A lack of nutritious food can have a profound effect on health, and hospitals and health systems increasingly are making efforts to intervene on this social risk factor. An estimated one in nine Americans experienced food insecurity in 2018.
During a one-hour webinar, participants joined America’s Essential Hospitals and the Social Interventions Research and Evaluation Network (SIREN) to learn how health systems nationwide are exploring ways to help mitigate food insecurity among their patient populations.
Food Security Interventions
Emilia De Marchis, MD, assistant professor in the Department of Family and Community Medicine at the University of California-San Francisco, works with SIREN to improve screening for and targeting of social risk factors to reduce health disparities. During the webinar, De Marchis explained how she and co-investigators conducted a systematic data review with the guiding question: How do interventions affect food security, patient health and health behaviors, and health care utilization and cost?
The review focused on interventions through to community food resources , vouchers, or direct food provision. Researchers found that interventions through referrals primarily focused on process measures, such as referral rates, enrollment, or use of food resources. Interventions using vouchers primarily focused on health behaviors to measure outcomes. These interventions had a mixed effect on self-reported vegetable and fruit consumption. Finally, interventions that directly provided food also reported primarily on process measures, including increased referrals or use of food resources.
Overall, the team found that vouchers and food provision might have greater effects on patient health than referral programs. Additionally, De Marchis said patients who received medically tailored meals in food provision studies had fewer inpatient visits and more cost savings than those who received nontailored meals.
As food insecurity interventions in health care settings grow, early evidence shows positive effects on health, health care use, and cost — especially for voucher and food provision studies. However, there is a need for more high-quality studies on the topic to increase the evidence base for effective interventions.
Webinar attendees also learned how essential hospital Lee Health, in Ft. Myers, Fla., tackles food insecurity through its Flavor Harvest@HOME initiative, a four-week program to combat malnutrition caused by food insecurity in elderly populations.
Individuals 65 and older comprise 48 percent of Lee Health’s patients, and the potential for malnourishment is significantly higher for this population. Malnutrition not only increases rates of diabetes and hypertension but also is costly to the health system, as these patients are likely to spend more days in the hospital. Flavor Harvest@HOME targets individuals unable to access or cook healthy food due to medical conditions.
Flavor Harvest@HOME is designed to counter the adverse effects of malnutrition through improved identification, clinical care, and post-discharge nutrition support. Lee Health developed a malnutrition screening tool, based on work by the Academy for Nutrition Diabetics, that includes a best practice alert (BPA) in the electronic medical record that flags patients at admission based on critical criteria. The program also educates staff on identifying malnutrition, incorporates assessment protocols, and offers nutrient-dense meal programming with at-home delivery. Demonstrating the return on investment and financial benefit to the hospital through reimbursement was essential to getting providers on board and engaged with the BPAs.
After three weeks in the program, most patients tend to transition to an attitude and approach of self-care. An impact analysis demonstrated that malnourished patients who complete the program are more likely to have lower hospital readmission rates than malnourished patients who did not complete the program. Additionally, patients who complete the program are more likely to have initial and total health care costs less than that of patients who did not complete the program. The program has demonstrated a positive financial return on investment every year.
Additional Questions from Webinar
Due to the high volume of questions during the webinar, we were unable to respond to everyone. Below are answers from De Marchis and Larry Altier, systems director of food and nutrition at Lee Health, to the additional questions.
Food Security Interventions
What funding sources did the programs in the systematic review use?
De Marchis: For the interventions reviewed during this study, funding sources varied. Primarily, interventions were funded by grants and private foundation support. Some programs had hospital or health system support. For information on how safety-net clinics pay for social care programs, including interventions to address food insecurity, I’d recommend reading a separate SIREN report that reviews this in detail.
Is there a national committee SIREN and essential hospitals can create to develop a common language to evaluate food programs?
De Marchis: SIREN is always looking for ways to partner and advance research on health care–based interventions. The U.S. Preventive Services Task Force has developed recommendations on how to increase the evidence behind social care interventions.
What are the most common causes of elder malnutrition?
Altier: As people age, appetite suppression is a natural phenomenon, often leading to malnourishment. Elderly [people] struggle with financial/mobility constraints, limiting their ability to purchase food. When this is coupled with a medical condition, it can facilitate malnutrition significantly.
Can you describe what leads patients to not complete the program (the one- to three-week enrollees)?
