Screening for Food Insecurity in Pediatric Primary Care: A Clinic s Positive Implementation Experiences Elizabeth Adams, Dana Hargunani, Laurel Hoffmann, Gregory Blaschke, Joanna Helm, Anneliese Koehler Journal of Health Care for the Poor and Underserved, Volume 28, Number 1, February 2017, pp. 24-29 (Article) Published by Johns Hopkins University Press DOI: https://doi.org/10.1353/hpu.2017.0004 For additional information about this article https://muse.jhu.edu/article/648742 No institutional affiliation (3 Oct 2018 03:19 GMT)
REPORT FFROM THE FIELD Screening for Food Insecurity in Pediatric Primary Care: A Clinic s Positive Implementation Experiences Elizabeth Adams, PhD, RD Dana Hargunani, MD, MPH Laurel Hoffmann, MD, MPH Gregory Blaschke, MD, MPH Joanna Helm, MS, RD Anneliese Koehler, BA Summary: Our project s purpose was to assess the acceptability of a screening and intervention program to address food insecurity (FI) in pediatric primary care. We implemented systematic FI screening during routine health supervision visits. Our positive results can help to inform implementation of routine FI screening in clinical practice. Key words: Food insecurity, patient- centered care, pediatrics, prevention. Food insecurity (FI), the limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways, 1 is a preventable problem in children s health. In 2014, 14% of all U.S. households were food- insecure and households with children experienced FI at a level nearly twice that of households without children (19.2% vs. 11.7%). 2 Food insecurity is one of many social determinants of health that influence well- being across the life course. A child s growth, cognitive development, academic performance, and physical and psychological health are negatively affected by FI. 3 6 Food insecurity not only adversely affects health through nutrition, but it adds to the stressors of family life, parenting, and parent- child interactions. 3 Health care providers are well- positioned to address childhood hunger in routine health supervision visits. It is a common problem for families and there are effective, accessible interventions available. Federal food programs including the Special Supplemental Nutrition Program for Women, Infants and Children, the Supplemental Nutrition Assistance Program (formerly known as the Food Stamp Program), and the DR. ELIZABETH ADAMS, DR. LAUREL HOFFMANN and DR. GREGORY BLASCHKE are affiliated with the Department of Pediatrics, Oregon Health & Science University, Portland, OR. DR. DANA HARGUNANI is affiliated with Children s Community Clinic, 27 N. Killingsworth Street, Portland, OR. MS. JOANNA HELM is affiliated with the Inherited Metabolic Diseases Clinic, Children s Hospital Colorado, Aurora, CO. MS. ANNELIESE KOEHLER is affiliated with the Oregon Food Bank, Beaverton, OR. Please address correspondence to Dr. Laurel Hoffmann, Department of Pediatrics, Oregon Health & Science University, 3181 SW Sam Jackson Parkway, Mail Code CDRC- P, Portland, OR, 97239; phone: 503 418 5170; fax: 503 346 0645; email: murphy@ohsu.edu. Meharry Medical College Journal of Health Care for the Poor and Underserved 28 (2017): 24 29.
Adams, Hargunani, Hoffmann, Blaschke, Helm, and Koehler 25 National School Lunch Program are effective in mitigating FI in children. 7,8 Despite participation in one or more federal food and nutrition program by 84% of low- income, food- insecure households with children nationally, some families continue to experience FI. 2 Screening for FI at pediatric visits and linking families to community resources was recently recommended by the American Academy of Pediatrics (AAP). 9 The AAP recommends a two- question, validated screening tool to identify food- insecure families. 10 The purpose of this project was to assess the attitudes of providers during the implementation of the two- question screening tool and the feasibility of providing referrals and interventions. These findings will provide a model for other practices as they embrace the AAP recommendations to address FI. Pilot Study Participants and Setting We implemented systematic screening and intervention to identify and address FI in an academic general pediatric practice. The practice, located in an academic medical center within a large metropolitan region, serves over 5,000 patients and provides more than 13,000 clinic visits annually. Over 50% of the patient population has Medicaid insurance. As an academic practice, our resident providers are continually adapting their practice styles. There are over 50 resident providers rotating in our general pediatric clinic each year. Most of them have weekly afternoon continuity clinic sessions at this site as well. Provider Training Faculty and resident providers received education about the prevalence of, health impact from, and screening methods for FI. The screening questions (see Box 1) were available for reference and providers were informed of the screening process during routine health supervision visits. Providers were advised how to document FI in the electronic health record (EHR). All providers completed the Childhood Hunger Coalition s online course on childhood FI. 11 The Childhood Hunger Coalition is a multidisciplinary group composed of key health care, educational, and non- profit agencies that aims to address FI prevention and mitigation. Implementation of Screening and Intervention During health supervision visits, families completed paper forms asking the two questions validated to screen for household FI. 10 These screening questions were presented along with other routinely administered health and development screening questions. All screening questions were presented in English and Spanish. Families answered the questions prior to seeing the child s provider. Providers then reviewed the answers before meeting with the families. When families answered affirmatively to the food security screening questions (Often true or Sometimes true) they were classified as Food Insecure. Providers were encouraged to follow the Childhood Hunger Coalition s screening and intervention algorithm to address FI, providing further testing or referrals at their clinical discretion. 12 For families identified by screening, we recommended providers discuss food security status
