Roughly 40 million Americans live in households with food insecurity. According to 2017 data from the Department of Agriculture Economic Research Division (USDA-ERD), food insecurity is present in 11.8 percent (15 million) of US households and in 15.7 percent of US households with children. The USDA defines a food-insecure household as one in which “access to adequate food is limited by a lack of money or other resources.” Adults and children who experience food insecurity may be at an increased risk for a variety of negative health outcomes and health disparities, including obesity, diabetes, and hypertension.
The Gap Between Food Systems And Health Care Providers
Food insecurity may represent one of the more tractable non-medical social determinants of health, as there are many innovative governmental assistance (such as the Supplemental Nutrition Assistance Program, the Commodity Supplemental Food Program, or Women, Infants, and Children) and community-oriented approaches (such as foodbanks, food pantries, and food vouchers) that have been developed to assist individuals and families experiencing food insecurity.
The community-oriented approaches, in particular, represent opportunities for cross-sector collaboration between the health care system and non-governmental agencies that provide food resources. In the US, there are more than 200 foodbanks that rescue large quantities of healthy food, including fresh produce and other fresh foods, and distribute it through a network of emergency feeding sites. Foodbanks function at a regional level and provide infrastructure and technical support to partner emergency feeding sites in their service area, including food pantries. Food pantries function at the neighborhood level and are typically housed in places of worship, community centers, and other nonprofit social agencies. Finally, food vouchers are another common approach to addressing food insecurity needs. In voucher programs, individuals receive vouchers for participating farmers markets and grocery stores to purchase and receive discounts on food purchases.
These governmental and community-oriented approaches to addressing food insecurity are helpful, yet they lack strong linkages to the health care providers involved in the care of the individuals being served. These existing programs present opportunities for formal partnerships between health care providers and community-based organizations to more closely link vulnerable patients with available food resources. Linking health care providers with community-based organizations may help support patients by drawing a bridge from their health to their food resources. Moreover, this approach has potential for scalability, as it leverages both the expertise in food distribution of local partners and professional health care services. An emerging body of evidence suggests that these linkages can reduce food insecurity and potentially improve health outcomes.
There is limited reporting regarding the challenges of creating these linkages. These barriers span regulatory, legal, technological, and financial frameworks and are national in scope. Thus, we think that our story in its successes and challenges could benefit other health systems seeking to form partnerships to address food insecurity. Below, we describe our experience of establishing this link between an academic medical center and a regional foodbank to address food insecurity in a health care setting, with the goal of providing guidance for future efforts to establish these linkages to empower health care providers to address social determinants of health.
Mid-Ohio Foodbank (MOF) is the seventh largest foodbank in the country with more than 650 partner agencies, including food pantries, across 20 central and eastern Ohio counties. In 2015, the MOF launched what is now known as the Mid-Ohio Farmacy with a local federally qualified health center (FQHC) in Franklin County, Ohio. The Mid-Ohio Farmacy is an attempt to answer that missing linkage between governmental and community food resources and health care provider teams. This program uses a variation on the food voucher model: Primary care practitioners give referrals to one of the 14 MOF partner food pantries in Franklin County to patients who screen positive for food insecurity. The goal of the Mid-Ohio Farmacy is to establish a systematic way to screen for and address food insecurity through an electronic, closed-loop referral system, which connects patients to fresh produce from a food pantry near their home. Today, approximately 19,000 patients have been screened for food insecurity and are enrolled in this program through the FQHC. However, this FQHC serves only a portion of the population of Franklin County, where more than 69 million meals are missed annually due to lack of access to food resources.
Scaling Up: Mid-Ohio Farmacy Partners With The Ohio State University Wexner Medical Center Department Of Family Medicine
The mission of the Mid-Ohio Farmacy is to put fresh produce in the hands of as many patients as possible, on a regular basis, to improve health outcomes. In line with this mission, a key aspect of the initial project was to develop a scalable process that could work for multiple providers across the central Ohio region. Thus, the MOF sought to build on the success of the initial project with the FQHC and form a collaborative partnership with the Ohio State University Wexner Medical Center Department of Family Medicine to formulate a similar referral program. Mid-Ohio Farmacy partners the Ohio State University Wexner Medical Center with a strong community-oriented agency and aligns with the medical center’s Healthy Communities strategic plan initiative to support the regional underserved population and meet their health care needs.
The Ohio State University Wexner Medical Center Department of Family Medicine operates nine clinical practices across Franklin County. The Mid-Ohio Farmacy was implemented in two Department of Family Medicine clinics as part of a quality improvement “Plan, Do, Study, Act” (PDSA) pilot project to address food insecurity. The two Department of Family Medicine clinics involved in the pilot phase of the project are located in urban, lower-socioeconomic-status neighborhoods that actively screen high-risk patients and families for food insecurity. High-risk patients targeted for screening are defined as those individuals who are experiencing difficulty in managing their chronic health conditions (that is, diabetes, type 1 or 2 with hemoglobin A1c (HbA1c) >8%, obesity with body-mass index (BMI) >30, hypertension with blood pressure (BP) >140/90) as well as pregnant patients who have gestational diabetes.
How It Works: Patient Screening In Practice
Risk for food insecurity can be screened for by using two widely accepted screening questions that are part of the USDA-ERS 18-item household food security screening module: 1) Within the past 12 months, we worried whether our food would run out before we got money to buy more; 2) Within the past 12 months, the food we bought just didn’t last, and we didn’t have money to get more. A response of sometimes true or often true to either statement is considered to be evidence for risk of food insecurity.
