ties, relatively modest investments in coordination infrastructure could have a significant impact. New federal funding opportunities, including the Rural Health Transformation Program (RHTP), may provide states with an opportunity to strengthen the connection between rural primary care and FIM. For example, through RHTP, North Carolina plans to establish locally governed regional hubs that connect medical, behavioral, and social services, including FIM; and Nebraska is developing regional food hubs that connect farmers and ranchers with rural communities as part of its FIM strategy.

Looking Forward

Food is Medicine interventions are powerful tools for preventing and managing chronic conditions while advancing whole-person care for Medicaid members. As states move beyond benefit design and into implementation, primary care can serve as a critical link between Medicaid members and FIM services. By strengthening the connections among primary care providers, CBOs, and Medicaid members, states can build more coordinated systems that expand access to FIM services, strengthen primary care, and improve health outcomes.