Food is Medicine: Promoting Food Security in Health Care and Community Settings

Transcription

1 Food is Medicine: Promoting Food Security in Health Care and Community Settings Richard Sheward, MPP Senior Policy Analyst State Policy Children s

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3 431 B.C.

4 Roadmap Background: Why children? Need: Why screen for food security? Creation of the Hunger Vital Sign : Testing and results Connecting the dots: Examples from the field Policy challenges Policy solutions

5 Founded: 1998 Non-partisan, pediatric research and policy network Collect data in urban hospitals across the country on infants and toddlers from families facing economic hardship Improve health & development of young children alleviate economic hardships inform public policies Difficulty affording enough food (food insecurity) Unstable housing (housing insecurity) Trouble keeping heat/lights on (energy insecurity) Provide policy makers with evidence from the frontlines to develop policies that protect young children s health and development

6 Where our data come from: Collecting real-time data in frontline healthcare settings: Boston, Baltimore, Philadelphia, Little Rock and Minneapolis Interviews - caregivers with children 0 to 4yrs More than 60,000 surveys in our data set - invisible group - critical window of time

7 Why infants and toddlers? Human Brain Development Most Vulnerable Period: Birth Age 4yrs Synapse formation, neural networks brain architecture

8 Brain architecture physical structure, interconnections, & neural networks Blooming and Pruning First 3 years, child s brain will have twice as many synapses as it will in adulthood Years 0-3 largely set trajectory: cognitive/socio-emotional development school readiness academic achievement educational attainment

9 Why child health and development matters

10 Definitions Food security noun I food se cu ri ty USDA calls hunger "...a potential consequence of food insecurity that, because of prolonged, involuntary lack of food, results in discomfort, illness, weakness, or pain that goes beyond the usual uneasy sensation." Food Security High food security: No reported indications of food-access problems or limitations. Marginal food security: One or two reported indications typically of anxiety over food sufficiency or shortage of food in the house. Little or no indication of changes in diets or food intake. Food Insecurity: limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire food in socially acceptable ways 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 patterns and reduced food intake.

11 Prevalence In % of households with children (3 million families) were food insecure 0.7% of households with children had VERY low food security (that s 274,000 families!) At some point during the year, about 1 in 4 Americans participates in 1 or more of 15 domestic food and nutrition assistance programs that provide children and needy families better access to food and a more healthful diet.

12 Impact of food insecurity on children s health Children younger than 3 years who live in food-insecure households have: 90% greater adjusted odds of being in fair/poor health (versus good/ excellent) 31% greater adjusted odds of being hospitalized since birth 76% greater adjusted odds of being at increased developmental risk compared with food-secure families Developmental and cognitive delay in toddlers Adverse behavioral and and mental health outcomes in preschoolers Increased risk of asthma and ADHD in school-aged children Increased likelihood of missing school and activities Lower reading and math scores Increased depression and suicidal ideation in adolescents Trade-offs between paying for food and paying for other basic needs, like healthcare costs, housing, heating, and electricity

13 Economic impact

14 Seed of the idea Large body of research on associations with poor health and development outcomes 2 interrelated streams of interest: Group of marginally food secure households being officially counted as food secure Question undercounting the problem? Also cumbersome (though accurate) nature of USDA Food Security Module 18 questions - time-consuming, not practical for clinical/outreach settings

15 Other shortened screeners 6-item module Developed by National Center for Health Statistics Intended to address need for shorter, more practical screen still too long for many settings 1-item hunger screen Published by Kleinman, et al, 2007 Exclusive focus on hunger misses FI families experiencing stress -> uncertain access to enough food but not the physiologic sensation of hunger

16 Need: brief, sensitive, specific, valid Efficient method - identifying young children in FI households to ensure access to nutrition services Healthy food Alleviate caregiver stress

17 Testing 1,2,3 Most common affirmatively answered questions with best sensitivity/specificity 1 st 2 questions Compared to gold standard (HFSM) Sensitivity 97% 97% of families identified as FI (HVS) were also FI (HFSM) Specificity 83% 83% of families identified as FS (HVS) were also FS (HFSM)

