Linking The Clinical Experience To Community Resources To Address Hunger In Colorado

One in seven U.S. residents struggles to afford food which increases the likelihood of poor diet quality, nutritional deficiencies, chronic diseases, depression, and anxiety. Despite the established link between nutritional deficiencies and disease, health care providers often do not screen for the ability to afford food or link patients with food resources. These efforts would improve the quality of patient diets and diminish the substantial stress associated with not having enough to eat, resulting in improved health and quality of life.

Addressing patients’ hunger and other social and economic needs requires that health care providers step outside their clinic and hospital walls and partner with community groups that can address the social determinants of health — an approach referred to as clinic-to-community integration (CCI). Successful clinic-to-community integration efforts comprise three key elements.

First, these efforts require an ability to assess patients’ social and economic needs that impact their health. Second, an appropriate scope of community services and agencies must be identified to address those needs. Third, clinic-to-community integration requires the creation of a reliable referral system to facilitate the exchange of patient information between clinical and community settings while protecting the privacy of patients’ health data. This post takes a deeper look at one model of clinic-to-community integration: hunger-screening efforts in Colorado.

Colorado Hunger Screening — A Case Study In Clinic-to-Community Integration

Despite rates of food insecurity that mirror national trends, Colorado consistently ranks at or near the bottom among the 50 states and the District of Columbia for the share of eligible residents participating in the Supplemental Nutrition Assistance Program (SNAP), commonly known as food stamps.

In 2011, Kaiser Permanente of Colorado, an integrated delivery system covering more than 600,000 members, began partnering with Hunger Free Colorado, a statewide hunger advocacy and outreach organization, to implement a comprehensive hunger-screening program. The program’s goal is to increase nutritious food access and decrease diet-related diseases throughout the state.

Kaiser Permanente started by administering a two-question hunger screen during clinical visits:

“In the past 12 months, did you worry whether your food would run out before you had money to buy more?”

“In the past 12 months, did the food you bought not last, before you had money to buy more?”

Initially, qualifying individuals who answered positive to the hunger screen were given a card with the Hunger Free Colorado Hotline and instructed to call. Hunger Free Colorado personnel then determined eligibility for food assistance, provided education about available programs, and completed an application for federal nutrition programs on the individual’s behalf if they qualified. Individuals were also referred to other resources when appropriate, such as food pantries, summer food programs, senior food programs, or home-delivered meals.

The program was first piloted in two pediatric clinics and has since expanded to 10 departments and over 10 medical offices. Since 2012, Kaiser Permanente has referred 1,839 members to Hunger Free Colorado, 78 percent of whom received successful outreach from the organization.

Securing Provider Buy-in And Establishing A Workflow

A critical first step in securing providers’ buy-in to the program was demonstrating that food insecurity is prevalent and is associated with poorer health outcomes among the populations they serve. Many providers were not aware of the extent to which food insecurity is a real problem among their low- and middle-income patients.

Once provider buy-in was secured, a project team of physicians and staff from Kaiser Permanente and Hunger Free Colorado worked with participating departments to integrate hunger screening into the existing clinical workflow, tailoring the process for each department. Depending upon the care situation, the screening was administered via a questionnaire, during phone consultations, or during an in-person visit.

The Referral Process

Once a patient is identified as having a potential hunger concern, the efficiency and efficacy of the referral process is vital to making sure that he or she is connected with appropriate community resources. As noted, during the initial pilot phase of the program in 2011, patients identified with food insecurity were given a card with Hunger Free Colorado’s hotline number and were then expected to contact the organization themselves. However, evaluation efforts showed that fewer than five percent of Kaiser Permanente referrals were calling the hotline.

To increase the number of patients receiving food assistance, program staff developed a referral form in the electronic medical record, which patients could sign to authorize Hunger Free Colorado to contact them directly. The time frame of inquiry about food insecurity was shortened from 12 to three months (“In the past three months have you worried whether your food would run out…?”), helping staff identify patients with more current needs. These two changes to the process increased the proportion of referred patients receiving resources from 5 to 78 percent.

In early 2014, the referral process changed again to include newly hired Kaiser Permanente community specialists whose role was to connect patients with resources, not just for food insecurity, but also for other social and economic needs — housing, dental care, transportation, loss of health insurance, and financial assistance. Now, when a patient’s screen indicates food insecurity, the health care provider electronically refers him or her to the community specialist who completes the referral form with the patient, obtains consent for information transfer, and submits information to Hunger Free Colorado. Hunger Free Colorado contacts the patient directly.

