About one in six children in the U.S. live in a food insecure household, meaning they don't have reliable or consistent access to enough food through socially acceptable means, or there is not enough nutritious food available for all members of the household. There are poor health outcomes associated with food insecurity, such as higher rates of asthma and anemia and even developmental delays.
One way for health care systems to address food insecurity is through a screening when patients come to clinic. This identifies patients and families who may be food insecure and can link them to resources.
Nationwide Children's Hospital in Columbus, Ohio, is a long-time partner of a large nonprofit organization in central Ohio dedicated to ending hunger. Through this partnership, the hospital's senior leaders became aware of the food-related needs in patients' communities. They commissioned a team of hospital researchers and clinicians to implement a food insecurity screening in 2017 for Nationwide Children's Primary Care Network (PCN) patients, who mostly rely on Medicaid.
Screening objectives
Before 2017, Nationwide Children's did not have a standard way of screening for food insecurity. The organization had anecdotal knowledge patients may be struggling to access food; however, the network was not collecting data to show this. Clinics were doing their own interventions to address food insecurity, such as tending a community garden, passing out information about resources, or consulting social workers. A screening was the opportunity to address this systematically.
The hospital decided to test the feasibility of implementing a food insecurity screening across multiple clinics. Interns approached families at 12 outpatient clinics during designated time blocks and asked them to complete the screening. Ten primary care clinics, one specialty clinic and main campus urgent care participated. The goal was to approach all families for screening, although they could decline.
Families completed the screening on paper, which consisted of two food insecurity questions from the USDA, questions about barriers to accessing food and demographics. Regardless of food insecurity status, screeners gave families resources about food-related assistance in the community. The team kept track of process measures, such as the percent of patients approached, to measure feasibility.
Overall, 80 percent of families who attended clinics during the designated blocks were approached. The team found 54 percent of PCN patients identified as food insecure. Lack of information about food assistance and transportation issues were the most often reported barriers.
Engaging families and expanding
Nationwide Children's trained interns on human subjects research, social determinants of health, cultural competency and implicit bias. They approached families in the lobby, although some clinics preferred they visit families in patient rooms. Interns approached everyone entering the clinic and provided resource sheets to ensure families did not feel singled out or overlooked.
While Nationwide Children's approached more than 1,400 families and obtained data on 734 families, challenges remained—one was the language barrier. The team translated the screening into Arabic, Nepali, Somali and Spanish; but not all non-English speaking families spoke or read these languages, and interpretation services were not always available.
To continue to improve the screening, Nationwide Children's added questions about housing instability, transportation and utility needs. This yearly screening is integrated in the electronic medical record and is expanding to other clinics.