18 Development and Validity of a 2-Item Screen to Identify Families at Risk for Food Insecurity Hager ER, Quigg AM, Black MM, Coleman SM, Heeren T, Rose-Jacobs R, Cook JT, Ettinger de Cuba S, Casey PH, Chilton M, Cutts DB, Meyers AF, Frank DA. Development and Validity of a 2-Item Screen to Identify Families at Risk for Food Insecurity. Pediatrics; 2010;126:e26 e32. Complementary article: Are Food Insecurity s Health Impacts Underestimated in the U.S. Population? Marginal Food Security Also Predicts Adverse Health Outcomes in Young U.S. Children and Mothers. Cook, JT, Black, M, Chilton, M et al. Advances in Nutrition. Advances in Nutrition. 2013;4:

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20 Outcomes (external validity) Young children 56% more likely to be in fair/poor health 17% more likely to have been hospitalized 60% more likely to be at risk for developmental delays Mothers Almost 2x as likely to be in fair/poor health Almost 3x as likely to report depressive symptoms Compared to peers in food-secure households

21 Moving from islands of success to putting the puzzle together The Need A national repository of resources and information on screening for food insecurity The Solution Creating a brand for the 2- item screener The Hunger Vital Sign

22 How and where the Hunger Vital Sign is used

23 Examples from the field Hunger Vital Sign implemented in: Hospitals Community Health Centers Public Health Agencies Head Start, WIC Health Insurance Providers Food Banks Anti-Hunger Agencies Research Institutions For more detail, visit:

24 Examples from the field Oregon Food Bank Lynn Knox, Clinical Outreach & Training Coordinator Hennepin County Medical Center and Second Harvest Heartland Dr. Diana Cutts, Kurt Hager Kaiser Permanente and Hunger Free Colorado Dr. Sandra Stenmark, Hunger Free CO Family Health Center of Worcester Dr. Melanie Gnazzo, UMass Medical School

25 Leading education and institutionalization The Childhood Hunger Coalition: Free course on implementing Screen and Intervene targeting to medical settings More than 200 clinics & hospitals screening, plus Head Start & WIC Urban & Rural Success Screening as Medicaid Performance Indicator Screening & intervention was easy to add to our clinic protocols, it gives the physician valuable information for diagnosis & treatment and the Food Bank Staff (Lynn Knox), had valuable implementation suggestions Clinic Administrator

26 E-referral & partnership

27 E-referral & partnership Linking food insecure patients at Hennepin County Medical Center with food resources from Second Harvest Heartland

28 E-referral & partnership Connection: Simple outreach referral Patient confidentiality Business agreements Information exchange Measurement and Feedback

29 E-referral & partnership Credit: Hilary Seligman, MD Senior Medical Advisor and Lead Scientist, Feeding America

30 Kaiser Permanente and Hunger Free Colorado Collaboration External referrals are more successful when the burden is not on the family to reach out to the service

31 Community-based partnerships The Farm to Health Center Initiative Partnership between UMass Medical School Family Health Center of Worcester (FQHC) Community Harvest Project farm in Grafton, MA Patients are screened and offered free, fresh produce each week during growing season Patients are connected to other community resources

32 Interventions Best Good Local resource handout Better Patientinitiated external referral Internal services or partnerinitiated external referral

33 HUNGER Vital Sign National Community of Practice Facilitate conversations and collective action among a wide-range of stakeholders interested in addressing food insecurity through a health care lens Identify research on the connections between food insecurity and health Promote the use of the Hunger Vital Sign to screen for food insecurity Champion effective interventions to address food insecurity both at the practice and policy level The group includes physicians, public health researchers, anti-hunger agencies, health care professionals, and policy experts

34 HUNGER Vital Sign National Community of Practice

35 Documenting food Insecurity in the Electronic Medical Record Health care codes and electronic medical records (EMRs) have not yet fully able to report and capture on food insecurity. The ability to address food insecurity in EMRs is critical to: Creating sustainable models and protocols for screening and intervening to address food insecurity; Providing better health services to patients by capturing patient concerns so these can be monitored over time; Allowing for the documentation of the number of patients facing food insecurity, interventions, and health outcomes; and Fostering further research and quality improvements about food insecurity in clinical practice.

