News

Eskenazi Health is pioneering a new approach to addressing social determinants of health through its innovative closed loop model — a system that ensures patients not only receive referrals for services like food assistance, but that their providers can also confirm those services were accessed.

This model mirrors traditional health care coordination. Just as a referral to a cardiologist is tracked through the electronic health record, Eskenazi Health now applies the same infrastructure to food insecurity. When a patient screens positive for food insecurity, the electronic health record automatically generates a $30 grocery voucher with a unique QR code. This code links back to the original visit, allowing providers to track when — and where — the voucher is redeemed through Eskenazi Health’s Fresh for You Market at the Frank & Katrina Basile Pavilion or Fresh for You Market on Wheels. The result: a seamless, trackable connection between clinical care and community support.

“This is the beginning of meeting the patient where they are — to provide them with what they need in the moment,” says Christopher Callahan, M.D., Eskenazi Health chief research and development officer. “Over time, as trust is built, we can engage them more deeply in managing chronic conditions.”

The program is working at scale. We are screening over 30,000 patients per month, and one in three of these patients are food insecure. This results in $30,000 worth of food support given to our patients each month. With each transaction, providers gain clearer insight into whether a patient’s needs are being met, transforming patient outcomes.

Eskenazi Health is now exploring additional applications of the model, including legal aid and SNAP benefit verification. Though regulatory barriers remain, the goal is clear: empower providers to act meaningfully on social needs, reduce demoralization in the clinic and deepen patient trust.

“There’s no reason to screen for food insecurity if you don’t have anything you can do about it,” says Callahan. “This model gives us something we can do.”