Learning Circle #1: Screening and Referral: An Essential Link Between Patient and Community
Connecting patients to care through community-rooted supports.
SEPTEMBER 2025
Learning Circle #2: Building Collaborative Partnerships and Contracts for Nutrition Supports
Building fair, lasting partnerships across health and food systems.
NOVEMBER 2025
Learning Circle #3: Food is Medicine in Hawaiʻi: Priorities & Opportunities in 2026
Aligning health and food efforts and learnings to guide Hawaiʻi’s priorities.
DECEMBER 2025
Learning Circle #4: Scaling up for Institutional Demand: Infrastructure and Capacity-Building for Food is Medicine
Growing capacity to meet local and institutional demand.
JANUARY 2026
Learning Circle #5: Food is Medicine: The Financial Picture
Exploring funding models, reimbursement, and the true costs of sustainable Food is Medicine work.
MARCH 2026
Learning Circle #6: Food is Medicine Evaluation: Metrics, Data, and Impact
Tracking outcomes, storytelling, and sharing data to drive change.
MAY 2026
Learning Circle #1
Screening and Referral: An Essential Link Between Patient and Community
September 18, 2025
Connecting patients with Food is Medicine and other community supports starts with effective screening and referral. But identifying a need is only one part of the process. Healthcare and community partners also need clear workflows, strong relationships, timely follow-through, and ways to know whether people actually receive the services they were referred to. This Learning Circle explores screening and referral practices generally and within Hawaiʻi’s Medicaid 1115 waiver, including who screens patients, how eligibility is determined, and what helps referrals lead to care. Speakers from Children’s HealthWatch and Unite Us share screening tools, referral approaches, and care coordination practices, while participants consider how technology, warm handoffs, and community-based relationships can work together in ways that fit Hawaiʻi’s communities.
Featured Speakers:
Richard Sheward, Director of System Implementation Strategies at Children’s HealthWatch
Graham Charlton, Director of Network Development for California and Hawaii at Unite Us
Carol Hayashida, Sr. Customer Success Manager at Unite Us
What We Explored
How screening for food insecurity and other health-related social needs currently happens across healthcare and community settings.
How eligibility and referral pathways may operate within the Medicaid 1115 waiver and what implementation could require from healthcare and community partners.
Different food insecurity screening tools and approaches, including the Hunger Vital Sign.
How closed-loop referrals, care coordination, and data sharing can help partners understand whether patients successfully connect to services.
How technology and referral platforms can support coordination while preserving warm handoffs, personal relationships, and culturally grounded ways of connecting people to care.
Key Takeaways
Warm handoffs and relationships matter. Trust and personal connection remain central to whether referrals successfully connect people with services.
Closing the referral loop is a persistent challenge. Many communities lack reliable ways to track what happens after a referral leaves a healthcare setting.
Technology can support screening, referrals, and care coordination, but it needs to complement rather than replace culturally appropriate, relationship-based practices.
Screening and referral cannot rest solely on healthcare providers. Community-based organizations and other partners can play important roles in identifying needs, connecting people to services, and supporting follow-through.
Frontline staff need adequate time, training, awareness, and clear workflows to successfully connect patients with food and other social supports.
Questions for Reflection
What does your organization’s current workflow for screening patients or community members for food insecurity look like, and where are the gaps?
How does your organization receive, manage, and follow up on referrals for food assistance or Food is Medicine programs?
How could your systems better communicate referral outcomes back to healthcare and community partners so the referral loop is closed?
How can technology support screening and referrals while preserving face-to-face communication, warm handoffs, trust, and local cultural practices?
Learning Circle #2
Building Collaborative Partnerships and Contracts for Nutrition Supports
November 20, 2025
Strong Food is Medicine programs depend on more than a signed contract. Community-based organizations, healthcare partners, food hubs, aggregators, and farmers need relationships built on trust, clear expectations, transparent communication, and a shared understanding of what each partner can realistically deliver. This Learning Circle explores how community-based organizations can navigate contracting and partnership-building for locally sourced Food is Medicine interventions. Through peer discussion and examples from national healthcare and food system partners, participants consider what makes contracts and collaborations equitable, mutually beneficial, and sustainable, as well as the structural and operational barriers that can get in the way.
