Evaluation of Project Bread's Flexible Services Program

The Dana-Farber Cancer Institute funded a three-year study at Project Bread to determine the impact of our FSP model on the food security and health of clients. Project Bread collected data from Community Health Workers (CHWs) who refer clients into the program and from former clients of the FSP to assess program impact from the perspective of those closest to the program. Below are the qualitative findings from the CHW interviews and former client focus groups and the quantitative findings from the phone surveys with former clients. 

During our conversations, CHWs discussed that the program is providing their clients with autonomy and purchasing power and supplementing clients' SNAP benefits. CHWs have also seen improved health outcomes, particularly for their diabetic clients. Finally, CHWs discussed how the Flexible Services Program is meeting the basic needs of their clients, which allows the CHWs to address physical and mental health concerns. 

One of the most common themes across the interviews was the financial impact that the program has had on clients. One CHW told us: I've had patients tell me that they've been able to feed their families during these hard times."

For those facing food insecurity, the past few years have been particularly difficult, and federal assistance benefits don't cover all the necessary food costs. For example, a CHW described the situation of one of her clients: 

She has cancer and her diet had to be very strict - she could only eat fruits and vegetables, and this is very expensive through any grocery store, right? She was having trouble not being able to afford food. She was going through a rough time where she didn't have any income. SNAP benefits only did so much for her. And with the assistance of the Project Bread gift cards, she was able to buy more fruits and vegetables.

Some CHWs discussed the health impact they have noticed on their clients. As one CHW described: 

You can see the face of the patient transform. For example, if a patient has diabetes and their blood sugar is at 600, immediately the blood sugar decreases. If their blood pressure is 200, immediately you see the blood pressure decrease. 

The CHWs also discussed how the combination of services provided their clients with the resources and knowledge necessary to meet their basic needs. This offered the CHWs the opportunity to focus more on their clients' physical and mental health. Clients also had more availability to attend doctor's appointments. One CHW said it clearly: I think it's comforting to them that their needs are being addressed, so we can shift our conversation to the behavioral health and medical concerns that they might have.

Likewise, CHWs described that they felt supported in their own work knowing that they could refer clients to a program that would improve their situation. During an interview. a CHW stated: I know that once I place a referral, I know that you guys are doing the work. We really trust in you guys. You guys are getting the work done.

Based on the 16 interviews. CHWs felt that the Flexible Services Program is a service they could rely on to support the immediate needs of their clients. By providing this support, clients had a better relationship with their health center and their health outcomes improved while they were in the program.

Clients reported that the program helped them put food on the table by supplementing their income and SNAP benefits, which were not always enough. For clients with complex health conditions, maintaining a healthy diet is especially important but can be expensive.

Many shared that the Flexible Services Program allowed them to add fresh fruits and vegetables to their diet without sacrificing the staples. One person said: Once I got the gift cards, I was able to buy healthier stuff because I had the extra. I'd use the gift card for my fruits and vegetables versus using my food stamps for my meats, rice, and to get the basics. 

With the budget to eat healthier, clients were inspired to improve their nutrition. One client we spoke to said of the program: It made me want to eat healthier, because I was able to buy the food, Like fruits and vegetables. So, then I started changing my whole eating pattern. 

The program also included nutrition education and counseling that equipped clients with knowledge for preparing healthy meals. As a result clients saw improvements in their health outcomes: My A1C and my sugar levels were really high. When I started the diabetes classes and I started using the book, I brought it down. It was like a 13, which is really high. Now I'm a 7. So, it brought my sugar levels down a lot by using those classes, and Listening, and them explaining how diabetes works. 

The health benefits of the Flexible Services Program went beyond the individual. too. Clients told us how it empowered them to help their families. One person said: I gained more knowledge. With more knowledge, you can guide your family, your siblings, your parents. You want them to have a healthy diet, so they don't have to go to the hospital every day to take the medicine there. 

Many clients remarked that the Flexible Services Program helped them get through uniquely difficult circumstances in their lives and shared that the kitchen supplies have continued to enable their healthy eating post-program. As one person stated: I'm a recovering addict. So, I didn't have much. When I got the kitchen supplies, it was a relief. It helped me in my recovery. I just moved too, so I brought everything to the new house when I started my new Life, and it gave me a fresh start. 