26 Food insecurity screening in a pediatric clinic Box 1. FOOD INSECURITY SCREENING QUESTIONS For each statement, please tell me whether the statement was Often true, Sometimes true, or Never true for your household: A. Within the past 12 months we worried whether our food would run out before we got money to buy more. B. Within the past 12 months the food we bought just didn t last and we didn t have money to get more. to assess the severity of the situation. Providers were also advised to explore options for intervention with families and to include the comprehensive list of community food resources, accessible via the EHR, in the patient instructions for home. These resources provided information about how to access federal food assistance programs. Resource lists also informed families of community assets, including emergency food boxes, free lunches at community sites in the summer months, gardening classes, and a community resource referral phone number. The resource lists provided tips on using food assistance program benefits and saving money at local farmers markets. When providers were concerned about the family s urgent inability to access adequate food resources, the providers were advised to contact the clinic s social worker for help accessing emergency food boxes or other resources. Clinicians were encouraged to enter an International Classification of Disease (ICD) code as documentation of FI in the patient s problem list within the EHR, to aid providers in following up on the issue. Feedback from Providers on the Implementation of Screening Resident providers were asked about their experiences with the screen and intervene model in a focus group. A facilitator asked for feedback on experiences with the screening process and adequacy of resources for families. Providers indicated that they appreciated learning about and intervening in an issue facing many families, but not often covered in medical education. One provider stated: I thought it was really high yield because it was something I hadn t particularly asked about before, and it was nice to have an exact script to use, and then it really got into something that I felt like I could help the family with. Several providers indicated that the screen and intervene model fit nicely into clinical flow and allowed them to spend more time talking to families instead of searching for community resources. Providers also appreciated the integration of the two- question tool into the often- full agendas of routine health supervision visits. A different provider noted: I m very glad it s on a screening form, and then it
Adams, Hargunani, Hoffmann, Blaschke, Helm, and Koehler 27 doesn t have to get addressed unless they answer that it s sometimes true or always true, and then if they are answering that way they probably... would like to talk about it [to] get help. One provider reflected on her discomfort in asking the screening questions aloud, as opposed to using our paper forms. She worried that families would feel stigmatized if they felt she was only asking certain families these questions. With the forms, she felt that families understood the questions were administered universally. As an academic practice, we often implement new screening methods, such as for perinatal mood disorders and adolescent drug and alcohol use. As our providers are comfortable integrating new elements into the practice on a regular basis, they may have adapted to this new model more easily than other providers would. We identified two main areas for improvements. None of the providers reported using ICD codes to document FI status of patients. They documented FI status in clinical notes, but not on the patient s problem list. Food insecurity is not available as an ICD code and providers noted they could not remember the code we provided during training, Lack of Adequate Food. A next step in primary care is to develop a standardized documentation system for FI and other social determinants of health within the EHR. For our practice, the problem list was not an ideal place for FI documentation due to inconsistent use among providers. There was also hesitation to add Lack of Adequate Food to patients problem lists, as families take home their problem list (as it is included in the patient instructions document). Providers were understandably concerned that this documentation would make families feel uncomfortable. Another area for improvement was the resource lists. Providers noted the lists were very comprehensive, but too long for some families (the lists average four pages, but differ by county). They requested a one- page resource list, which we were able to create and update in the EHR. This resource list contained one line about each federal nutrition program, highlighted resources at the food bank, and emphasized that families could learn more about available programs by calling a community resource phone number. Food insecurity in the pediatric population has implications for nutritional outcomes in childhood and across the life course. Food insecurity during this critical window of growth and development is associated with adverse health events such as hospitalization and overall poor health status. 