Food insecurity is defined by the United States Department of Agriculture (USDA) as “limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways.”
Usha Kollipara, Network Program Manager and Lean Six Sigma Black Belt with the Care Transformation and Innovation (CTI) team at Southwestern Health Resources (SWHR), places this definition into context. “Numerous studies have demonstrated a correlation between food insecurity and poor health status,” says Kollipara, “which can contribute to rising healthcare costs. In the past year, SWHR has refined our efforts to identify and reach individuals who are at high risk for poor health outcomes and live in areas where we know it’s difficult to find nutritious and affordable meal options. Building community collaborations and a close working relationship between our multidisciplinary care teams and network providers has been making a difference in screening for social determinants of health (SDoH), including food insecurity.”
The COVID pandemic highlighted disparities in care across the country, prompting both national health efforts and regional hospital systems to rethink the critical role of social determinants and how to incorporate them into improved care models.
“SWHR has always been aware of the major role that diet and nutrition play, not just in the management of chronic diseases but in the prevention of those same diseases,” explains Jaqueline Mutz, SWHR VP of Care Transformation and Innovation. “For that reason, educating patients on the benefits has been incorporated into our care management programs for years. Recently, recognizing we could do more in this area, CTI added eight dietitians to our interdisciplinary care teams. The dietitians bring nutrition science, research findings, behavioral health and social sciences into practice with our patient members to help them optimize health and wellness. Whole person care has been, and will remain, a focus of SWHR.”
With the ACO REACH (Realizing Equity, Access and Community Health) model introduced by the Centers for Medicare and Medicaid Services (CMS) on Jan. 1, 2023, healthcare professionals working in the accountable care space received a clear directive to identify underserved communities and launch initiatives demonstrated to measurably reduce health disparities within their patient populations. In addition to the ACO REACH model, 2024 guidelines for Medicare Star Ratings have been updated to better address social determinants of health, incorporating these measures into assessments of health plan performance.
Screening identifies at-risk patient members
“To support national efforts related to healthcare equity, primary care providers have a unique opportunity to play a critical role in how we identify and address food insecurity in North Texas,” continues Kollipara. “By including screening questions that address social determinants, providers can incorporate food insecurity into their clinical dialogue with patients and identify ways to tackle these issues.”
For primary care providers within the SWHR clinically integrated network, a multistep process is encouraged:
- Screen patient members for potential food insecurity.
- Connect at-risk patients with local support and community resources.
- Assess clinical needs that may be amplified by food insecurity and include in treatment discussions.
- Follow up with patients at the next office visit to verify need was met.
Below are just a few of the initiatives SWHR is taking to reduce food insecurity within the communities it serves:
- Screening and Referrals: Simple and validated food insecurity screening questions are incorporated into the CTI care management workflow. If a patient member screens positive, a Community Health Worker and Registered Dietitian work with the patient member to determine eligibility for local food assistance programs and/or participation in a government-funded nutrition programs like SNAP (Supplemental Nutrition Assistance Program). Additionally, SWHR network providers can refer patients with potential food insecurity to the Care Transformation and Innovation (CTI) department.
- Collaborations with Community Organizations: SWHR collaborates with the Tarrant Area Food Bank and North Texas Food Bank, as well as Meals on Wheels and other food delivery solutions, to raise awareness and access to the services and programs offered by these organizations. In addition, SWHR provides up to four free roundtrip rides for eligible patient members to visit their primary care physician throughout the year, a vital step to gathering SDoH information.
- “Food as Medicine” Initiatives: CTI developed a screening program using predictive models to prospectively identify members who are at high risk for rapid progression of chronic conditions such as diabetes and chronic kidney disease. Members may have food insecurity as one of the contributing factors for worsening their condition. Along with other interventions, CTI dietitians provide customized group and individualized nutrition education programs. These education programs include grocery store tours and cooking classes to help inform patients about budget-friendly lifestyle adjustments that can improve their well-being. In addition, eligible Medicare members at high risk for poor outcomes who screen positive for food insecurity are offered medically tailored meals along with enrollment into sustainable community benefits.
- Community Health Workers: CTI care management teams include community health workers who are subject matter experts on local resources, able to connect patients to non-profit services or assist members with their applications (or reapplications) for the Supplemental Nutrition Assistance Program (SNAP). These team members have a deep understanding of the community resources and can provide culturally appropriate assistance.
- Advocacy and Policy: As previously acknowledged, participation in the Centers for Medicare and Medicaid Services’ ACO REACH model requires addressing multiple social determinants of health, including food insecurity. In addition, new calendar year updates to Medicare Advantage and Part D policies encourage health plans to improve performance for social risk factors and replace the previous reward program with a health equity index (HEI) that addresses factors like food insecurity, transportation and access to quality care in its assessment of care providers.
According to Feeding America, the largest charity working to end hunger in America, the current food insecurity rate is 12.9 percent in North Texas, with Dallas County being the 6th highest in the number of food-insecure persons in the nation.
“SWHR sees many of these individuals in our network hospitals and clinics every day. Food-insecure older adults are more likely to have diet-related chronic medical conditions such as high blood pressure, diabetes or cardiovascular diseases. As healthcare professionals, we can’t ignore this need,” Kollipara concludes.
If you are someone dealing with food insecurity and don’t have a primary care physician (PCP), visit this page to find a doctor and begin your journey to better health.
SWHR Resources:
Consider taking this checklist to the next visit with your provider:
The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document.