Altier: The vast majorities of those patients eligible either pass away or have a medical condition too complex to be supported at home.
What is the average cost per participant in the Flavor Harvest@HOME program? What costs did AARP cover versus Lee Health?
Altier: The AARP aspect of the program funded only our outpatient program. The acute program supported more than 1,600 patients in 2018 and costs $835 per person, per month for meals three times per day, seven days a week, plus oral nutritional supplements.
What happens when the grant runs out? How will the program be sustained financially?
Altier: All clinical aspects of the program are imbedded into the health system; meal support depends on funding. Fiscal services have determined that the program yielded a positive return in excess of $250,000 each year in value for Lee Health when all elements are considered. It has proved cost beneficial to the health system, but it is evaluated annually for utilization due to competing priorities.
How were you able to offer the Flavor Harvest meal delivery while complying with beneficiary inducement rules?
Altier: This program is not a giveaway designed for any purpose other than facilitating recovery. A patient is under no obligation to participate, nor are they pressured to maintain the program. We did not bill the patient, insurance providers, or CMS for any of the meals provided.
How did you assess whether the readmission came first (and resulted in a suspension of food delivery), or if the suspension/omission of food delivery came first (and was followed by a readmission)?
Altier: We only assessed readmission rates in which those who took four full weeks of meals were significantly lower than those who did not. This was true in all three studies we completed.
Have you found the same stats for individuals dually eligible for Medicaid and Medicare?
Altier: We only look at provider status for statistical purposes because medical condition is the driver for qualification in the program. Provider status doesn’t make any difference to us.
Do you have any recommendations on how to embed food insecurity questions in a current workflow of patient screening? Second, do you have any tips on how to encourage providers to refer their patients for federal food programs — such as the Supplemental Nutrition Assistance Program or the Special Supplemental Nutrition Program for Women, Infants, and Children — if they are not doing so already?
Altier: We added three questions to the nursing admission nutrition screen that ask if the patient is able to feed themselves, prepare food, and get food to their place of residence. Physicians need to be educated on malnutrition and the meal programs. Many times they don’t refer because they don’t know about them.
What was the source for the data relating the percentage of malnourished patients to the percent of patients readmitted? Is that a national figure or a local number strictly related to your hospital system?
Altier: Each year we used actual patients who dieticians determined were malnourished and the actual patients that received the meals. These were local numbers related to our specific hospital system.
Do you have any stats on the outcomes for connecting the patients with those community resources after the four weeks?
Altier: We provide the patient a list of resources of other community programs that might be free or have an associated fee. We don’t have any stats on whether they used the programs or not.
While the aging population continues to grow, so does the homeless population among the elderly. Any support for those who are over 60/65 years old and experiencing homelessness?
Altier: In our program, we required the person to have a refrigerator with freezer and microwave. Therefore, if someone were homeless, they would not be eligible. We did not attempt to address this population with Flavor Harvest@HOME.
What critical criteria were flagged in the electronic health record?
Altier: When the dietitian assesses the patient and identifies them as malnourished, they document weight loss, appetite loss, muscle loss, fat loss, fluid accumulation, and grip strength. They also review whether they were moderately or severely malnourished, as well as access to food at home. This information is sent to the physician to ask if they want to add malnutrition to their diagnosis. The program is driven by physicians’ orders and must have clinical designation to be initiated.
Have you been able to identify risk indicators in the population you screen and refer so that you can do more preventive care?
Altier: [We noted that we could target patients who had experienced] heart disease, chronic obstructive pulmonary disease, acute myocardial infarction , and pneumonia, and try to prevent them from being admitted to the hospital.
Are these interventions sustainable in the long term and repeatable in other health systems around the country?
Altier: The clinical elements of the program — identification of malnutrition and early intervention in the hospital — are sustainable for the long term. Standardized documentation by the dietitian allows support for physicians to diagnose malnutrition, which increases severity of illness and reimbursement. The meal provisions are harder to sustain due to cost of the program. If funding is procured or reimbursement for meals is used, then it could be sustained longer. Yes, these interventions, especially the clinical [elements], are repeatable for any institution.
More information on evidence-based social needs interventions in the health care setting is available on the SIREN website.
Further examples of essential hospitals’ efforts to address social needs and social determinants of health can be found on our Essential Communities site.