Project Leads: Amir Barzin and Jennifer Wills

1. Acknowledging Food Insecurity in Hospitalized PatientsFamily Medicine Inpatient Service/ Family Medicine Transitions Clinic Project Leads: Amir Barzin and Jennifer Wills Project Team Members: Rayhaan Adams, Alyssa Collins, Kelsey Cossio, Beth MacIntosh, Kate Sayre Project Sponsor: Dan Lehman IHQI Faculty Coach: Amy Shaheen Project Managers: Candice Hunt, Will Stanley, Monecia Thomas

2. To identify food insecurity prevalence in a hospitalized population at risk for readmissions • To demonstrate a need for a system-wide screening and referral model • To identify and link patients with resources • To identify gaps and barriers in the process in order to create sustainability Aims of the Food Insecurity in Hospitalized Patients Project

3. “studies found that food-insecure children are at least twice as likely to report being in fair or poor health… food-insecure seniors have limitations in activities of daily living comparable to those ... fourteen years older.” Why is This Important? Gundersen C, Ziliak JP. Food insecurity and health outcomes. Health Aff (Millwood). 2015;34 (11):1830-1839. https://www.fcnl.org/updates/top-10-hungriest-states-in-the-u-s-1629

4. Patient’s SNAP (formerly known as food stamps) benefits may not be available following discharge Patient Perspective Patient qualifies for only $15 a month in SNAP benefits; interested in Meals on Wheels - not in area, placed on wait list for 1 frozen meal/week Prior to hospitalization, patient drove, shopped and prepared meals; Now, will need to rely on support, plans to apply for SNAP

5. Nurses currently screen for malnutrition • Malnourished patients are not necessarily the food insecure patients. • No one is responsible for food insecurity screening • No one is responsible for addressing identified food insecurity Current State

6. 34%

7. Screening began

8. Lists of Community Resources Developed for Distribution

9. Experimented with Screening all Family Medicine Inpatients

10. Stopped Screening Low Readmission Risk Patients

11. Bags of Food from PORCH Distributed

12. Readmission Rate is Higher for Food Insecure Patients

13. Potential Interventions Medically Tailored Meals Potential Food Access Point at Hillsborough Hospital Food Bank items Distributed SNAP Application Assistance List of Community Resources

14. CHOOSE YOUR MEALS Select every meal from a broad menu of nutritious meals. Medically Tailored MealsHow it Works 2. MEAL DELIVERY Delivered to your home or any address nationwide. 3. STORE MEALS Refrigerate upon arrival. Meals will last up to 14 days.

15. Spread and Sustainment Plan DONE In Progress Next Steps

16. Questions? Thank you to an amazing team that has worked so hard to make this past year a great one!

18. Acknowledging Food Insecurity in Hospitalized PatientsFamily Medicine Inpatient Service/ Family Medicine Transitions Clinic Project Leads: Amir Barzin and Jennifer Wills Project Team Members: Rayhaan Adams, Alyssa Collins, Kelsey Cossio, Beth MacIntosh, Kate Sayre Project Sponsor: Dan Lehman Project Managers: Candice Hunt, Will Stanley, Monecia Thomas

19. 22% of Our Patients Would Qualify forMedically-Tailored Meals Covered by an Insurance Plan

20. Additional Information

21. Spread and Sustainment Plan • Met with leaders from Care Management and Nursing to establish workflow for universal screening • Working with ACO & Medicare Advantage plans to establish medically tailored meal delivery plans • Applying for Medicaid Innovations grant to roll out medically tailored meals

22. Questions?

23. Medically Tailored Meals Potential Food Access Point at Hillsborough Hospital List of Community Resources Potential Interventions SNAP Application Assistance Food Bank items Distributed

24. Potential Interventions • List of community resources distributed • Food bank items delivered to the hospital and distributed to discharged patients • Food access point at Hillsborough Hospital • SNAP application assistance • Medically tailored meals delivered to the homes of discharged patients

25. Smart: Develop a method to identify food insecurity in hospitalized patients and provide resources to those in need • This includes screening for food insecurity among the moderate to high-risk readmission patients Food Insecurity Smart Aim(Improvement Scholars)

26. Food Insecurity Assessment Process & Results • Current Infrastructure and Assessment Process Challenges • Next Steps Meeting Overview

27. Why is This Important? https://www.fcnl.org/updates/top-10-hungriest-states-in-the-u-s-1629

28. “Meal Delivery Programs Reduce The Use Of Costly Health Care In Dually Eligible Medicare & Medicaid Beneficiaries” Participants in the medically tailored meal program [also]had fewer inpatient admissions and lower medical spending. 

29. Who will screen for food insecurity? • If patients screen positive, who will provide/arrange resources? • How do we leverage a partnership with Advantage Plans and our ACO to provide medically-tailored meals for our highest risk populations? The ASK

31. Historical average for Family Medicine for moderate and high-risk readmissions is ~ 18%

32. VIZIENT COST DATA needed for Symposium

34. If Mom's Meals were provided at no cost to ACO Advantage/BlueAdvantage patients, could we reduce readmissions?

35. PROCESS ACCOUNTABILITY SUGGESTION

36. PROCESS ACCOUNTABILITY SUGGESTION

37. https://www.ncjustice.org/publications/north-carolina-remains-in-top-10-hungriest-states-in-the-nation/https://www.ncjustice.org/publications/north-carolina-remains-in-top-10-hungriest-states-in-the-nation/

38. WHY ARE PEOPLE HUNGRY IN NORTH CAROLINA? November 28, 2018 Tina Tru explains the facts about hunger in North Carolina — and looks at the kinds of policies, both local and system-wide, that could make a difference. North Carolina is the ninth-hungriest state in the nation, with 16.2 percent of residents receiving some amount of federal assistance to buy food in the form of the Supplemental Nutrition Assistance Program (SNAP). One in eight individuals in the state were food insecure last year — food insecurity is defined as not having reliable access to your next meal. https://socialistworker.org/2018/11/28/why-are-people-hungry-in-north-carolina