How CareHarmony incorporates technology and clinician-led care to address nutritional concerns, food insecurity

March is National Nutrition Month, a month dedicated to promoting informed food choices and healthy eating habits. But food insecurity is not a seasonal issue. It is a significant and often under-addressed driver of avoidable utilization in chronic care management and value-based care environments.

Patients living with chronic diseases require targeted nutrition to manage symptoms, stabilize blood sugar and cholesterol, and reduce medication dependence Unfortunately, an estimated 30 to over 35 percent of U.S. adults with chronic conditions experience food insecurity, putting them at a higher risk for illnesses like congestive heart failure, high blood pressure, and asthma. In value-based care models, these unmet social needs often translate directly into higher readmissions, medication non-adherence, and increased total cost of care.

CareHarmony is working to overcome the additional health challenges that patients with food insecurity and nutrition deficits face. CareHarmony integrates Social Determinants of Health (SDoH) screening directly into its chronic care management workflows to proactively address food insecurity before it escalates into more costly interventions. We developed proprietary technology that flags potential barriers to care for clinicians and offers real-time solutions to address them. These CareBlocks combine machine learning with human oversight to provide in-depth data analysis that helps a clinician create a tailored, personalized care plan.

The program is specifically designed to identify Social Determinants of Health and create alerts for clinicians, who can then take that information to deliver targeted interventions. Unlike traditional SDoH screening tools that stop at identification, CareBlocks operationalize intervention.

“CareBlocks alert us to unanticipated issues identified during a call with a patient and provide resolutions we can share,” explained registered nurse and CareHarmony’s Head of Clinical Innovation Ashley Kowalski. “This is critical because while the healthcare sector is good at identifying problems, it isn’t always good at solving them. CareBlocks ensure that the action is driven through the entire process, resolving issues like food insecurity by telling the care coordinator the exact next step to take.”

Oftentimes, that next step involves connecting the patient with community resources, such as food banks, Meals on Wheels, or even local charities. Care coordinators can also connect the patient with a CareHarmony social worker to explore further options, such as checking to see if they qualify for federal assistance through programs like SNAP.

Olivia Blalock, a registered dietitian and head of CareHarmony’s diabetes care and education program, said many patients may feel embarrassed about admitting they have trouble finding or affording nutritious food. It is one reason why CareHarmony care coordinators are trained to build rapport with patients over several calls before discussing what may be more sensitive topics for the patient. “Food insecurity does not discriminate. Someone does not have to be of a lower economic status to be food insecure. That is why it is so important to ask the right questions and ask them the right way, otherwise the opportunity to identify and intervene can easily be missed.”

For health systems operating in accountable care organizations, Medicare Advantage, and other risk-based models, identifying and resolving food insecurity is not just compassionate care – it is financial stewardship. Addressing nutritional gaps improves chronic disease management, strengthens patient engagement, and reduces preventable utilization across populations.

Through rigorous training, compassionate care coordinators, and advanced technology, CareHarmony is helping to pave a better pathway for chronic care management. Learn more about our comprehensive approach to chronic care management here.