Key Points

Hunger Vital Sign Explainer Series

Part One: Richard Sheward, Children’s HealthWatch

Ep 1: ORIGIN OF HVS

Children’s HealthWatch partnered with Drs. Erin Hager and Anna Quigg to create Hunger Vital Sign as a way for health care practices to know if patients were at risk for poor health outcomes related to food insecurity before they showed clinical indications of health problems. In other words, at a stage when early prevention was possible. This research was done in the early 2000’s and published in 2010.


  • The U.S. Department of Agriculture had a screening tool in place that identified levels of food security referred to as the HFSS for Household Food Security Survey. 

    • Important Point: Food Security is measured by levels - it is not a binary secure / insecure. It is simplified to positive / negative for screening purposes.


  • Other research (including research by Children’s HealthWatch) linked these food security levels to risks of various negative health outcomes.

  • There was an established food security definition and established links between that and poor health outcomes. The problem was that having research tools didn’t help in a clinical setting, where the goal wasn’t to publish research for an academic paper, it was to help individual patients in that moment.


  • What the team needed was a valid, reliable, and brief survey that could be used in a range of practice settings. They wanted to convert a research tool into a risk screening tool.  

    • Technically the goal was to build a tool from the USDA HFSS that was: (1) applicable to families with young children (later research expanded to all age groups); (2) brief; (3) highly sensitive (90%); (4) specific (80%); and (5) showed convergent validity. Defined in the next section.

Ep 2: SCREENING TOOLS


  • A risk screening tool is not a diagnostic tool. 

    • A risk screen is a first step, flagging “there may be an issue here” so that someone can follow up with a patient about that risk. 

    • A social risk (food insecurity) becomes a social need (something a patient wants assistance to address) after the patient says it is a concern.      

    • HVS doesn’t indicate degrees of food insecurity or quality of diet, it is a simple positive / negative result. Follow up with a longer version of the HFSS (or other diagnostic) is needed for this detailed evaluation.

  • Screening tools include three characteristics, the screens are: 

    • Valid - in this case, validity is based both on how close the results are to the HFSS food insecurity screen and the degree to which this correlates with negative health outcomes. 

    • Reliable - the results are the same across a variety of settings and with different people screening / responding

    • Acceptable - not too long, not embarrassing, not violating a social norm 


  • One element of acceptability in a health care context is that practices screen with intent to use the results to provide better care to patients. Collecting results for data purposes alone is a research project, not a risk screening system.

    • Part 2 talks about next steps at greater length.


  • Three pieces of statistics vocabulary that will be useful for reading the research papers on validating risk screens:

    • Sensitivity: Screen correctly identifies patients who do face food insecurity - HVS sensitivity parameter is 90%.    

    • Specificity: Screen correctly identifies patients who do not face food insecurity - HVS specificity parameter is 80%.

    • Convergent Validity: Results reflect an underlying set of variables - in this case, the health impacts of food insecurity.  

Ep 3: CREATING A VALID TOOL

  • As a valid risk screen, Hunger Vital Sign reflects the likelihood that the person being screened is /is  not experiencing an underlying condition (food insecurity) and factors associated with that condition (negative health outcomes).

  • Risk screens lead to diagnostics. Examples of follow up options:

    • Need for Assistance - Conversation with Community Health Worker / Care Coordinator

    • SNAP Eligibility - Financial measures

    • Dietary Quality - Registered Dietitian, validated dietary screener

    • Levels of Food Security - Full USDA HFSS tool 

    • Diet-Related Health Conditions - Clinical tests depending on condition

  • One advantage of the Hunger Vital Sign risk screen is that it connects to a number of different follow up pathways, making it useful in a variety of settings.

  • Researchers also studied how responsive the Hunger Vital Sign is to changing conditions - policies around food assistance, recessions, pandemics, etc. 

    • Important Note: While the USDA HFSS research establishes stable trend lines across the nation, the HVS risk screen is not intended to be stable. It is supposed to be a warning sign, allowing health care practices and others to take preventive action to avoid spikes in food insecurity.  

