Kofi Essel, MD, MPH, FAAP Children’s National Health System The George Washington University School of Medicine & Health Sciences Washington, DC

Co-Authors: Micheal Burke, PhD

Mark Weissman, MD

William Dietz MD, PhD

• Food insecurity describes “the limited or uncertain availability of nutritionally adequate and safe foods, or limited, or uncertain ability to acquire acceptable foods in socially acceptable ways.”

• Core Indicators of Nutritional State for Difficult to Sample Populations, 1990

• Food Security is when “all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life.”

• World Food Summit, 1996

Lived Experiences of Food Insecure Households

“Food Anxiety”

Basic anxiety or worry about food.

Preoccupation with access to enough food.

“Monotony of Diet”

Decrease in Nutritional

Quality, Variety, and/or Desirability

of diet.

“Adults decrease intake”

Food shortage experience and adults decrease

intake

“Children intake decreases”

Food intake of children decreases and adults acquire

food in socially unacceptable ways

Nord, J Hunger Env Nut, 2013; Fram et. al, J Nutrition, 2011; Alaimo, Top Cli Nut, 2005

2015 • Screen & Intervene @ “scheduled health

maintenance visits or sooner if indicated” • Advocate for programs/policies that end

childhood food insecurity • Hunger Vital Sign recommendation

™

Finding Food Assistance Partners in Your Community

CAFB Service Region: District of Columbia, Maryland (Prince George’s and Montgomery Counties) and Virginia (city of Alexandria, and Arlington, Prince William and Fairfax Counties) capitalareafoodbank.org/get-help/ To find a food assistance partner outside of Maryland, Virginia and the District of Columbia: feedingamerica.org

FY 2017, CAFB distributed 46 million pounds of food through partners and our own direct distribution programs. More than 1/3 of those pounds was fresh produce.

Addressing Food Insecurity

Fredric Garner, MD Koffi Essel, MD Annie Turner Sarah Bennett, FNP Molly Lalonde, PNP Cecelia Vergaretti, JD Amy Joyner, RN Rod Taylor, RD Morgan McGhee, RD

WHAT IS FOOD INSECURITY?

Food Insecurity

The U.S. Department of Agriculture defines food insecurity as a lack of consistent access to enough food for a healthy, active life

Hunger Vital Signs

• “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.”

WHAT DOES FOOD INSECURITY LOOK LIKE MEDICALLY?

Children with food insecurity can present in a variety of ways:

• Developmental delays • Behavioral problems • Obesity • Poor growth • Inappropriate feeding practices

Food insecurity can lead to:

• Poor health status • Risks to normal development • Mental health problems • Poor educational outcomes

HOW PREVALENT IS FOOD INSECURITY?

FAIRFAX COUNTY

In Fairfax County, Virginia:

• 180,000 students

• 28% are on a supplemental food program, which means:

• There are 58,000 students at risk for food insecurity, especially during the summer months

ADDRESSING FOOD INSECURITY

Barriers

• Food insecurity is often not addressed for many reasons: – Not aware of the problem

– Not sure what to do about it

– Time constraints during visits

– Lack of funding/concerns about cost

– Fear of making patients uncomfortable by asking them about food insecurity

– Unaware of existing resources or unsure of how to work with them

Other Barriers

• Schools are unable to release their data of who is on free and reduced meal programs

• Lack of transportation to the food source

• Concern about insurance reimbursement for screening

• People may be embarrassed to ask for help or unaware of what resources exist

The Role of Clinicians

• Pediatricians and other clinicians have the potential to play a critical role in protecting children from food insecurity as they:

– See children and families year-round, including in the summer when they may not have access to school based food programs

– Have long-term relationships with patients

– Act as a “medical home” for coordinating information and services

Rx for Food

• Given these barriers, the need for a new approach was identified

• A committee of clinicians, dieticians and community resources was established

• Overall goal: use a medical office to identify food insecure families and coordinate with existing resources to give them access to food

