At Boston Medical Center, physicians write prescriptions for food when patients don’t have enough to eat. Doctors in the center’s emergency department and more than 20 clinics screen all patients for hunger, writing those who struggle to feed themselves a script to the on-site Preventive Food Pantry. They write a lot of food prescriptions – enough to keep the food pharmacy serving 7,000 people each month.
“A hungry child will have more ER visits than a healthy child,” notes Latchman Hiralall, manager of the center’s food pantry. A registered dietetic technician, Hiralall gets a copy of each food prescription via the center’s electronic health record, and compiles each patient a bundle of medically and culturally appropriate foods, including fresh produce and meat, to last several days. “We provide food for the whole family, not just the patient,” he says, adding that patients can return twice a month for as long as they are receiving care from BMC providers. Three staffers and many volunteers run the pantry, which relies on the Greater Boston Food Bank to provide the food.
The need is great, as 48 million Americans live in food-insecure households, according to Feeding America. In 2014, hunger and food insecurity drove up U.S. health expenditures by $160 billion, an amount equal to one-third of the national debt, according to a recent study by Bread for the World Institute. Food insecurity is associated with higher rates of depression, cardiovascular disease, high blood pressure, diabetes, HIV, osteoporosis and other conditions.
“Food insecurity can impact health in at least two key ways,” says Dr. Seth Berkowitz, an internist and faculty member at Massachusetts General Hospital and Harvard Medical School who studies the effects of unmet basic needs on chronic disease. “The first may be causing disease directly – for example, by constraining dietary choices to calorie-dense, nutrient-poor food that results in obesity or Type 2 diabetes. Secondly, it may make conditions that are not initially related to food insecurity harder to manage.” Consider a food insecure cancer patient going through chemotherapy; improper nutrition jeopardizes recovery.
Students from a Little Rock, Ark., high school help pack the free meals that are distributed to kids at Arkansas Children’s Hospital.Courtesy Arkansas Children’s Hospital
Around the country, a handful of hospitals and health systems have taken steps in their communities to chip away at the problem of hunger, a so-called social determinant of health. Largely via community partnerships, Boston Medical Center, Arkansas Children’s Hospital and Toledo, Ohio-based ProMedica are among those hospitals that understand the impact hunger, housing and other social determinants of health have on health – they play a far larger impact on people’s health than the medical care and services hospitals and doctors deliver.
With its focus on prevention and population health, the Affordable Care Act is a catalyst for some of the new thinking among hospitals. The health reform law includes assorted payment carrots and sticks, such as hospital readmission penalties, accountable care organizations, risk-based payment changes and stronger community benefit requirements for nonprofit providers.
Specifically, the IRS last December finalized and clarified a rule on the actions nonprofit hospitals can take to improve local community health beyond charity care to preserve their nonprofit tax status. This includes addressing social determinants of health, including “access to adequate nutrition” for people in the community, not just patients.
hungry child will have more ER visits than a healthy child,” says Latchman
Hiralall, manager of the Boston Medical Center food pantry.Courtesy Boston Medical Center
For the one-third of the nation’s nonprofit hospitals in 2016 updating their community benefit programs – a detailed plan that involves assessing a community’s health needs and then providing steps to show how the hospital will address those needs – this is something new. (The rule’s release late last year came too late to affect hospitals’ three-year community assessment in 2015.)
ACA requires all nonprofit hospitals to do an in-depth community health needs assessment, accounting for social determinants of health, once every three years and to complete an implementation strategy to meet the community’s needs. This must be done to protect the hospitals’ nonprofit tax status. Hospitals are encouraged to work with other groups in the community to tackle issues that fundamentally impact health.
“While the rule doesn’t mandate that nonprofit hospitals tackle social determinants of health, what’s important is the legal toehold it provides in calling attention to the growing imperative for hospitals to address population health,” says Marydale DeBor, a former hospital executive who is the founder and managing director of Fresh Advantage, a Massachusetts-based consultancy helping hospitals to integrate food and nutrition into their operations. “Visionary hospital leaders will see the expanded community benefit requirement as a tool to strengthen social service infrastructure and community resources that can prevent disease, reduce unnecessary ER visits and avoidable readmissions.”
ProMedica hospital system has worked with casinos and other partners to reclaim tens of thousands of pounds of food to feed hungry neighbors, has led an effort to open a grocery store in a food desert, and has started to screen for food insecurity at some of its facilities and provide food prescriptions. In October, it took its anti-hunger effort national, teaming up with AARP Foundation to launch a national coalition of health care organizations and businesses to work with community groups and others to tackle hunger as a way to improve health.
“You can feed someone for a year for what it takes to care for then one day in the hospital,” says Barbara Petee, executive director of The Root Cause Coalition and ProMedica’s chief advocacy and government relations officer.
During the first two weeks that Arkansas Children’s Hospital offered free lunches, it provided 1,900 meals to hungry kids. That was in 2013 and the
program has grown significantly since.Courtesy Arkansas Children’s Hospital
An emerging body of research over the last couple of years shows that food insecurity is associated with an ever increasing number of health conditions. That spurred the American Academy of Pediatrics in October to urge U.S. pediatricians to screen all children for food insecurity and become familiar with and refer families to needed community resources, and to advocate for federal and local policies that support access to adequate, nutritious food. That’s important for hospitals, as more and more employ pediatricians and other physicians.
“It’s impossible to separate children’s health and their nourishment,” observes Dr. Patrick Casey, a pediatrician and director of the Arkansas Children’s Hospital Growth & Development Clinic. As part of a research project with Children’s Health Watch, Casey has surveyed since the late 1990s the impact of food insecurity on families visiting the hospital’s emergency department. In 2008, the rate doubled so that 20 percent of families were food insecure. That has grown to nearly 28 percent, he says.
Casey was instrumental in getting the hospital to respond. The hospital screens patients and their families for food insecurity and signs up eligible families for Supplemental Nutrition Assistance Program and Women, Infants and Children benefits. It began a USDA Summer Food Service Program site in 2013 and has since expanded the program to be year-round, providing free lunches to children up to age 17 at the 29-block campus. Casey says about 40,000 free meals have been served. It also has started a food prescription and pantry program along the lines of that at Boston Medical. Arkansas Children’s also sponsors tours of grocery stores and cooking classes to help those on fixed budgets learn to buy food and prepare healthy meals.
Arkansas has the second-highest overall population rate of food security in the nation, with nearly one in five households reporting lack of food. Arkansas Children’s has tackled hunger largely because it’s the right thing to do: “Reimbursement still is not aligned” to do such programs on a large scale, notes Dr. Robert Steele, senior vice president and chief strategy officer, adding that the hospital still relies solely on fee-for-service reimbursement. It undertakes its community needs assessment in 2016, but already has a good start on addressing underlying causes of ill health in Little Rock. It relies on a network of community partners to help fight hunger, Steele notes, as the hospital cannot do it alone.
While a clear-cut business case has not yet emerged for many hospitals to take on food insecurity, Steele says, “there is a way, I truly believe, that improving health and improving quality lowers cost, but it’s very complex.” Until then, he adds, it’s like having “one foot in the boat and one foot on the dock.”
Between the IRS rule on community benefit, a growing body of research on the impact of food on health, and policy changes made by the nation’s pediatricians, improving health by fighting hunger seems to be gaining momentum. “If we want to get serious about helping our patients be as healthy as possible even when they’re not in the office or hospital, we need to get serious about finding ways to make nutritious food available for everyone,” Berkowitz says.