Hunger Vital Sign (HVS) shows the risk that a patient is experiencing food insecurity and that they will experience negative health outcomes connected to food insecurity. The screen’s purpose is to make an invisible need (food access) visible to health care providers. That is only a first step. Understanding how this risk affects a patient’s health and how they might want to address any dietary concerns requires a follow up conversation.

The list of things HVS does not directly measure suggests what some appropriate follow up conversations might include:

HVS does not measure whether a patient needs assistance with food access, that is determined by the patient. The HVS risk screen is meant to quickly identify patients who are likely to be interested in assistance. Similarly, HVS does not measure all the barriers that exist for an individual trying to accessing adequate nutritious food - care coordinators, community health workers, care plan managers, social workers, wellness coaches, and others are trained to have these more detailed conversations and set up a plan with a patient.

HVS does not measure eligibility for SNAP or other USDA nutrition assistance programs. These programs are (mostly) income-based and final eligibility determination can be a long process. See, for example, this tool from Hunger Free Vermont.

HVS does not measure levels of food insecurity, that would be more akin to a diagnostic tool than a risk screening. The equivalent diagnostic tool are the USDA food security surveys. For example, a program would use these additional surveys would to record a change in food security levels before and after participating in a food access program.

HVS does not assess dietary quality. And HVS is measuring for a very general definition of food security - it is not reviewing a patient’s ability to participate in a specialized diet following a medical diagnosis. There are tools available to review general dietary quality. Assessing an individual’s diet for purposes of treating a particular health condition requires a qualified provider such as a registered dietitian. Connecting with the appropriate licensed provider is particularly important as health care practices address conditions that combine dietary changes with prescribed medications.

HVS measures food insecurity in, at most, annual increments. Food security status changes throughout a lifetime and the risk screen provides a snapshot in time.

HVS is designed to work as a universal screening tool so that all patients can be screened. Because food security status can change, and because it often takes a few iterations to become comfortable responding to HVS questions, it rarely is used only once for a patient (except in settings with low levels of returning patients — like an emergency department).

Some practices begin using the tool with a group of patients at elevated risk of a change in food security status, for example in pediatric clinic sites with families that have recently expanded, or as part of health care planning around a significant new medical condition. In CY2024 hospitals will need to start reporting whether they screen for SDOH like food insecurity as part of patients’ inpatient stays. Medicare Advantage plans are required to screen as part of building health care plans for their SNP enrolled patients.

The basic health equity goal is to move from pre-selecting patient groups for screening to more universal screening.

Using HVS systematically reduces stigma and avoids bias in who is asked about food access. See, for example, the HITEQ SDOH Screening toolkit for steps in writing a policy and recording whether screening occurs to match that policy. This requires tracking patients eligible for screening per the policy, # of those patients who were invited to answer the screening questions, and # of those patients who were either positive, negative, or declined to complete the survey. Additionally, because HVS is not complete without a second step after screening, policies should include the patient pathway if a HVS result is positive.

For assessing existing screening procedures, key questions include: Is there a clear policy for screening? Is this policy still the right one (for example, if screening began in a few sites is it now time to expand)? Are screening results being entered correctly into the EHR? Is screening occurring according to policy most of the time (for example, more than 80%)? This case study from the Accountable Health Communities Model provides one example of screening data and quality improvement. The UVM Children’s Hospital presentation linked from this update includes another example.

Hunger Vital Sign (HVS) is the shortest set of questions that reliably predicts whether a patient will fall in the food insecure range of the USDA’s food security measure. The USDA measure is the standard measure in the U.S. (other tools are used in international work) and connects to over 25 years of tracking and research.

Background on measuring food insecurity is available from the USDA. Feeding America provides a tool for exploring food insecurity data by county. County Health Rankings provides a tool for exploring this data alongside other health measures.

If you are screening a patient population that is representative of the broader community, then average trends in HVS results would look similar to results reported by organizations using the USDA tool (as discussed in the extended explainer series, the tool is designed to err on the side of over-reporting risk). It is unlikely that a health care practice is screening a statistically representative sample of the community. Screening a sub-population at higher risk, for example patients who frequently use the emergency department or patients who have already screened positive for a different social risk, should result in higher positive results. Again, on average.

One key difference between HVS and the USDA official reports is that HVS is designed to be highly responsive to changing conditions while the USDA reports stable trends. A major disruption, for example local job losses or a national recession, should result in a spike in HVS positive screens and help guide a rapid response.

HVS can also be more targeted - getting to a town level of aggregated data, while national statistics go to a county level.