36 How Food Insecurity is currently documented in the EMR 1. ICD codes or International Statistical Classification of Disease and Related Health Problems (ICD). are often used at the point of Diagnoses in the EMRs 2. SNOMED-CT codes are often used to populate the section of the EMR called Problem Lists 3. Problem List in a patient s chart is where chronic concerns are documented and reviewed by multiple providers over the continuum of care

37 How Food Insecurity is currently documented in the EMR Current ICD10 codes are available related to food insecurity and other social determinants of health. These are largely contained within the root Z59 Z59.4- Lack of adequate food and safe drinking water is the commonly used ICD10 for food insecurity, but is broad. There is a lesser known set of codes called, SNOMED-CT CT (Systemized Nomenclature of Medicine-Clinical Terms) codes. In the United States, because of the pervasive utility of the ICD10, these SNOMED-CT codes are used primarily in a section of a patient s medical record called The Problem List. An ICD10 Diagnosis is the result of an office visit, whereas, the SNOMED- CT codes form the Problem List. Thus a Problem List can read: Insufficient Food Supply ; Food Insecurity Hungry ; Food Insecurity Inadequate Housing; Housing Instability

38 Policy Solutions The American Academy of Pediatrics recommends that pediatricians engage in efforts to mitigate food insecurity at the practice level and beyond A 2-question validated screening tool (Table 2) is recommended for pediatricians screening for food insecurity at scheduled health maintenance visits or sooner, if indicated

39 Accountable Health Communities Model Policy Solutions

40 Oregon Performance Metric Policy Solutions The Health Authority has accepted a performance improvement metric for food insecurity screening The Hunger Vital Sign will be recommended but other versions of screeners will be listed as options The questions must be asked of all Medicaid patients at least once a year but is recommended to be asked every visit

41 Oregon Performance Metric Policy Solutions The Health Authority has accepted a performance improvement metric for food insecurity screening Patients screened positive will be provided written information about local food and nutrition resources available to them and someone will review this information with them Health Care organizations will be encouraged to consider partnering with others in their community to develop new access for patients to healthy food

42 Massachusetts ACO Development Policy Solutions MassHealth plans to advance alternative payment methodologies and delivery system reform through accountable care organizations (ACOs) and community partners for behavioral health and long term services and supports ACOs will be expected to work with social service providers to address members health-related social needs. ACOs will receive funding designated for flexible services to address social determinants through the DSRIP program. Categories of flexible services include: Housing stabilization and support, search and placement Utility assistance Non-medical transportation Physical activity and nutrition Sexual assault and domestic violence supports

43 And the moral of the story is Children thrive when we respond to their realities

44 Thank You! The mission of Children s HealthWatch is to improve the health and development of young children by informing policies that address and alleviate economic hardships. Contact us: richard.sheward@bmc.org

45 References Alisha Coleman-Jensen, Matthew P. Rabbitt, Christian A. Gregory, and Anita Singh. Household Food Security in the United States in 2015, ERR-215, U.S. Department of Agriculture, Economic Research Service, September 2016.Shankar P, Chung R, Frank D. Association of Food Insecurity with Children s Behavioral, Emotional, and Academic Outcomes: A Systematic Review. J Dev Behav Pediatr Feb/Mar; 38(2): Oliveira, Victor. The Food Assistance Landscape: FY 2016 Annual Report, EIB-169. U.S. Department of Agriculture, Economic Research Service, March "Linking The Clinical Experience To Community Resources To Address Hunger In Colorado". Health Affairs. N.p., Web. 12 Apr Cook JT, Frank DA, Berkowitz C, et al. Food insecurity is associated with adverse health outcomes among human infants and toddlers. J Nutr. 2004;134: Feedback to House Agriculture Committee- Past,Present, and Future of SNAP Hearing Series. Hunger-Free Communities. N.p., Web. 11 Apr Hager ER, Quigg AM, Black MM, et al. Development and Validity of a 2-Item Screen to Identify Families at Risk for Food Insecurity. Pediatrics July; 126(1). Cultivating Healthy Communities: Lessons from the Field on Addressing Food Insecurity in Health Care Settings. Children s Healthwatch. N.p., Web. 11 Apr Annual Hunger Report: Appendix 2. Bread for the World Institute. N.p., Web. 11 Apr Hanson KL, Connor LM. Food insecurity and dietary quality in US adults and children: a systematic review. The American Journal of Clinical Nutrition May; 100 (2). Mangini LD, Hayward MD, Dong YQ, Forman MR. Household Food Insecurity Is Associated with Childhood Asthma. The Journal of Nutrition December; 145 (12).