Food Insecurity and Health: Two Questions that Changed the Landscape for Human Services and Evaluation Shana Alford, BBA, MPP Director of Program Evaluation Feeding America s Center for Research and Learning
Presentation and Discussion I. Defining Food Insecurity II. Overview of Feeding America III. Current State of Hunger in America IV. Social Determinants of Health and A New Way of Business V. Screening for Food Insecurity in a Clinical Setting A Case Example VI. Q&A/Audience Discussion
The Intersections Social Determinants of Health Food Security Chronic Disease Poverty Health Outcomes
Defining Food Insecurity Food security means that all people at all times have access to enough food for an active, healthy life. Food Security High food security: no food access problems Marginal food security: one or two reported indications (anxiety over food shortage but little or no indication of changes in diets or food intake) Food Insecurity Low food security: reports of reduced quality, variety or desirability of diet. Little or no indication of reduced food intake. Very low food security: reports of multiple indications of disrupted eating patters and reduced food intake. Source: United States Department of Agriculture
How is Food Security Measured in the U.S.? U.S. Household Food Security Survey Module: 18 item survey to capture the full range of severity of food insecurity among households. It is used annually in the U.S. Census Current Population Survey. Other Surveys: ou.s. Adult Food Security Survey Module: 10 item survey ou.s. Six Item Short Form Food Security Survey Module: 6 item survey oself-administered Food Security Survey Module for Youth Ages 12 and Older Source: United States Department of Agriculture
Household Food Security has improved but an estimated 40+ million Americans are still food insecure.
US Economic Improvements 1. Overall, national poverty rate has declined. 2. Overall, median household income has increased. 3. More people with health insurance Source: All Key Information found here https://www.hungernet.org/research/foodinsecpov/pages/2016incomepovertyrelease.aspx
Number of people (millions) US Economic Improvements Trends in Health Care Coverage and Poverty Rates 60 50 40 30 46.5 46.9 45.6 46.3 36.9 36.4 37.2 39.8 50.6 49.9 48.6 47.9 43.5 46.1 46.2 46.4 45.3 46.6 42 33 43.1 29 20 10 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Year Individuals living in households with incomes below poverty threshold Individuals without health care coverage
Dollars (thousands) US Economic Improvements Median Household Income 2005-2015 60 50 46.3 48.2 50.2 51.3 49.7 49.4 50.0 51.0 51.9 53.6 56.5 40 30 20 10 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Year
Overview: Feeding America The Nationwide Network
How Feeding America Works A More Food-Secure Nation NATIONAL OFFICE National vision and plan to achieve clear goals The leading hunger research organization Highly efficient use of resources by measuring program outcomes and impact National reach and grantmaking allow for strategic market focus and community impact Unmatched cause-marketing, branding and communications capacity Unmatched national advocacy capacity Ability to scale anti-hunger activities Developing approaches to ending hunger FOOD BANK NETWORK Reaches into every county in the U.S. Regional and local authority on hunger relief Rooted in local communities, immediately connected to the people we serve and donors Deep opportunities for community engagement Tailored, responsive programs for agencies, food-insecure people, volunteers and donors
The Impact of the Feeding America Network We serve 42 MILLION AMERICANS annually, including 12 million children and 6 million seniors We source and distribute 11 MEALS for each $1 donated We provide 4 BILLION MEALS each year to people in need We source 1.25 BILLION POUNDS of fruits and vegetables through the network We have 200 FOOD BANKS in the Feeding America network 2 MILLION VOLUNTEERS help carry out our vision for a hunger-free America Source: Network Activity Report and Hunger in America 2014
Overview: Hunger in America Trade-Offs and Negative Impact on Health