  • The Hunger Vital Sign builds from a strong research base - we know it has the attributes it does in part because USDA clearly defined food security and there is ongoing research on food insecurity’s impacts on households, along with tools to reduce those impacts. 


Ep 4: CREATING A RELIABLE TOOL

  • The original research behind the Hunger Vital Sign included elements to establish a reliable tool, one that would provide valid results in many settings:

    • Researchers pulled data from a large starting sample, over 30,000 surveys.

    • Surveys were conducted in different cities, in different parts of the country, and in different languages.

    • The tool was tested for brevity and acceptability to screener and responder.

  • The testing did not stop at that first big study - it continues today, considering different health care practice types, age groups, languages, geographical regions, etc.

  • An active research community extends beyond Hunger Vital Sign to integrate that original screen into new applications - including in screens that combine multiple types of health risks, such as the Accountable Health Communities demonstration project.


  • Researchers have also tested what happens when the tool is changed - reducing the number of questions to one, or reducing the answer options to true / false. Both push the margin of error outside of acceptable parameters. 

    • Important Note: The Hunger Vital Sign screen shortens a longer survey as much as possible. Shortening it further leads to missing a significant number of people who may need assistance.


Ep 5: IS HVS USEFUL?

  • It’s inherently difficult to tell whether the Hunger Vital Sign is useful because it’s only meant to be a first step -  utility depends on the second steps.

  • National programs for addressing food insecurity are imperfect, but they do make it likely a next step is available - SNAP, WIC, School Meals, Child Care Meals, Adult Day Centers, Senior Nutrition Programs, TEFAP, CSFP, and non-governmental programs partnering with federal, state, and local governments to reach full national coverage - such as the foodbank network and 2-1-1 assistance lines.

  • Hunger Vital Sign has some attributes that increase its utility:

    • Validation - If you are using screening as a starting point for accessing food benefits, it’s important to know you aren’t missing eligible patients.  

    • Multiple next steps - HVS can be a first step to connecting with resources for food access, counseling for nutrition services, adjustments to health care plans . . . 

      • Important Note: Unlike measures such as SNAP (based on financial data), HVS can reflect other barriers to food access (for example, transportation)

    • Specificity and reactivity to changing conditions - Food security is not the only important area for health care practices to invest resources, by being both specific (ie not over-representing need) and reflective of changing conditions, HVS can help guide targeted investment. 

      • Important Note: When HVS is integrated into workflows that track both the screening results and referral results, practices can identify specific gaps to address. For example, maybe there are resources for patients who can prepare their own food, but a gap in meal-based options. Or transportation. Or maybe there are times of the year or month with resource scarcity. Etc. 

Ep 6: IS HVS VALID / RELIABLE / USEFUL AS IT EXPANDS?

  • One way of tracking HVS utility is through how many practices, associations, and other entities have adopted it or endorsed its use. There is a potential downside, though, since the more places where HVS is replicated, the more chances that it will be implemented in a way that doesnt’ match the original structure - questions morph, staff needs training, follow up steps may be poorly thought through. . . so what happens as use of the screen expands?


  • We can start with expansion among researchers and entities that create social risk screening tools. Readily available research details and the ability to contact the research teams behind HVS make it straightforward to incorporate HVS into new validated tools in a thoughtful way.

    • The Accountable Health Communities demonstration project is one example.


  • The available research and documentation behind Hunger Vital Sign in theory make it something that can be implemented by anyone in a standardized way. Some other tools that help this happen:

    • Adding as a structured field to the Electronic Health Record (EHR, sometimes abbreviated EMR)

    • Coding options that allow for data to appear in the same way across different practices (recognizing that individuals often see more than one health professional)

    • Supporting organizations, which develop tools and other assistance for implementation, and also perform implementation research into best practices for screening at the practice level

  • There is a balance to reach between providing all necessary information for implementation of HVS screening and regulating its implementation to ensure it is rolled out in a standardized way. This is an area of current policy debate.

