Arkansas Children’s Hospital initiative addresses food insecurity and other social determinants of health
By Anna Strong, MPH, MPS, Executive Director of Child Advocacy and Public Health, Arkansas Children’s Hospital
Hospitals and health care providers work diligently to treat illness and promote health for their patients. Population health research shows, though, that 80% of the factors that determine health outcomes are outside of clinical care: education, employment, income, health behaviors, community safety and housing.
As payment models evolve to add value-based components that depend on these health outcomes, health care providers are exploring innovative, systematic ways to bridge the gap between medical and social needs to improve outcomes for patients.
We at Arkansas Children’s Hospital (ACH) are no exception. Over the past 15 months, we have been screening patients in a primary care clinic for social needs and providing associated resources, including a medical-legal partnership and programs to address food insecurity, in an effort to ensure our patients are better today and healthier tomorrow.
A Community-Driven Strategy
To determine what social needs the hospital should address, a multi-disciplinary team looked to ACH’s 2016 Community Health Needs Assessment. The team noted the shocking fact that one-quarter of children in Arkansas are food insecure, while 18% of the overall population lacks, at times, enough food for all family members to lead a healthy, active life.
Adding to the problem of food insecurity, Arkansas is one of two states in the nation lacking an implied warranty of habitability for tenants that would require landlords to maintain livable homes for tenants, and almost 22,000 children in Arkansas are homeless. The team also observed that just 31% of fourth graders read proficiently, with significant disparities by race and ethnicity.
Community members echoed the need to address these three issues – food insecurity, housing and educational attainment.
As ACH developed its social needs screening form, one principle guided the work: the team would not ask questions that couldn’t be answered. The hospital’s cross-departmental team sought a way to quantify social needs, but it was equally important to give clinicians the tools to address a problem and focus on clinical care.
The team selected validated questions that were written at appropriate reading levels for patients’ families. ACH’s initial screener included 14 yes-or-no questions written at the 6th grade level, and it was printed double-sided in English and Spanish, on bright green paper. Any “yes” response was a positive screen.
To address food insecurity, housing and educational attainment, ACH worked with existing community partners through the Natural Wonders Partnership Council to develop solutions. Within the hospital, ACH’s Food Insecurity Workgroup and Medical-Legal Partnership team coordinated hospital resources.
To Address Food Insecurity
- Helping Hand food bags: A neighborhood food pantry, which is a member of the Arkansas Food Bank, provides bags of healthy, non-perishable food to the clinic, which distributes them to families that identify an immediate need for food.
- Helping Hand mobile pantry: A previously-used school bus, retrofitted by a local church to be a grocery store on wheels, stops at the hospital weekly and distributes fresh and non-perishable food to patients’ families.
- Summer and afterschool meals: Through a partnership with the USDA, ACH distributes summer and afterschool meals to children – more than 60,000 have been given out since the program began in 2013. The lunches are prepared by students from local high schools’ community-based instruction classes.
- SNAP applications: ACH financial counselors assist qualified families in applying for the Supplemental Nutrition Assistance Program.
- On-Campus WIC clinic: ACH partners with the Arkansas Department of Health to offer a Women, Infants, and Children enrollment clinic each week.
- Pantry resource list: ACH maintains a list of neighborhood food pantries that families can access when they return home.
For Housing Needs
- Medical-Legal Partnership: ACH partners with Legal Aid of Arkansas to address patients’ health-harming legal needs, including housing issues such as evictions or housing quality.
- Shelter resource guide: Families at risk of homelessness are referred to community programs that help prevent homelessness and are given a guide to local shelters if they currently lack a safe, stable home.
- Utilities Assistance guide: ACH provides a handout regarding utility assistance if a family is concerned about electricity, gas or water being turned off, and the clinic provides letters of medical necessity to families.
To Assist With Education
- Medical-Legal Partnership (MLP): ACH partners with Legal Aid of Arkansas, which employs one of the only special education attorneys in the state. The MLP addresses issues such as individual education plans or special education services that are not being implemented properly.
Piloting the Process
Once the screening tool (the “screener”) was developed and resources were identified, the screening and referral process was piloted in a busy primary care clinic with a volume of around 20,000 visits each year. The clinic’s payer mix was about 80% Medicaid. The multi-disciplinary screener team trained staff on social determinants of health and the screening process. Front desk staff distributed the paper screener, and families filled it out as they waited.
During triage, nurses reviewed the positive results with the families, providing resources and referrals with the help of a “cheat sheet” posted at the nurses station that outlined resources for each question. The nurses documented interventions on the screener and shared the results with physicians, who aimed to document the needs and interventions in the electronic medical record (EMR). Screeners were then placed in a green screener basket for collection by staff.
The screening team ensured that support staff were in the clinic during the first couple of months of the screening to help with the transition. After the screener was piloted and moved to implementation, process improvement projects helped to streamline and simplify the clinic flow, improve accuracy of data tracking and guard against abuse of the program.
Making an Impact
The team used grant and donor funding to support data entry and analysis of the screener data. This was the only new staff employed for this project. The results were kept in an Excel spreadsheet that allowed the team to monitor trends and project resource needs.
Over the first 15 months of the program, staff distributed screeners at more than 20,000 visits. Approximately 56% of these were completed and had a positive consent. Of those completed, 43% had at least one positive screen.
Of the patients who completed the screener:
- 29% screened positive for food insecurity.
- 15% said they “need food today.
- 15% had at least one housing need.
- 4% were concerned about rats or pests in their home.
- 10% were concerned about their utilities being turned off.
- 7% had at least one educational services need.
Families welcomed the resources. The clinic made more than 800 referrals to the medical-legal partnership. They distributed more than 1,200 bags of food and more than 2,500 food pantry packets to clinic patients. Financial counselors supported more than 900 families who wanted to apply for WIC or SNAP.
After the pilot, ACH wanted to share this success with other clinics. Through the Natural Wonders Partnership Council’s Innovation Fund, four successful community clinic pilots were conducted in southeast, southwest, northeast and central Arkansas, proving that with the right supports, any clinic can work to address social needs.
ACH’s efforts to improve awareness of social needs also extend beyond the social needs screener and into the community. A vibrant community garden on the corner of ACH’s campus grows fruits and vegetables that are donated to Helping Hand and often come back to ACH families. During the summer of 2017, the GardenCorps service member who manages the garden oversaw harvesting of more than 3,000 pounds of produce.
The hospital’s Community Outreach team teaches Cooking Matters classes to help families plan, budget, shop and cook healthful food. Pop-Up Cooking Matters offers a portable version of the shopping curriculum to high school students across Arkansas. These evidence-based programs are the result of a partnership with the Arkansas Hunger Relief Alliance and the national No Kid Hungry Campaign.
Going forward, hospital staff members hope to embed the screener and resource provision into the EMR and expand the program to new clinics to reach more families. As ACH works to further its mission of bringing care close to home for families across Arkansas, it’s hard to imagine anything closer to home than a healthy dinner served served on a family’s own kitchen table.
The above article is from Arkansas Hospitals magazine, a custom publication of Vowell, Inc., which also produces Arkansas Money & Politics.