13 Access to nutritious food is crucial while children experience rapid brain growth and development and establish healthy eating habits during these formative years. Implementation of the model is straightforward and provider training is accessible, as many providers are already familiar with the EHR and collaborating with other providers such as social workers or registered dietitians. The longitudinal nature of routine health supervision visits and wide range of topics addressed during those visits makes pediatric primary care an ideal setting for implementing this model. One provider described a family s situation: The mom is now staying at home and taking care of the child. And they had always checked off never true, but I asked it every single visit, and at the nine- month visit she [said] it s not really true, but we re, sort of, getting to a point where I m worried it s going to become true. That provider noted that her longterm relationship with the family aided their comfort in addressing this occasionally uncomfortable issue. For another clinician, the screening questions opened the door to address other social determinants of child health: I had a patient the other day that
28 Food insecurity screening in a pediatric clinic screened positive on her questions and I got [the social worker] involved, and he found out that they were going to turn off her water. The screening questions were a way of starting dialogues with families to discuss social determinants of health with their providers and collaborate to solve problems as patient- centered teams. In this project we implemented and evaluated a screen and intervene model for FI and found it was readily accepted in the pediatric primary care setting. Expansion of this model to additional clinical settings including subspecialty, prenatal, and family practice clinics is currently underway. This screen and intervene model could also be used to identify needs related to other social determinants of child health, such as housing, utilities, education, domestic violence, transportation, and legal issues. As one provider explained, pediatric primary care offices have a unique place in society: I think it s a place that families come through regularly and I can t think of too many other places where that question can be asked in a systematic fashion where people will then have some resources to offer. By using primary care to address the social determinants of health, the needs of families drive the discussion, so we deliver true patient- centered care, regardless of demographic and socioeconomic background. Acknowledgments This project was funded in part by ConAgra Foods Foundation through a grant to Oregon Food Bank. ConAgra Foods Foundation had no role in study design, collection, analysis or interpretation of data, in the writing of the report, or in the decision to submit the article for publication. Funding for this work was provided as a subcontract between Oregon Food Bank and OHSU. Research reported in this publication was supported by National Center for Advancing Translational Sciences of the National Institutes of Health under award number UL1TR000128. Dr. Adams was Principal Investigator for project subcontract. The authors have no conflicts of interest to report. References 1. Anderson S. Core indicators of nutritional state for difficult- to- sample populations. J Nutr. 1990 Nov;120 Suppl 11:1559 600. 2. Coleman- Jensen A, Matthew P. Rabbitt, Gregory C, Singh A. Household food security in the United States in 2014. Washington, DC: United States Department of Agriculture (USDA), 2015. Available at: http://www.ers.usda.gov/media/1896841/err194.pdf. 3. Cook JT, Frank DA. Food security, poverty, and human development in the United States. Ann N Y Acad Sci. 2008;1136(1):193 209. Epub 2007 Oct 22. http://dx.doi.org/10.1196/annals.1425.001 PMid:17954670 4. Weinreb L, Wehler C, Perloff J, et al. Hunger: its impact on children s health and mental health. Pediatrics. 2002 Oct;110(4):e41. http://dx.doi.org/10.1542/peds.110.4.e41 PMid:12359814 5. Kleinman RE, Murphy JM, Little M, et al. Hunger in children in the United States: potential behavioral and emotional correlates. Pediatrics. 1998 Jan;101(1):E3. http://dx.doi.org/10.1542/peds.101.1.e3 PMid:9417167
Adams, Hargunani, Hoffmann, Blaschke, Helm, and Koehler 29 6. Larson NI, Story MT. Food insecurity and weight status among U.S. children and families: a review of the literature. Am J Prev Med. 2011 Feb;40(2):166 73. http://dx.doi.org/10.1016/j.amepre.2010.10.028 PMid:21238865 7. Frongillo EA, Jyoti DF, Jones SJ. Food stamp program participation is associated with better academic learning among school children. J Nutr. 2006 Apr;136(4):1077 80. PMid:16549482 8. Perry A, Ettinger de Cuba S, Cook J, et al. Food stamps as medicine: a new perspective on children s health. Boston, MA: Children s Sentinel Nutrition Assessment Program (C- SNAP), 2007. Available at: http://www.childrenshealthwatch.org/wp- content /uploads/food_stamps_as_medicine_2007.pdf. 9. Council on Community Pediatrics, Committee on Nutrition. promoting food security for all children. Pediatrics. 2015 Nov 1;136(5):e1431 8. http://dx.doi.org/10.1542/peds.2015-3301 PMid:26498462 10. 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. 2010 Jul;126(1):e26 32. http://dx.doi.org/10.1542/peds.2009-3146 PMid:20595453 11. Oregon State University. Childhood food insecurity. Corvallis, OR: Oregon State University, 2016. Available at: https://pace.oregonstate.edu/catalog/childhood-food-insecurity. 12. Childhood Hunger Coalition. Childhood Hunger Screening & Intervention Algorithm. Portland, OR: Oregon Food Bank, 2011. Available at: http://www.oregonfoodbank.org/chc/digests/algorith2011d[1].pdf. 13. Cook JT, Frank DA, Berkowitz C, et al. Food insecurity is associated with adverse health outcomes among human infants and toddlers. J Nutr. 2004 Jun;134(6):1432 8. PMid:15173408