Food Insecurity Screening

For more recent information, see this Oct 30, 2022, Update Post on results of the 2022 Food Insecurity Screening Survey.

The Food Access and Health Care Consortium received grant funding from the Health Resources & Services Administration (HRSA) to conduct strategic planning around integrating food access in health care. In our 2020-2021 work we reviewed common core elements of programs that successfully integrated food access in health care, with “success” defined as models that result in measurable clinical improvements for individuals receiving food-related services and the capacity to receive reimbursement from health care payers. One of those core elements was standardized food insecurity screening using a validated screen (such as Hunger Vital Sign) with results entered in a patient’s medical record. Based on this, we wanted to get a sense of the state of food insecurity screening in health care practices and so conducted a survey in September 2021 to get an initial sense of the landscape. A summary of the results is below.

Survey Results and Resources:

We had a very strong response from hospital systems and FQHCs, with only a few organizations unrepresented. We had a much smaller response from our third target group of independent primary care practices. This survey was exploratory, it is not a definitive description of food insecurity screening in Vermont.

80% (18 of 23) respondents have a formal food insecurity screening process, 100% of those screening use the Hunger Vital Sign questions for at least some patients. Note that the Hunger Vital Sign is the food security screen incorporated into SBINS and CMS Accountable Health Communities. PRAPARE (the FQHC screening tool) does not include the validated version of food insecurity questions, some FQHCs mentioned modifying PRAPARE with Hunger Vital Sign questions.

Why Hunger Vital Sign? We were interested in Hunger Vital Sign because it is the standard screen and has been validated against both the USDA Household Food Insecurity measure and clinical outcomes. A collection of Hunger Vital Sign resources is available here from Children's HealthWatch. For anyone who really wants to go deep on this topic there is a national Community of Practice co-convened by Children's HealthWatch and the Food Research and Action Center.

For more context-setting discussion on the role of SDOH screening in health care practices, this series of "Coffee & Science" talks from SIREN (Social Interventions Research & Evaluation Network). The screening conversations are near the start of the series.

75% of practices screening for food insecurity enter the results into the EHR in a structured way. Recent changes to standard EHR packages to incorporate these screens has helped this shift. Some respondents expressed concern about being on EHR systems that do not yet have food insecurity results as a standard option and about confusion created by using different screening tools for enrollment in different programs.

Standardized data systems for SDOH are an issue being discussed nationally, for example in this Health & Human Services report (2019), ONC work on SDOH data in Health IT, and the Gravity Project. This was also a question specifically asked in a recent Congressional request for information, briefly summarized in this update post.

The most common ways listed for screening to be incorporated were at primary care locations for new patient intake, adult annual wellness visits, well child visits. Hospital systems also provided lists of specialty areas where screening is incorporated and noted plans to expand specialty-by-specialty. Several respondents noted the extensive work done in Vermont on integrating food insecurity & screening into pediatrics and several respondents flagged new mothers as a key group for screening. Other areas highlighted were case management during care transition and ED patient intake. Two respondents reported food insecurity screening only when tied to enrollment in a specific program.

One limitation of this survey was that not every respondent knew what was happening in different parts of each practice or network. The intent was to get a rough overview of how practices think about screening. One overarching question was whether practices who begin with a screening in a pilot program or for a subset of patients then expand to more general screening, and the answer is clearly yes - that was reflected both in how screening is incorporated into workflows now and in plans for future expansion. If you're interested in resources on expanding screening in your practice, Hunger Free Vermont works with health care professionals on this topic.

In the literature on food insecurity screening, there are many applications of a positive food insecurity screen result, including:

• Referral to an individual who can connect patients to additional resources - Community Health Worker, Care Coordinator, Social Worker, etc.

• Direct provision of services / food by the health care practice - for example, a food box for people who need food immediately. (Note: we know many health care practices have food available for those who need it without connecting to a food insecurity screen, here we were looking for complementary programs tied to a screen + "prescription"). 

  • Food insecurity screening may also be part of reimbursement systems that cover defined food-related benefits for patients. See, for example, North Carolina Medicaid. 

• Modification of treatment plans to reflect food insecurity status - for example, approaches to managing chronic conditions, referral to a dietitian, targeted prevention work, etc.

• Integration of patient data into population health and community health initiatives, including outreach plans to engage patients at risk for food insecurity at times other than medical visits.
  

The survey did not provide much insight into how results are used beyond the first bullet point - which received a strong endorsement and appears to be common practice among the group surveyed. The other elements appeared in only a few responses. That result likely reflects how the survey was structured more than practice on the ground. This may be an area for future review.

This survey was part of a larger strategic planning project on integrating food access and health care in Vermont. Extended notes on the survey with connection to other questions raised as part of that strategic planning process are available here.