Minutes of the Meeting of the
Integration of Care Committee
Veronica Fortunato & Steve Hemraj, IOC Co-Chairs
Wednesday, June 18, 2025
10:00am-11:40pm
Minutes
M I N U T E S
Members Present: Ronnie Fortunato (Co-chair), Steve Hemraj (Co-chair), Mitchell Caponi, Dorothy Farley, Billy Fields, Deborah Greene, Christopher Joseph, David Klotz, Marcelo Maia, Jeff Natt, Cesar Nuñez, Leah Richberg, John Schoepp, Scott Spiegler (for Guadalupe Dominguez Plummer), Joel Zive
Staff Present: NYC DOHMH: Doienne Saab, Michael Navejas, Adrianna Eppinger-Meiering, Gina Gambone, Sara Kramer, Nikki Harris, Arnelle Vincent, Abraham Omeyoma
Agenda Item #1: Welcome/Introductions/Minutes/Public Comment
Mr. Hemraj opened the meeting followed by a roll call and a moment of silence. The draft minutes from the May 21st meeting were approved with no changes.
Agenda Item #2: Food & Nutrition Services (FNS) Directive
Digital Food as Medicine Model
Mr. Joseph presented on EngageWell’s “digital food as medicine” program, explaining the role of EngageWell IPA, which represents a network of non-profits (including many HIV service providers), that contracts with a company called Tangelo to provide digital food as medicine. This model provides a digital tool for accessing care, a standard of care with medical insurance companies, but not with Medicaid or social services. It is an additional option to engaging in care by going to a provider’s brick and mortar location. In ways, this is an extension of virtual care that became common during COVID. The network covers all five boroughs, although is more heavily concentrated in upper Manhattan, Bronx and Brooklyn. The network is similar to a Medical 1115 waiver Social Care Network (which exist in all boroughs). The program’s client demographics match closely with those of Ryan White programs. People over 60 are more one third of clients. Tangelo has 1400 unique clients and made over 22K meal deliveries (the equivalent of over 221K meals).
The intervention is app-based (also available on a PC, tablet and by phone), and a client receives two free healthy food boxes per month (each enough for about a week of food) for a year, tailored to their specific needs and preferences. There are three different kinds of grocery boxes (for different levels of self-preparation) and three kinds of healthy ready-to-eat meals. Built into the app is a diet assessment to identify eating habits. Nutrition education is also provided through the app, which bundles multiple functions, but is not a replacement for clients who want to continue getting the service through other means (e.g., congregate meals). Health indicators (e.g., HIV+ and diabetic) are used for providers in the network to recommend clients for enrollment in Tangelo’s program. Clients who enroll in the intervention are more likely to be virally suppressed and maintain suppression. Clients are also less likely to be in the emergency room or inpatient care. Costs are also lower than providers of traditional models of delivery.
In the ensuing discussion, it was noted that there are no shared medical records. Costs include a one-time enrollment fee and monthly platform fee, which add to less than $100/person per year. The economy of scale can help providers offset high costs of creating infrastructure for food delivery systems.
The Committee thanked Mr. Joseph for his presentation. Council staff will incorporate this into the service model as an option for RWPA providers.
Service Directive Goals and Objectives
Ms. Saab presented a draft revision of the Service Category Goals. Overarching goals are to increase the proportion of clients with an undetectable viral load and to improve overall immunological health, and to increase the proportion of diagnosed individuals who are engaged in primary care and have an optimal level of ART. Goals specific to the non-core portion of the directive (as defined by HRSA to include food banks, home delivered and congregate meals, pantry bags, vouchers and nutritional education) include: reduce the proportion of people with HIV (PWH) who are food insecure by providing nutritious food, promote access to and maintenance in HIV-specific medical care, reduce preventable morbidity and mortality, reduce (and then maintain below significance) socio-demographic differences in: linkage to and retention in primary medical care, viral suppression, and HIV-related morbidity and mortality, and build client knowledge, skills, and independence around healthy eating and nutrition through education/counseling.
Goals from the current (2022-26) Statewide Integrated Plan that align with the service category goals include: Increase the percentage of persons newly diagnosed with HIV who are linked to HIV medical care to 90%, Increase the percentage of persons living with diagnosed HIV who receive HIV medical care with suppressed viral load to 95%, and decrease disparities in health outcomes for priority populations.
Mr. Klotz explained that currently, both the core and non-core services are bundled into one service, but HRSA requires that they be reported as separate service categories. The Committee will consider how these are integrated while technically two separate categories. After the revised directive is approved, the PSRA Committee will determine the separate allocations.
There was a discussion on medically tailored meals, which require a registered dietician, compared to clinically appropriate meals, which do not. This will be discussed further when considering revisions to the service model.
At the next meeting, on Wednesday, July 16th, 10am-12pm, the Committee will begin discussion of possible revisions to the FNS service model.
There being no further comment, the meeting was adjourned.