One thing that HVS does not do is return food insecurity levels, it only reports a binary positive / negative for risk of food insecurity.

For an example of comparing health care practice SDOH screening results with external community databases, see the first evaluation report from the Accountable Health Communities model.

HVS is designed to be broadly useful for any health care application connected to food, nutrition, and food access. This means that specific next steps will be different by context.

The most common next step is connection to community resources for assistance - usually after a conversation to determine more details on the type of assistance a patient wishes to receive and other barriers that may need to be addressed. Generically this pathway would be:

Eligible Patients Screened —> Positive Patients Offered Assistance —> Patients Interested in Assistance are Connected to Services that Meet Their Needs. (A slightly more elaborate diagram is here)

Two common variations are:

1.) A closed loop, where the health care practice records whether the patient participates in the referred services and the outcomes.

2.) A stratification of some patients into a higher-risk category based on clinical indicators, with higher risk patients offered additional services beyond referral to community food access programs.

Examples of tracking patients through all the phases of screening and referral are available through Accountable Health Communities, HITEQ SDOH dashboard modules (note this focuses on PRAPARE as the screening tool, not HVS, but the steps are the same), SDOH Business Case (see p. 8 Fig 3 for tracking).

The AHC Model first evaluation report provides examples of results from early closed loop tracking.

It is important to distinguish between tracking next steps (how a patient moves through the system) and tracking the impact of those steps. The most common way to measure impact is with a pre- and post-survey using the 6 question food insecurity module from USDA, which can identify levels of food insecurity for at-risk patients.

One element lacking from many of the structures for ‘next steps’ tracking is clinical next steps. Some health systems already track this pathway in electronic health records, including referrals to related medical services (Medical Nutrition Therapy, for example) and use of the ICD-10 “Z-codes” that reflect SDOH present at the time of an office visit. Many practices have care management platforms for patients with complex health needs to trace all the services involved in their health plans. Indirectly related to this question is a national movement to include more nutrition education in medical school, preparing doctors to better integrate food and nutrition. referrals into patient care.

Visit our Outreach Systems page for information on identifying community food resources in Vermont, plus models from other regions illustrating ways to aggregate and share this kind of information.

Federal nutrition programs provide an important starting point because they reach every town and integrate with local food retailers. The SNAP Program, or 3SVT, is one of the largest nutrition safety nets, and information on enrollment is found here. Note that eligibility is based on income and assets, not on food insecurity levels. School food programs and WIC are two other examples, as are the Older Americans Act funded nutrition programs and related services for older Vermonters. Hunger Free Vermont is a VT FAHC partner focused on increasing access to these federal resources.

Systematic food insecurity screening both connects patients with available resources and helps identify gaps in those resources. General information exists on Vermont food access systems and connected health outcomes, see for example the VT Food Systems and Community Health resource collections, but data from patient screening can add specificity to where a health system might make local investments.

Health Net (an AHC Model Participant) provides an example of using community advisory boards to begin aligning resources. The Colorado SDOH information exchange white paper provides and example of using information collected from a multi-sector referral platform to identify & fill gaps (more information on that approach is found here, from ONC).

There is ongoing research into new applications of both the HVS tool and other screening tools built from the USDA food insecurity survey. More about that work is available from Children’s HealthWatch and SIREN. Researchers try out variations on these tools all the time.

Making changes outside of the research context essentially means you aren’t using the Hunger Vital Sign tool any more. This has practical implications. The screener would not qualify for policies that require a validated or standardized tool. Results would not be comparable to other organizations who use HVS. It would also be important to monitor whether the new tool is missing people who are food insecure. For example, changing the available answers from “Often / Sometimes / Never” to “Yes / No” or reducing to a single question have both been shown to miss a significant number of people.

A key question before changing the screener is whether HVS is the right tool in the first place (see FAQ #1).

For example, if food assistance takes place for patients after diagnosis with a particular diet-related condition, maybe the risk screening was clinical (the condition) and the next step is a diagnostic tool that can provide details on diet quality. If the patients being screened have already elected into a food access program, then the question isn’t whether they desire assistance (the focus of HVS). A better goal might be to understand food program participants’ food insecurity levels and how those change, using something like the 6-question USDA survey tool. Or, if a health care practice is working with community partners and has a robust food access program already in place, but is worried about patients not being reached by the open access program and wants a systematic screening for that goal, the HVS may be the right tool, but maybe the health care practice isn’t the right setting (or isn’t the only setting) and the best initial strategy is to work with community partners in a broader outreach effort.