Featured Speakers:
Rachel Landauer, Clinical Instructor at Harvard Center for Health Law & Policy Innovation
Katelyn Smoger, Director of Food is Medicine and The Farm at Trinity Health Michigan
Monica Lin, Food as Medicine Coordinator at Foodshed Cooperative
What We Explored
How community-based organizations can prepare for and navigate Food is Medicine contracting, negotiation, and partnership-building.
What makes contracts and MOUs feel mutually beneficial rather than one-sided.
How trust, role clarity, realistic expectations, flexibility, and transparent communication contribute to strong cross-sector partnerships.
Operational and structural barriers to partnership, including regulatory uncertainty, limited infrastructure, capacity constraints, staffing, billing, and clinical workflows.
What community organizations, food aggregators, farmers, and healthcare partners need to better understand about Medicaid-recognized provider/vendor pathways and supplying locally sourced food.
Key Takeaways
Trust and relationship-building come first. Contracts and collaborations are strongest when they grow from mutual respect and existing relationships rather than being treated only as transactions.
Clear and realistic expectations support sustainability. Roles, deliverables, timelines, capacity, and operational limitations need to be understood and communicated across partners.
Communication and transparency must continue after a contract is signed. Ongoing dialogue helps partners adjust expectations, address challenges, and maintain trust.
Fair contracts need to reflect the realities of food production and community-based work, including pricing, volume, timing, staffing, infrastructure, and other capacity constraints.
Some barriers cannot be solved through individual relationships alone. Regulatory confusion, infrastructure gaps, administrative requirements, and other systemic challenges require broader solutions.
Questions for Reflection
What helps a contract, MOU, or partnership feel mutually beneficial rather than one-sided?
How well does your organization understand the operational realities and constraints of its Food is Medicine partners, including growing seasons, storage, labor, staffing, billing, and clinical workflows?
What parts of your current contracts or partnership processes could be clearer, more transparent, or more flexible while still meeting compliance requirements?
How should farmers and community-based partners have a meaningful voice in shaping contract terms and Food is Medicine programs that rely on their labor, land, relationships, and cultural knowledge?
Learning Circle #3
Food is Medicine in Hawaiʻi: Priorities & Opportunities in 2026
December 18, 2025
As Food is Medicine efforts grow across Hawaiʻi, learning from what is already happening on the ground can help shape what comes next. This Learning Circle looks ahead to 2026 through shared reflection on the Kau ʻAi Pono: Season of Eating Well Medicaid produce prescription pilot, where participating health centers and food aggregators are providing weekly boxes of locally grown produce and protein to eligible Medicaid participants. Participants explore early lessons from implementation, including screening, distribution, administrative costs, sustainability, and collaboration across health and food systems. The session also creates space for island cohorts to begin identifying local priorities, relationships, and goals for community-centered Food is Medicine convenings in 2026.
Featured Speakers:
Jesse Lipman and Kau'i Tuihalafatai, Roots Cafe and Food Hub
Darrin Sato and Angela Catekista, Kalihi Palama Health Center
Jane Adams, Farm Link Hawai‘i
What We Explored
Early lessons from the Kau ʻAi Pono: Season of Eating Well Medicaid produce prescription pilot and the experiences of participating health centers and food aggregators.
Operational challenges affecting Food is Medicine delivery, including screening processes, transportation, cold storage, staffing, administrative costs, and household food needs.
The tension between eligibility requirements and broader equity and prevention goals.
What cross-sector collaboration needs to look like when health centers, food aggregators, farmers, and community organizations work together.
Island-specific priorities, relationships, and desired outcomes for 2026 Food is Medicine Community of Practice convenings.
Key Takeaways
Real-world implementation reveals system-level barriers that may not be visible in program design, including screening delays, transportation challenges, limited cold storage, staff overload, and administrative burden.
Long-term sustainability depends on adequately resourcing the organizations doing the work. Participants raised concerns about underfunding, burnout, and whether administrative reimbursement reflects actual costs.
Eligibility and program design should be considered alongside equity goals, particularly when rigid requirements may exclude people who could benefit from preventive support.
Strong relationships between farmers, food system partners, health centers, and community organizations are foundational to locally rooted Food is Medicine efforts.