Rx for Food

• Other Key Goals:

– Partner with existing resources and involve other community resources when possible

– Make the practice cost and time investment “insignificant”

– Develop a clear process for identifying food insecure families

– Make the process simple enough that it could be used in other offices

Rx for Food

• The committee developed Rx for Food:

– Patients are screened for food insecurity at their medical appointment

– Patients identified as food insecure were given a prescription for food

– Food for Others, a local food pantry (our food pharmacy), committed to giving these patients an allotment of food for the summer

IMPLEMENTATION PILOT PROGRAM: BURKE PEDIATRICS

Burke Pediatrics

• A private pediatric office in Burke, VA

– Patients primarily live in Fairfax, Burke and Springfield

– Includes families in Clifton, Dale City, Lorton and Woodbridge

• 3 physicians, 4 nurse practitioners

• Approximately 10,000 active patients

Burke Pediatrics Workflow

• 7 question nutrition survey given to every family at check-in

– Survey contained 2 “hunger vital signs” questions used to identify food insecurity

• Questionnaire reviewed by clinician

– Rx for Food prescription was given to the family if they identified as food insecure

Survey Questionnaire • I worry about my child/children's eating habits and nutrition • Within the past 12 months, I worried whether our food

would run out before we got money to buy more • I would attend classes at Burke Pediatrics offices on

preparing balanced meals

• I am concerned about my child/children being or becoming “overweight”

• I would like more information on preparing balanced meals and healthy family nutrition

• When school is closed, I become more concerned with my children’s nutrition

• Within the past 12 months, the food I bought just didn't last and we didn't have money to get more

Food Insecurity Screening Office Flow Diagram

Office

Registration

History Questionnaire

including

Room

patient

Complete medical visit

With an Rx for Food…

• Patients could go to the Food for Others pantry and receive up to 100lbs of food/week (amount is based on family size) for 8 weeks throughout the Summer, in addition to their usual monthly opportunity for emergency food

• Patients with Medicaid, InTotal Health and Anthem Healthkeepers could also receive free transportation to and from the pantry or reimbursement for their travel

RX FOR FOOD OUTCOMES AT BURKE PEDIATRICS

Survey Results

• In-office screening from April to August

• 2200 families completed the survey during office visits

• 190 surveys positive for food insecurity

– 8.6% positive

Further Breakdown of Positive Surveys

• Insurance Type –25% private/self pay insurance

–75% state insurance (VA Medicaid, InTotal, AHKP)

• Primary Language

–60% English speaking

–36% Spanish speaking

–4% other

Use of Food For Others

• 42 unduplicated families served through the Rx for Food program

– 181 unduplicated individuals

• 17 of the 42 families have been served more than once (2 to 6 times)

• 35 of the families are new to Food for Others

Amount of Food Served

7,568 pounds of food for 181 individuals

Other Findings

• Some insurance companies (Medicaid, InTotal, Anthem Healthkeepers) did reimburse for screening

– ICD 10: Z13.21 Encounter for Screening Nutritional Disorder

– T1023 Nutrition Screening

ADDRESSING FOOD INSECURITY ON A LARGER SCALE

Next Steps:

• Recruit more medical offices to help identify and assist more food insecure families

• FREE tools, personalized software and consultation are available to any interested offices

• Capital Area Food Bank has committed to provide food for families in Fairfax County

Contacts

• Burke Pediatrics, LLC

• Websites: www.burkepediatricsllc.com

www.rxforfood.com

• Email: rxforfood@gmail.com

• Phone number: 703-974-6061

• Ask for: – Fred Garner, MD

– Sarah Bennett, FNP

– Molly Lalonde, PNP

2018 Goals

• 100 practices in Northern Virginia

• 10,000 patients screened as food insecure

• 1,000,000 lbs of food prescribed and delivered from 13 USDA participating food pharmacies

• Expand beyond Fairfax County

Watch us on WUSA channel 9 around Thanksgiving

QUESTIONS?