Hunger s Impact on Our Nation HUNGER IMPACTS A child s ability to learn and focus in school A person s social and behavioral response in stressful situations A child s cognitive and physical development at ages 0-3, a critical period of rapid growth A person s physical, emotional and social preparedness for the workforce A family s health, as those who are food insecure are more likely to be hospitalized or experience health crises Source: Feeding America s 2009 report, Child Food Insecurity: The Economic Impact on our Nation
Making Tough Choices The people Feeding America serves report that their household income is inadequate to cover their basic household expenses. 69% 67% 66% 57% HAVE HAD TO CHOOSE BETWEEN PAYING FOR UTILITIES AND FOOD HAVE HAD TO CHOOSE BETWEEN PAYING FOR TRANSPORTATION AND FOOD HAVE HAD TO CHOOSE BETWEEN PAYING FOR MEDICINE AND FOOD HAVE HAD TO CHOOSE BETWEEN PAYING FOR HOUSING AND FOOD Source: Hunger in America 2014
The People We Serve Have High Rates of Nutrition-Related Illnesses Hunger in America 2014 findings show that high blood pressure and diabetes are common in the households of the people we serve. 58% 77% 33% 47% OF HOUSEHOLDS HAVE AT LEAST ONE MEMBER WITH HIGH BLOOD PRESSURE OF HOUSEHOLDS WITH SENIORS HAVE AT LEAST ONE MEMBER WITH HIGH BLOOD PRESSURE OF HOUSEHOLDS HAVE AT LEAST ONE MEMBER WITH DIABETES OF HOUSEHOLDS WITH SENIORS HAVE AT LEAST ONE MEMBER WITH DIABETES Source: Hunger in America 2014
Eating Produce and Healthier Foods Improves Health Clinical trials have shown the positive effects of eating produce on cardiovascular disease and high blood pressure: Lower risk of heart attack and stroke Lower risk of coronary heart disease Reduced blood pressure More than half of the people Feeding America serves identify fresh fruit and vegetables as the most desired foods not received at their food bank. Multiple Sources
Community Health Initiatives at Feeding America FAITH-DM: Diabetes Trial and Intervention in Food Pantry Settings https://hungerandhealth.feedingamerica.org/resource/feeding-americasresponse-to-diabetes-and-food-insecurity/ Health and Hunger Website: Food Banks, Nutrition and Health Professionals https://hungerandhealth.feedingamerica.org/understand-food-insecurity/ Nudges in Food Pantries (Behavioral Economics) https://hungerandhealth.feedingamerica.org/resource/the-power-of-nudgesmaking-the-healthy-choice-the-easy-choice-in-food-pantries/ AmeriCares Partnership (New) Americares selected 3 free clinics that will partner with Feeding America member food banks in a Diabetes Prevention Healthy Food Integration Project.
Social Determinants of Health and New Ways of Business Progress= Advocacy + Policy+ Research + Funding
Social Determinants of Health The World Health Organization (WHO) defines the social determinants of health as the conditions in which people are born, grow, live, work and age. o These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. There has been growing interest in thinking more critically about these determinants when improving health outcomes and lowering healthcare costs.
New Rules for Hospitals by IRS New Requirements for 501(c)(3) Hospitals Under the Affordable Care Act The Affordable Care Act (ACA), enacted March 23, 2010, added new requirements that hospital organizations must satisfy in order to be described in section 501(c)(3), as well as new reporting and excise taxes. Source: Center for Medicare and Medicaid Services
New Rules for Hospitals by IRS 1. Written financial assistance and emergency medical care policies, Related to 2. Limited amounts charged for emergency or other medically necessary care to individuals Patient eligible Debt and for assistance. Financial Assistance. 3. Make reasonable efforts to determine whether an individual is eligible for assistance under the hospital s financial assistance policy before debt collection actions. 4. Conduct a Community Health Needs Assessment and adopt an implementation strategy at least once every three years. Food Banks and Pantry Agencies Source: Center for Medicare and Medicaid
Policy and Federal Dollars Make A Difference Center for Medicaid and Medicare Services Accountable Health Communities Model addresses a critical gap between clinical care and community services in the current health care delivery system testing if the health-related social needs of Medicare and Medicaid beneficiaries through screening, referral, and community navigation services will impact health care costs and reduce health care utilization. 32 Participants testing new payment and service delivery models Source: Center for Medicare and Medicaid Services: Innovations. CMS. GOV
