Background: Food insecurity (FI), the lack of access to nutritious food to maintain an active lifestyle, is associated with poor health outcomes and morbidities in both children and adults. COVID-19 has exacerbated FI and disproportionately impacts communities of color and low-income households. Hospitalization can be an important time to address FI as a social determinant of health. Hospital-based providers can provide health education, health coaching and are important referral sources to connect patients with programs.
Purpose: We developed a medical student-led quality improvement program to screen for food insecurity and refer hospitalized patients to community and federally funded food programs. The objectives were to 1) collaborate with nutrition services (dietitians and dietetic technicians) and social workers and 2) implement a daily nutrition services workflow to screen, document and refer patients to social workers.
Description: A team of medical students, dietitians, social workers, and hospitalists assembled in the fall of 2020. As part of a 13-month quality improvement project, the team reviewed and analyzed the current state of food security screening in hospitalized adult patients at an 800-bed academic medical center. From January to October 2020, only 2.9% of adult patient encounters were screened for FI (1516/52078), with 13.5% of those screening positive (204/1516). Surveys of 150 providers and interviews with 15 providers revealed both limited knowledge on screening and addressing FI. A multimodal intervention (Figure 1) was piloted over 4 weeks in May 2021 on two hospital units including: 1) a 2-hour educational program for dietitians and dietetic technicians on FI, FI screening and incorporating social work referrals into daily workflow, 2) standardized documentation in the electronic health record under the “Social Determinants of Health Wheel,” and 3) social work consultation and education on community and federal food programs. All participating dietitians and dietetic technicians received weekly audit and feedback email communications. Out of a total of 356 patients on the intervention units, 88 (25%) were screened; of those, 13 screened positive. In contrast, four of 182 patients on a comparator unit were screened during the same period. Analysis by race and ethnicity identified that patients that self-identified as Asian were less likely to be screened for FI (p< 0.05) compared to their non-Asian counterparts (Table 1). Nutrition service providers were interviewed and reported increased knowledge and self-efficacy around FI and embedding FI screening and referrals. Based on post-pilot provider and patient interviews, the team identified the need for additional content for increasing patient and family education and engagement.
Conclusions: A multimodal interprofessional quality improvement program to identify and screen for FI in the hospital was successfully implemented. A follow up review identified that both providers and patients valued screening in the inpatient setting and the potential to engage with multiple providers with different areas of expertise. Nutrition services touches a wide swath of patients who can benefit from referral to social work, education, and resources. Feedback included requests for additional patient-facing education, counseling on food as medicine and sustainable sources of healthy food, engaging with patients and their families, and targeted collaborations with our community partners.