When an eligible patient presents for care, he or she is screened using this validated food insecurity screening tool embedded into the Ohio State University Wexner Medical Center’s electronic health record (EHR) as part of the MyChart app’s social determinants of health “wheel.” For patients who screen positive, a referral to the MOF is initiated. The patient is then assigned a unique identifier number in the EHR and given an informational brochure, with location information and a unique barcode number to present at pantry locations. The MOF PantryTrak software system at each pantry location provides a detailed inventory of the location, frequency of patient visits, and the type of visit the patient made (that is, produce only or full grocery shop). This utilization information is then transferred securely from the MOF back to the Ohio State University Wexner Medical Center and then used to link reports on clinical outcomes. At this stage, the program at the Ohio State University Wexner Medical Center Department of Family Medicine is currently referring roughly 20 patients a week to the Mid-Ohio Farmacy program.
The experience of establishing the partnership between the Ohio State University Wexner Medical Center and the Mid-Ohio Farmacy was fraught with challenges. Below, we highlight four specific challenges that required innovative solutions.
The formation of the Mid-Ohio Farmacy benefitted from alignment of mission and commitment to addressing food insecurity between the the Ohio State University Wexner Medical Center and Mid-Ohio Foodbank. However, the organizational structure of a state-sponsored academic medical center and its operational and fiscal decision-making processes differed in non-trivial ways from that of a community nonprofit organization. As such, we encountered several barriers to smooth, timely implementation of the project. One significant barrier pertained to navigating privacy and compliance in transfer of health information (that is, personally identifiable information) to and from the food bank. As a nonprofit organization that is not regulated by the Centers for Medicare and Medicaid Services, the MOF is not obligated to abide by the Health Insurance Portability and Accountability Act (HIPAA) privacy regulations and is not set up to engage meaningfully in a business associate agreement. To overcome these regulatory hurdles and allow for transfer of information between the two partners, the privacy office at the Ohio State University Wexner Medical Center requires Mid-Ohio Farmacy-eligible patients’ signatures on release of information forms (ROIs). This requirement means that the pool of potentially eligible patients is limited to those patients who are physically present in the clinics as opposed to phone call or electronic invitation via the patient portal. Currently, there is not an approved process for obtaining a verbal consent or an electronic signature for the ROI. Ultimately, the ROI forms may result in fewer patients entering the program and adds an additional step in the referral process that adds to clinic workload. Once release authorization is obtained, a secure file transfer protocol (FTP) process is used to send lists of patients who screened positive for food insecurity to the MOF; the MOF can send utilization data back to the Ohio State University Wexner Medical Center using the FTP. This process allows the Ohio State University Wexner Medical Center to link the patient lists to EHR reports of clinical outcomes data (that is, HbA1c, BMI, BP), thereby closing the loop and enabling evaluation of the program.
Effective EHR data capture of the unique patient identifier number is another challenge area. While modern EHR systems are robust and complex, many lack unassigned data entry fields that can be used to customize mapped data targets for such items as the unique identifier. The unique identifier is necessary given the HIPAA issues described above. The workaround developed for the Mid-Ohio Farmacy for this issue has included both manual processes in the clinic setting as well as ongoing inventive repurposing of existing unused data fields in the EHR system. This solution has been effective, but a specified data field would allow for a more straightforward and indexable approach to facilitate data management and quality improvement.
Securing final funding approval for the project was a challenge, and the Ohio State University Wexner Medical Center and the MOF agreed to split the cost for the pilot project to allow funding to set up processes, work out logistics, and generate early outcomes data as part of the PDSA quality improvement project. Currently, in the state of Ohio, Medicaid does not cover the produce prescription cost as a definable benefit, so sustainable funding near term relies on internal funding resources from the MOF and the Ohio State University Wexner Medical Center. For longer-term sustainability, external grant funding or foundation support will be needed. Advocacy for inclusion of food referrals as a covered benefit by Medicaid is a long-term goal and if successful, would create a funding structure to allow expansion of this pilot project to a larger population of patients served by the Ohio State University Wexner Medical Center.
The final struggle in establishing the Ohio State University Wexner Medical Center—MOF partnership was in finalizing the legal documents and protocols. Given the transfer of funding, a memorandum of understanding was drafted to define expectations of each partner for the project. Additionally, given the health system’s financial support to a community agency, it was important to avoid concerns about possible inducement of patients. Inducement implies that the Ohio State University Wexner Medical Center is providing incentives to patients to gain their business. To answer this concern, we turned to the Ohio State University Wexner Medical Center’s accountable care organization (ACO), which is a Medicare Shared Savings Program ACO. Using a waiver drafted by the ACO, we were able to support the Mid-Ohio Project in a way that does not create concerns about inducement and in a fashion that clearly sets expectations for how each organization will honor its commitments to this project. Future expansion of the project may need to develop alternative solutions that allow for transfer of funds in ways that do not conflict with Stark Law.
The lessons learned from the experience of the Mid-Ohio Farmacy serve as a useful example of how to form linkages between health care providers and community-based organizations. The Mid-Ohio Farmacy is a scalable model to empowering health care providers to address an important social determinant of health: food insecurity. Addressing social determinants of health as part of a broader strategy of population health initiatives is a key component of achieving reductions in health disparities and promoting healthy communities. Linking key stakeholders in communities such as academic health systems with area food resources for the purpose of improving health outcomes of individuals in communities is a powerful way to leverage the strengths and skill sets of each partner.