    • Important Note: This balance is particularly delicate for social risk screens because of their “first step” nature. If regulations push health care practices to screen without adequate follow up in place, then that can harm trust with patients. On the other hand, setting up formal requirements both preserves the integrity of the screen and could signal a route to financial resources to back up the informational resources that support implementation today.

  • Part 2 of this series looks at the efforts of one non-profit organization, Hunger Free Vermont, to implement universal HVS screening in Vermont. 

Part Two: Katy Davis, Hunger Free Vermont

Ep 7: PARTNERING WITH HUNGER FREE VERMONT


  • Hunger Free Vermont is a non-profit organization with the goal of ending the injustice of hunger and malnutrition for all Vermonters. Towards this goal they look at systems that are broadly available to support food access and how to optimize Vermont’s use of those systems - for example, federal nutrition programs like SNAP, WIC, School Lunches.

  • Health care is a good point of connection for this work because Vermont has extremely low uninsured rates and extremely high health care engagement, especially primary care. That makes this sector a point of connection for a broad cross section of our communities.

  • Hunger Free Vermont’s goals match the goal of health care, discussed in Part 1 of the series: to be sure there is always a “second step” available after food insecurity screening.

  • The Hunger Vital Sign screen appealed to Hunger Free Vermont as a starting point because:

    • It was a concrete, validated tool already in use by Vermont health providers’ peers throughout the country 

    • The focus on universal screening could help remove stigma from food access conversations

    • Hunger Vital Sign is tied to food insecurity levels, not financial eligibility the way SNAP / 3SquaresVT is

    • Broad implementation of HVS provides current and community-specific data, which can help with policy making and identifying community resource gaps

  • Hunger Vital Sign screening isn’t the only way that Hunger Free Vermont engages with health care providers, the Community Health Needs Assessment process and regional Hunger Councils are two other examples. 


Ep 8: CONVERSATIONS ABOUT FOOD INSECURITY

  • A key part of the success of Hunger Vital Sign screening is how it opens up conversations about food access and assistance patients might need.

  • Ways a validated, universal screening tool can help with these conversations:

    • Everyone is asked - no one feels singled out or is skipped over.

    • Emphasizes that diet is part of health and health risks, like other commonly accepted risk screens such as blood pressure readings or tobacco use screens 

    • As the people doing the screening repeat the questions, they become more comfortable asking and see the changing food security landscape in their communities, removing bias around who does / does not need assistance

    • As patients hear the questions repeated, they become more comfortable answering and if their circumstances change they know they have an opportunity for the conversation with their health provider

      • Important Note: Food security status changes - and in health care in particular a new diagnosis / event / life stage can signal shifts in food security.


  • A well-implemented food insecurity screening process can support patients both by immediately providing resources to those who need assistance and by building a relationship where the health provider is seen as a resource for a “whole person” approach to good health.

    • Important Note: It takes time and careful attention to build a strong screening system, it is not as simple as putting two questions on a patient survey.



Ep 9: THE BIGGER PICTURE

  • These episodes have highlighted the opportunity to accomplish big goals with Hunger Vital Sign screening as a starting point - the flip side is that health care providers are already working on big goals, life and death sorts of goals, adding “ending hunger” to the to-do list is unreasonable.

  • Hunger Free Vermont emphasizes HVS screening as also being a step in community collaborations and partnerships to address the shared goal of reducing food insecurity’s negative impacts on health. Ways that Hunger Free Vermont assists health care partners:

    • Helping provide and cultivate community input

    • Convening multi-partner conversations about addressing hunger, such the regional Hunger Councils

    • Direct technical and training assistance in HVS implementation

    • Learning about health care systems and being an ambassador within those systems and to other community groups

    • Assistance in referrals and enrollment in programs for food access and related barriers (eg transportation) 

    • Aggregating community level data to support needed policy changes 

    • Connecting with federal programs and national policy conversations

  • There are opportunities to improve support for these effective collaborations. Two examples provided:

    • Easier referral systems, including “closed loop” systems, for health care providers and community organizations to communicate and share information.