Data Collection, Evaluation, And Improvement

Every month, Hunger Free Colorado provides Kaiser Permanente staff with a report that includes the number of people enrolled in the Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), as well as other resources such as food pantries and meals on wheels. In addition, as a way to share best practices and identify and address challenges, the project team from Hunger Free Colorado and Kaiser Permanente convenes a quarterly telephone meeting open to all providers participating in hunger screening. During these calls, participants are encouraged to identify processes that are working well and ways to improve the referral and outreach.

Growth In Referrals

Since the referral process for food insecurity has been formalized, the number of referrals to Hunger Free Colorado increased from 60 in 2012, to 1,547 in 2014. This resulted in the enrollment last year of 222 people in the SNAP program, 79 in the WIC program, and the referral of 857 patients to food pantries. Table 1 (source: Hunger Free Colorado) illustrates the growth in assistance since the program was formalized.

*Submission of the online application began in late summer 2014. An online application is completed by Hunger Free Colorado on behalf of the individual once eligibility is determined via a phone conversation (current as of November 2014).

Linking Programs To Policy

The fullest expression of clinic-to-community integration includes not only connecting members with high-quality, community-based resources, but also support for policy, systems, and environmental changes to ensure broader access to social and economic support. The hunger screening and referral process—together with the anti-hunger policy, advocacy, and outreach efforts of Hunger Free Colorado and other like-minded organizations—have resulted in Colorado improving its SNAP participation ranking from 50th in the nation in 2009, to 45th in 2014. One important policy victory was an administrative change that reduced the SNAP enrollment application from 26 pages to eight, significantly reducing a barrier to enrollment.

Such successes speak to the power of collaborative partnership between the health sector and community organizations that can connect patients to community resources and advocate for system changes. Without a strong community-based partner such as Hunger Free Colorado, and without state policies that reduce barriers to enrollment in federal nutrition programs, Kaiser Permanente’s efforts to screen and refer members to food resources would be much less effective, or perhaps impossible.

Lessons For Future Clinic-to-Community Integration Efforts

More work is needed to improve systems for identifying food-insecure patients and to increase our understanding of how connecting these patients to food resources impacts their health and use of health care services. However, we learned a number of lessons from our hunger screening efforts — lessons that are broadly applicable to evolving clinic-to-community integration efforts:

1. Early hunger screening efforts had to overcome considerable skepticism about the appropriateness of taking up valuable and scarce clinical time. This is not surprising given that providers are not typically exposed to the social determinants of health in their clinical training or in continuing education. Intensive communication, including engagement by passionate physician champions, is often required to overcome these gaps in knowledge and enthusiasm.

2. For the referral process to work, the community partner must have sufficient capacity to process referrals and reach out to patients. Care providers and community partners need to invest time to adapt and improve the referral process, applying the same kind of rigor and process improvement that health systems typically use to improve quality and clinical operations.

3. Integration of community partner data with patients’ electronic medical records is useful in the process to ensure appropriate follow-up of referrals. It can also facilitate efficient evaluation to assess the impact of those referrals on health and use of care. However, data integration can be challenging. Kaiser Permanente’s hunger-screening programs suggest that full data integration, while preferable, is not necessary to implement effective clinic-to-community integration.

4. There is no one-size-fits-all intervention that can be applied in the clinic-to-community integration model because each clinical setting has its own distinct population, care-delivery process, and workflow. Programs must tailor screening questions, processes, and referrals to the unique characteristics and available resources for each population.

Although the social determinants of health drive a large share of health-related outcomes, providers and health care organizations have been loath to take on an explicit role and responsibility in addressing the social and economic needs of their patients. Times are changing, and initiatives like Kaiser Permanente’s hunger-screening in Colorado suggest that stepping up to this role can yield valuable benefits for patients, providers, and for the U.S. health care system. Indeed, to do otherwise is to continue down a path that our nation and our patients can ill-afford.

Author’s Note

We would like to acknowledge these individuals for their contributions to leading this work: Kathy Underhill, CEO of Hunger Free Colorado, and Carmen R. Martin, Senior Research Specialist with Kaiser Permanente.