Diabetes is a common chronic health condition in Kentucky, with nearly 14 percent of adults diagnosed and an additional 12 percent identified as pre-diabetic and at risk of developing diabetes. Among adults enrolled in Medicaid in the state, 14 percent have diabetes. The diabetes rate among adults in Kentucky has more than doubled since 2000.¹

The Kentucky Department for Medicaid Services (DMS), in collaboration with other state agencies, is committed to improving health outcomes and preventing diabetes-related complications for Medicaid enrollees. As part of this commitment, DMS is working with its Medicaid managed care organizations (MCOs) and other stakeholders to ensure that Medicaid enrollees have access to evidence-based clinical and non-clinical services that can improve diabetes-related outcomes.

To align with the state’s goal, from October 2023 through December 2024, Passport by Molina Healthcare (Passport), a Medicaid MCO, partnered with FarmboxRx, Dare to Care Foodbank, and Play Cousins Collective to provide home-delivered healthy foods, cooking classes, and health education to Passport members living in Louisville who have insulin-requiring diabetes. This case study explores the partnership, including its approach to program implementation, factors that contributed to its success, and positive impacts of the pilot. The pilot was supported by The Leona M. and Harry B. Helmsley Charitable Trust through the Medicaid Innovation Collaborative.

Implementation Approach

Passport and FarmboxRx collaboratively designed the pilot to support Medicaid members with insulin-requiring diabetes through monthly nutritious food deliveries, health education, and regular telephonic outreach and engagement. During the planning phase, the project team refined eligibility criteria, structured food box delivery schedules, and defined roles across implementation partners. Early coordination with community partners helped ensure smooth logistics for in-person events.

Participant Identification and Enrollment

The program used Passport’s HEDIS measures dashboard to identify eligible members, which included individuals with diabetes who require insulin and had either poor A1c control (A1c >9%) or lacked recent A1c test results. FarmboxRx conducted outreach to eligible members and enrolled 44 percent of those members, totaling 210 participants.

Service Model

• Food Delivery and Health Education: Beginning in February 2023, participants received monthly deliveries of healthy food boxes, alternating between fresh produce and pantry staples. Each box included diabetes-friendly ingredients, simple recipes, and educational materials focused on healthy eating and diabetes self-management. Calls to action, such as scheduling annual wellness visits or A1c testing, were included in each package. All education materials were approved by Kentucky DMS.
• Telephonic Engagement: FarmboxRx and Passport staff conducted regular phone calls with participants to support program engagement. FarmboxRx’s engagement team provided ongoing encouragement for participants and reinforced the calls to action, while Passport’s engagement team assisted participants with transportation needs to attend in-person events.
• Community-Based Support: Monthly in-person events were held by Passport in collaboration with Dare to Care Food Bank and Play Cousins Collective; eight events were held in total. These events included health education presentations, healthy cooking demonstrations, and group exercise opportunities. Participants who attended received support tools, such as a vegetable peeler and food journal. Play Cousins Collective offered free childcare to reduce barriers to participation for members with young children, though no participants used this support.