    • Better options for interstate collaboration on food & health care integration - for example, other states are able to do more work with payers (aka insurers), reimbursement structures, and clinical evidence, while Vermont may be stronger in direct community collaborations and local food connections.

Part 3: Katherine Verlander, CMS Innovation Center

Ep 10: CMS INNOVATION CENTER

The Centers for Medicare & Medicaid Services (CMS) is a federal agency that administers the Medicare program and works with state governments to administer Medicaid and the Children’s Health Insurance Program.

CMS is invested in health outcomes both figuratively (as a social good) and literally (as a very large payer for health services). The CMS Innovation Center is an entity within CMS that experiments with new models of health care delivery and payment. Their models attempt to improve care and lower costs.

The Accountable Health Communities Model (AHC Model) is one of these innovations. It is testing whether systematically identifying and addressing health-related social needs of Medicare and Medicaid beneficiaries will reduce their overall health care costs, and in particular reduce avoidable health care utilization. “Reduce avoidable utilization” is one way to measure how well the system is preserving good health - essentially, it’s the emergency department visit that didn’t happen.

The AHC Model had the following core elements:

  • Bridge Organizations: The lead organization receiving the CMS grant and implementing the Model.

  • Screening: Patients were screened across 5 core domains for health related social needs (HRSN) and asked if they had 2 Emergency Department visits in the previous 12 months.

  • Referral: All patients with a positive HRSN screen were offered referral to community resources.

  • Navigation: All patients with an HRSN and 2 recent emergency department visits were offered additional navigation services to help connect with community resources.

  • Alignment Track: Bridge Organizations in this track performed additional work identifying gaps in community resources and filling those gaps.

Ep 11: ACCOUNTABLE HEALTH COMMUNITIES MODEL

The three core components of the AHC Model are screening, referral, and navigation. AHC Model’s HRSN screening tool has 5 core domains:

  • Housing

  • Food security

  • Transportation

  • Utilities

  • Interpersonal violence

Hunger Vital Sign is used for the food security component.

Bridge Organizations were required to screen for the 5 core domains. The tool also offered questions for 8 optional domains. The core domains were chosen based on:

  1. High quality evidence linking that social need to poor health or increased healthcare cost.

  2. Need is something that can be met by community service providers.

  3. The need is not already being systematically addressed by health care providers.

In their application to participate, Bridge Organizations had to demonstrate capacity to screen for these domains as well as connect patients interested in assistance with local services. They did not screen for social needs for which no services would be available.

The final format of the screening tool reflected the following design principles:

  1. Identified the broadest set of needs that could be met by community providers.

  2. Simple and streamlined - understood by the broadest audience and usable in the widest range of clinical settings & workflows.

  3. Evidence based and informed by practical experience.

The final system was tested in over 600 sites across the country, with 28 Bridge Organizations completing the 5 years of the demonstration.

Ep 12: EVALUATING THE AHC MODEL

The AHC Model has completed the 5 years of programming and is now in the evaluation phase.

Preliminary findings, case studies, and promising practices are found on the CMS Innovation Center’s AHC Model website. These materials can be used by other communities interested in screening, referral, and navigation.

The final evaluation will consider a range of factors outlined in the Affordable Care Act that determine whether the Secretary of Health and Human Services can authorize the model for national expansion. Only 6 previous models have shown statistically significant savings and only 4 have met all requirements for expansion in duration and scope:

  1. Home Health Value-Based Purchasing Model

  2. Pioneer ACO Model

  3. Prior Authorization of Repetitive Scheduled Non-Emergent Ambulance Transport Model

  4. Medicare Diabetes Prevention Model

This evaluation will take several more years. However, certification for expansion under the ACA framework is very narrow definition of model success. The insights provided by models like AHC can inform a broad range of investment, policy, and community strategic planning.