Island communities share common goals but have different priorities and contexts. Local convenings can create space to clarify roles and workflows, strengthen trust, and shape Food is Medicine approaches around island-specific needs.
Questions for Reflection
How does your organization currently build and maintain relationships with farmers, food hubs, food banks, health centers, and other Food is Medicine partners?
Where do communication, referral, distribution, or other workflows currently break down, and what would help partners stay better aligned?
What does your organization need to assess before taking on new Food is Medicine contracts or increased volume, quality, and timeline expectations?
How should farmers and other community partners be represented in shaping Food is Medicine programs that rely on their labor, land, relationships, and cultural knowledge?
Learning Circle #4
Scaling Up for Institutional Demand: Infrastructure and Capacity-Building for FIM
January 22, 2026
Growing local Food is Medicine programs means more than increasing the amount of food produced. Farms, food hubs, healthcare organizations, and community partners need the people, equipment, technology, relationships, and systems to grow without losing sight of community values or putting unsustainable pressure on producers. This Learning Circle explores what it takes to scale local food procurement and Food is Medicine efforts to meet growing institutional demand. Speakers from Kākoʻo ʻŌiwi and Just Roots share lessons from expanding food production and community food access programs, while participants consider the infrastructure, partnerships, and capacity needed to scale responsibly in Hawaiʻi.
Featured Speakers:
Jonathan Kaneoka Kukea-Shultz, Executive Director at Kākoʻo ʻŌiwi
Nick Reppun, Farm Manager Emeritus at Kākoʻo ʻŌiwi
Joshua Faller, Co-Executive Director at Just Roots
What We Explored
How community-based organizations can prepare for and navigate Food is Medicine contracting, negotiation, and partnership-building.
What makes contracts and MOUs feel mutually beneficial rather than one-sided.
How trust, role clarity, realistic expectations, flexibility, and transparent communication contribute to strong cross-sector partnerships.
Operational and structural barriers to partnership, including regulatory uncertainty, limited infrastructure, capacity constraints, staffing, billing, and clinical workflows.
What community organizations, food aggregators, farmers, and healthcare partners need to better understand about Medicaid-recognized provider/vendor pathways and supplying locally sourced food.
Key Takeaways
Scale must follow capacity. Expanding too quickly without preparing farmers, workflows, infrastructure, and systems can create financial and operational risks.
Communication infrastructure is foundational. Farmers, aggregators, healthcare organizations, researchers, and other partners need regular opportunities to communicate and better understand one another's systems and language.
Financial sustainability must be considered alongside growth. Reimbursement and administrative requirements need to reflect the real costs carried by farmers and community-based organizations.
Trust and clear roles matter. Strong relationships and clarity about responsibilities across sectors are essential to building a sustainable Food is Medicine system.
A statewide coalition could help move shared priorities into action. Participants saw potential for a coalition to reduce duplication, influence policy and rate setting, protect community-grounded values, and elevate farmer-centered approaches.
Questions for Reflection
If demand for Food is Medicine services increased significantly next year, what part of your organization's current operations or workflow would be strained first?
What investments in staffing, equipment, technology, storage, processing, or other infrastructure would be needed to scale sustainably?
What risks could come from scaling too quickly, particularly for farmers and community-based organizations?
How could stronger coordination or a statewide Food is Medicine coalition help organizations address shared infrastructure, policy, and capacity challenges?
Learning Circle #5
Food is Medicine: The Financial Picture
March 19, 2026
Financing is one of the biggest questions shaping the future of Food is Medicine in Hawaiʻi. As organizations prepare for new opportunities through Medicaid, questions remain about reimbursement rates, billing systems, true service costs, and what it will take for community-based organizations, food hubs, and farmers to participate sustainably. This Learning Circle explores how Food is Medicine services can be financed and reimbursed, including different payment models, rate setting, and the infrastructure needed to navigate healthcare financing. Guest speakers from the Center for Health Law & Policy Innovation and Ceres Community Project share lessons from policy and practice, while participants consider how Hawaiʻi can build financing approaches that reflect the true cost of services and remain grounded in ʻāina, local food, and community values.
