A few years ago, single mother Seswaness Eaglepipe was experiencing recurring migraines and nausea, severe enough to send her to the emergency room. At the time, she accompanied one of her daughters to a checkup at a Providence Medical Center clinic in Portland, Oregon, and she was asked to fill out a survey about food. As part of the medical group’s new intake process—called “screen and intervene”—Eaglepipe was asked to respond to the following statements:
“Within the past 12 months we worried whether our food would run out before we got money to buy more.”
“Within the past 12 months the food we bought just didn’t last and we didn’t have money to get more.”
After she agreed with both statements, the staff connected Eaglepipe with a “patient navigator” who visited her at home and provided bus fare to the Oregon Food Bank’s food pantry. Soon, Eaglepipe says she was cooking dinner more often, her migraines disappeared, and her daughters were doing much better in school.
Hospitals and health clinics in Boston, Minneapolis, Denver and other cities have adopted this two-question screening tool in recent years thanks to language in the Affordable Care Act (ACA). Oregon, meanwhile, was the first to implement it statewide in 2014. At the 270 clinics now using the screening tool throughout Oregon, patients like Eaglepipe receive direct support in obtaining healthy food, ranging from Supplemental Nutrition Assistance Program (SNAP) enrollment and meal delivery to vegetable prescription programs and cooking classes.
However, as Congress endeavors to dismantle ACA, the funding and incentives for the healthcare screenings along with community-wide social services to address food insecurity are already in jeopardy. “I’m seeing a freeze of funding for innovation,” said Lynn Knox of the Oregon Food Bank. “There’s a paralyzing effect from the uncertainty.”
Knox coordinates Oregon’s “screen and intervene” program in 70 percent of the counties in the state. She says the food security information, “drives the diagnosis and treatment for some patients the day of the visit.”
Knox adds that the health and nutrition impacts have demonstrated early but convincing gains for healthcare providers, patients and communities. Meanwhile, health care providers from Texas, Wisconsin, Michigan, Massachusetts, Vermont, Oklahoma and other states have also been inundating Knox’s office asking for guidance on how to reproduce the Oregon program.
An Integrated Model of Healthcare
The U S. Department of Agriculture (USDA) defines food security as “access by all people at all times to enough food for an active, healthy life.”
Food insecurity, on the other hand, is not simply a governmental definition of hunger. Instead it is a prolonged lack of access to affordable and nutritious food and its impacts on households. For many Americans, a diet of low-quality and processed foods creates chronic malnourishment along with anxiety, stress, and alienation. Oregon has the highest growth rate of food insecurity in the country, which spiked to 16 percent in 2015. One in six Oregonians worry about having enough food to eat or skip meals compared to one in seven households nationally.
The Yakima Valley Farm Workers Clinic is one of the largest federally qualified health clinics in the country. With 22 health centers in both Oregon and Washington, it serves an ethnically diverse and low-income population. “One of the great things that has resulted out of the ACA is that we’re starting to look at healthcare differently,” said Michele Guerrero, a registered dietician who coordinates the food insecurity screening program there.
When the clinic’s 16 dietitians started using the screening tool for every patient intake, they found rampant food insecurity among patients ranging from 35 to 40 percent. “It’s a silent thing,” said Guerrero. “There’s a lot of shame and fear in admitting that people have trouble accessing food.”
The Yakima data exemplified a longstanding concept called the social determinants of health. Identified by the World Health Organization, this is the set of factors, including home, income, and education that determine overall health. And the greatest social determinant of health is economic status. In communities like Yakima, the poor housing conditions, low employment, high drop-out rates, and limited access to affordable fresh food run parallel to high rates of diabetes and other diet-related illnesses.
In addition to vastly increasing the number of low-income people on insurance, the ACA tied funding to metrics based on a value-based care model in place of the old fee-for-service system, especially in states like Oregon, which opted into expanded Medicaid coverage. “All of sudden, we’re switching to a ‘what are you accomplishing?’ funding system,” said Knox, “and that is a game changer.”
For patients with uncontrolled diabetes who are also food insecure, an emphasis on health outcomes—not treatment plans—allowed the staff at the Yakima Valley Farm Workers Clinic to bring in community health workers to examine individual patient’s lifestyles. The changes “allowed us to take a step back and to treat chronic illness in a different way,” says Guerrero.
The Costs of Food Insecurity
In a healthcare system with skyrocketing spending, now nearing 18 percent of U.S. gross domestic product, many see the ongoing health costs of food insecurity as unsustainable. According to a 2015 position paper by Promedica, a Michigan-based healthcare network, diet-related illnesses, including depression, anxiety, migraines, and general poor health cost the U.S. $130.5 billion a year—up from $32.1 billion in 2007.
“With more than 17.5 million U.S. households facing hunger—or one in every seven households nationwide—healthcare systems and leaders must recognize that lacking nutritious food to eat is a dire public health concern,” the paper stated.
With these numbers in mind, one of the best arguments for continuing to screen for food insecurity in medical settings may be an economic one. At Providence Medical Center in Portland, “screen and intervene” proved to be an easy-to-use and cost-effective tool for addressing food insecurity at two trial clinics. In pre- and post-care surveys given to over 2,000 families, over 14 percent showed signs of food insecurity. As a result, the doctors’ and medical staff at Providence had changed their perceptions about food insecurity. They came to see food insecurity is a medical issue worth treating and tracking.
Additionally, practitioners felt more confident while having conversations about food insecurity with patients and sharing knowledge of resources to improve their health and wellbeing. Charlotte Navarre, a registered nurse who administers “screen and intervene” at Providence, said, “There is a recognition that there is more to an individual’s health than just their disease state. The time is right for health systems to take a look at this all over the country.”
The early results of such a comprehensive approach to primary care convinced Providence’s foundation to invest in a new teaching kitchen and community resource desks designed to help patients access nutrition services. Overall, the experience of many communities in Oregon demonstrates how screening for food insecurity can be fast, affordable, and relatively easy to integrate into other elements of critical preventative care.
As Congress struggles with exactly how to replace ACA, the providers engaged in this new values-based approach to healthcare have more questions than answers. But many hope it will continue, regardless of the politics at hand. When asked how changes to ACA could impact Oregon’s food insecurity program, Knox replied by email. “I could guess until I am blue in the face,” she wrote. “I do believe that whatever happens, there is a new awareness of the role of social determinants in health outcomes, and a desire to address them where possible.”
Other health care providers agreed that the tide has turned at the operational level, at least. “Because food insecurity is something we’re now so aware of, we will continue to screen and intervene,” said Guerrero.” It’s hard to backtrack on those things once you know that someone is suffering.”
Photo copyright 2016 Josh Kohanek. Courtesy of the Robert Wood Johnson Foundation.