Another client told us: I was spending more time in the hospital, where sometimes there isn't much time to eat. So, I was getting home at night, and it was difficult for me to cook. The microwave helped me a lot because I didn't have one before. I would just heat up my frozen food or make my smoothie [with the blender]. The truth is that the kitchen supplies are things that have helped me a lot and are still very useful to me. 

Based on feedback from the focus group participants, Projct Bread's Flexible Services program, and its ability to tailor services to the specific needs of the individuals had positive impacts on the clients both during and after completion of the program

At the conclusion of the program, clients also reported gains in their ability to prepare healthy meals, nutrition knowledge, and health center satisfaction.

The impact data paints a clear picture of Project Bread's Flexible Services Program's efficacy, demonstrating a positive influence on key outcomes. From heightened food security to increased healthy eating, the program delivers tangible benefits. The program also helps clients manage chronic conditions by fostering knowledge of nutritious meals and the ability to prepare them. In addition, Project Bread's Flexible Services clients report higher satisfaction with their health center, an outcome that is critical to improving patient engagement and adherence to medication and other health goals. These findings not only validate the program's efficacy in achieving its intended objectives but also underscore the program's potential to promote important health-related behavioral and social change. 

At the end of a program, especially when financial support is involved, individuals often encounter a phenomenon known as the "cliff effect." This refers to the regression of improvements after services cease. Feedback from CHWs, focus group participants, and phone survey respondents indicated that the program's conclusion presented challenges for clients in maintaining some of the progress they had achieved.

In the focus groups, the cliff effect was discussed at length. We learned that transitioning off the program was difficult for many participants, particularly in relation to the loss of the grocery store gift cards. One client said, “It took away a source of food for me.”  

During our interviews with CHWs, they highlighted the difficulties associated with the end of the program for clients. One CHW illustrated the point with a specific client, stating, “It was definitely hard that there wasn’t going to be any other assistance because she was benefiting from the gift card so much.”  

These findings appear to be an outcome of the loss of financial input gained from the grocery store gift cards, which provided purchasing power for nutritious foods, as we learned from the focus groups.

The results underscore the critical need for proactive measures, particularly focused on nutritious food access, in the post-program period to mitigate the cliff effect among participants.

This report synthesizes findings from a three-year study funded by the Dana-Farber Cancer Institute, offering a comprehensive evaluation of Project Bread's Flexible Services Program's effects on clients' health and well-being. The qualitative insights from the community health worker interviews and the focus groups with former clients reveal a resoundingly positive experience with the Flexible Services Program at Project Bread. CHWs shared how the program has positively impacted their clients, and former clients in focus groups mirrored these sentiments. Quantitative data from phone surveys with former clients further bolster the program's efficacy, showing significant improvements in health and well-being among clients at the end of the program. Taken together, these findings not only validate the program's efficacy but also underscore its potential to drive meaningful change in the health and well-being of those facing food insecurity.

The report also sheds light on the reality of the “cliff effect “experienced by clients post-programming. The regression of improvements, such as increased food insecurity, reduced healthy eating, and declining health ratings appear related to the financial loss of the gift cards, and highlight the importance of proactive measures to support participants with nutritious food access beyond program completion. Insights from clients illustrate the various strategies used to cope with the cliff effect, emphasizing the necessity to address these challenges in a sustainable manner. Despite these setbacks, the nutrition counseling, cooking classes, kitchen supplies, and support in SNAP enrollment, have lasting impacts on a few key outcomes including continued confidence in nutrition knowledge, high satisfaction with health centers, and sustained SNAP enrollment, indicating that lasting success is happening.  

Ultimately, the stories and data are resounding; Project Bread’s Flexible Services Program effectively integrates food-security solutions into the healthcare system in a way that is beneficial to both health care workers and clients. The data collected help us to celebrate the program’s successes but also serve as a call to action, prompting further innovation and adaptation towards a sustainable and enduring solution to eliminating food insecurity.