Featured Speakers:
Erika Hanson, Clinical Instructor at Center for Health Law & Policy Innovation, Harvard Law School
Brenda Paulucci-Whiting, Chief Program Officer at Ceres Community Project
Karin Pimentel, Contracts & Business Development Officer at Ceres Community Project
What We Explored
How Food is Medicine services can be financed and reimbursed through Medicaid, including fee-for-service, bundled, per-member-per-month, and value-based payment approaches.
How rate setting, claims, billing, managed care workflows, and revenue cycle requirements affect community-based organizations and food providers.
The true costs of delivering nutrition support services, including food, labor, delivery, coordination, administration, technology, and billing infrastructure,
The roles of Med-QUEST, managed care organizations, healthcare providers, food aggregators, and farmers in building a sustainable Food is Medicine system.
How financing and procurement can better align with ʻāina, local food systems, cultural values, and community-led practice.
Key Takeaways
Reimbursement methodology matters: different payment models create different operational requirements and risks for providers.
Rates need to reflect the true cost of service delivery if Food is Medicine programs are to be sustainable.
Community-based organizations may need significant investment in billing, data, staffing, technology, and other infrastructure to participate effectively.
Clearer guidance on rates, billing, eligibility, and implementation is still needed as Hawaiʻi prepares for Medicaid 1115 Nutrition Supports.
Financing systems should support, rather than override, culturally grounded approaches, community knowledge, local sourcing, and relationships with farmers.
Questions for Reflection
What role does your organization play, or want to play, in the Food is Medicine financing and service-delivery system?
Where do current or emerging reimbursement models fail to reflect the true costs of growing, aggregating, preparing, or delivering food?
What infrastructure, partnerships, or intermediaries could reduce administrative burden while keeping farmers and community-based organizations meaningfully connected to the system?
How can financing and contracting approaches better reflect community and cultural values?
Learning Circle #6
Food is Medicine: The Financial Picture
March 19, 2026
Financing is one of the biggest questions shaping the future of Food is Medicine in Hawaiʻi. As organizations prepare for new opportunities through Medicaid, questions remain about reimbursement rates, billing systems, true service costs, and what it will take for community-based organizations, food hubs, and farmers to participate sustainably. This Learning Circle explores how Food is Medicine services can be financed and reimbursed, including different payment models, rate setting, and the infrastructure needed to navigate healthcare financing. Guest speakers from the Center for Health Law & Policy Innovation and Ceres Community Project share lessons from policy and practice, while participants consider how Hawaiʻi can build financing approaches that reflect the true cost of services and remain grounded in ʻāina, local food, and community values.
Featured Speakers:
Erika Hanson, Clinical Instructor at Center for Health Law & Policy Innovation, Harvard Law School
Brenda Paulucci-Whiting, Chief Program Officer at Ceres Community Project
Karin Pimentel, Contracts & Business Development Officer at Ceres Community Project
What We Explored
How Food is Medicine services can be financed and reimbursed through Medicaid, including fee-for-service, bundled, per-member-per-month, and value-based payment approaches.
How rate setting, claims, billing, managed care workflows, and revenue cycle requirements affect community-based organizations and food providers.
The true costs of delivering nutrition support services, including food, labor, delivery, coordination, administration, technology, and billing infrastructure,
The roles of Med-QUEST, managed care organizations, healthcare providers, food aggregators, and farmers in building a sustainable Food is Medicine system.
How financing and procurement can better align with ʻāina, local food systems, cultural values, and community-led practice.
Key Takeaways
Reimbursement methodology matters: different payment models create different operational requirements and risks for providers.
Rates need to reflect the true cost of service delivery if Food is Medicine programs are to be sustainable.
Community-based organizations may need significant investment in billing, data, staffing, technology, and other infrastructure to participate effectively.
Clearer guidance on rates, billing, eligibility, and implementation is still needed as Hawaiʻi prepares for Medicaid 1115 Nutrition Supports.
Financing systems should support, rather than override, culturally grounded approaches, community knowledge, local sourcing, and relationships with farmers.
Questions for Reflection
What role does your organization play, or want to play, in the Food is Medicine financing and service-delivery system?
Where do current or emerging reimbursement models fail to reflect the true costs of growing, aggregating, preparing, or delivering food?
What infrastructure, partnerships, or intermediaries could reduce administrative burden while keeping farmers and community-based organizations meaningfully connected to the system?
How can financing and contracting approaches better reflect community and cultural values?