Screen & Intervene A Public Health, Patient-Centered Movement
Two Question Food Insecurity Screener Hunger Vital Sign Tool 1. Within the past 12 months we worried whether our food would run out before we got money to buy more. 2. Within the past 12 months the food we bought just didn t last and we didn t have money to get more. Source: Children s HealthWatch
Screen & Intervene: Focusing on the Intervention Asking the questions is only the starting point Food Banks and anti-hunger organizations have the expertise that health care partners need to address food insecurity: Referrals to existing programs Considerations for expanding food distribution options at the health care site Connection with long-term benefits
Addressing Food Insecurity: Expanding Food Distribution for Immediate and/or Long Term Access Hospital or clinic emergency bags Hospital or clinic food pantry Mobile pantry at a hospital or clinic Mobile produce distributions Frozen meals distributed at discharge
Addressing Food Insecurity: Referrals to Existing Agencies & Food Distribution Programs in the Community Level 1 : Patient Directed Phone number or website for a central hotline, 2-1-1, or food bank referral Resource list with specific local programs and agencies Level 2: Patient Centered Voucher referrals to specific agencies and programs with targeted types of food & health education Involve case management approach for patient follow-up to improve likelihood the patient gets food
HIPAA Considerations for Non-Health Organizations Health Insurance Portability and Accountability Act (HIPAA) Requires Health Care Providers Covered Entities to protect patient data Sharing of names, contact information, health information invokes HIPAA rules Release of information Business Associate Agreements Security considerations for Storage and transmission of information to & from partners
A Case Example: Clinic-To- Community Integration Screen, Intervene and then Evaluate Kaiser Permanente and Hunger Free Colorado Source: Health Affairs Blog, July 13, 2015, Stenmark, Soloman, Allen-Davis, Brozena
Video: Screening for FI in Clinical Setting https://youtu.be/qnwhtnv2nbc Source: Health Affairs Blog, July 13, 2015, Stenmark, Soloman, Allen-Davis, Brozena
Colorado Hunger Screening 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. Source: Health Affairs Blog, July 13, 2015, Stenmark, Soloman, Allen-Davis, Brozena
Colorado Hunger Screening 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. Source: Health Affairs Blog, July 13, 2015, Stenmark, Soloman, Allen-Davis, Brozena
Learning Curve 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 middleincome patients. Source: Health Affairs Blog, July 13, 2015, Stenmark, Soloman, Allen-Davis, Brozena
Evaluating Services: What happened? Evaluation efforts showed that fewer than 5 percent of Kaiser Permanente referrals were calling the hotline. Response Program staff developed a referral form in the electronic medical record: patients could sign to authorize Hunger Free Colorado to contact them. The time frame of inquiry about food insecurity was shortened to 3 months (not 12) helping staff identify patients with more current needs. Source: Health Affairs Blog, July 13, 2015, Stenmark, Soloman, Allen-Davis, Brozena
RESPONSE TO EVALUATION: THE EFFECT This percentage increase represents the proportion of referred patients receiving resources. 5% 78%
Evaluating Services: New Staff In early 2014, the referral process changed again: Newly hired Kaiser Permanente community specialists whose role was to connect patients with resources, not just for food insecurity, but for: housing, dental care, loss of health insurance, and financial assistance. Source: Health Affairs Blog, July 13, 2015, Stenmark, Soloman, Allen-Davis, Brozena
Evaluating Services: Recent Status Since the referral process for food insecurity has been formalized, the number of patients enrolled and referred to services grew substantially. This includes Women, Infants and Children (WIC) and Supplemental Nutrition Assistance Program (SNAP) enrollment and Food Pantry Referrals Source: Health Affairs Blog, July 13, 2015, Stenmark, Soloman, Allen-Davis, Brozena
RESPONSE TO EVALUATION: THE EFFECT +2,478% increase in number of patient referrals to Hunger Free Colorado increased from 2012 to 2014. 60 1,547
Thank you! Q&A and Discussion Shana Alford, Feeding America salford@feedingamerica.org