Success Factors

• Robust member engagement strategy. Strong member engagement was foundational to the pilot’s success. Prior to launch, Passport and FarmboxRx collaborated on a targeted messaging and outreach strategy to raise awareness about the program. These efforts enabled Farmbox to meet its enrollment goal within two weeks. Once enrolled, participants received regular telephonic outreach from FarmboxRx and Passport. The use of consistent FarmboxRx and Passport staff for calls helped build participant trust and fostered strong relationships. This high-touch, personalized approach ensured that participants felt supported throughout the program and contributed to sustained engagement.
• Responsiveness to participant needs. Continuous feedback enabled the pilot to be responsive and adaptive. For example, enrollee participation in in-person events was consistently low, with participants describing a lack of incentive to participate. Ultimately, the pilot focused more on regularly checking in with participants over the phone instead.  Additionally, feedback gathered through regular outreach calls, led to two key program modifications: (1) adjusting food delivery timing to align with end‑of-month food-related benefits gaps; and (2) ensuring continuity of services for participants, even if they did not consistently respond to outreach. These changes demonstrated a commitment to centering member needs and removing barriers.
• Alignment with state Medicaid priorities. The pilot was designed to complement Kentucky DMS’ broad goal to improve health outcomes for people living with diabetes. This alignment helped secure DMS’ support and active participation, including in regular check-ins and dissemination of information about the project to other state agencies working on Food is Medicine efforts, such as the Department of Community Based Services.
• Strong cross-partner collaboration. The project’s success was underpinned by a highly collaborative and mission-aligned implementation team. Passport and FarmboxRx worked closely to clearly define roles and responsibilities upfront, minimizing duplication of effort and ensuring streamlined operations. Each team contributed their strengths to outreach efforts, leveraging their expertise to maximize engagement.
• Effective and timely communication. Ongoing communication between project partners played a critical role in the program’s success. Standing meetings provided a forum to review progress and maintain momentum. Frequent email communication enabled real-time troubleshooting and effective coordination. Frequent and ongoing communication allowed the teams to monitor and quickly respond to program changes, such as participant disenrollments, responses to services, and implementation challenges.

Impact

The pilot program aimed to improve diabetes-related outcomes among Medicaid enrollees by providing consistent access to healthy foods, education, and engagement supports. Impact was assessed using a combination of HEDIS measures, internal health plan data, and participant self-reported surveys. 

Clinical Outcomes

Passport monitored clinical impacts using HEDIS diabetes-related measures for A1c control and eye exams. Additional data on annual wellness visits and health risk assessment completion were tracked internally. Outcomes data are presented for the 165 Passport members who completed the program (versus the initial 210 participants that initially enrolled). While the results below (see Exhibit 1) have not been tested for statistical significance, they have been sufficient to convince internal stakeholders of the positive impacts of the pilot. Results showed lower A1c scores and increased engagement with critical preventive services among pilot participants compared to the control group. The control group consisted of Passport members meeting eligibility criteria for the pilot but not enrolled. Additionally, Passport reports that data for overall claims and emergency department visits per member are trending downward for participants compared to the period six months prior to program inception.

Exhibit 1. Select Pilot Outcomes: FarmboxRx Participants Compared to Control Group

Behavior Change and Diabetes Self-Management

FarmboxRx conducted surveys to evaluate participants’ diabetes self-management knowledge and behaviors related to food and diet. Of the 165 participants who completed the pilot program, 77 individuals responded to the survey.  Results demonstrated improvements in participants’ confidence and ability to manage their condition:

• 77% reported improvements in their blood sugar since the program began;
• 91% reported improved access to healthy food through the program; 
• 93% felt more confident in managing their blood sugar; and
• 88% reported a positive influence on their eating habits and healthy meal preparation skills.

Looking Ahead

The promising results of this pilot and other Food is Medicine pilots in Kentucky are spurring meaningful efforts to expand access to nutrition services for Medicaid members living with diabetes. Building on the pilot’s success, Passport and FarmboxRx expanded the program in January 2025 to serve an additional 200 Medicaid members with diabetes across other regions of the state. The expanded initiative retains the pilot’s core program components, including a continued focus on centering member needs and tracking program impact on diabetes-related outcomes. Kentucky DMS will use pilot findings and other studies to consider future opportunities to support Food is Medicine programs, in collaboration with other state agencies.

1. Kentucky Cabinet for Health and Family Services and Kentucky Personnel Cabinet. (2023) Kentucky Diabetes Report. Frankfort, KY: KY Cabinet for Health and Family Services, Department for Medicaid Services, Department for Public Health, Office of Data Analytics, and Kentucky Personnel Cabinet, Department of Employee Insurance, 2023. https://www.chfs.ky.gov/agencies/dph/dpqi/cdpb/dpcp/2023%20Diabetes%20Report%20%281%29.pdf