Doctors and nurses working for Geisinger, a health system based in Danville, Pa., no longer assume that their patients who are already struggling with uncontrolled diabetes have access to healthy food, or even enough food.
In 2016, Geisinger launched a program in Shamokin, Pa., to ask patients about food insecurity during clinic visits. Those who meet clinical criteria and admit to not having enough food are given a prescription to pick up free produce, whole grains, lean protein, and other healthy foods at a food pantry located on the hospital's campus. They're given enough to feed their households 10 healthy meals a week and, in return, the patients commit to working with a care team and attending 15 hours of group classes about managing their diabetes. The program already has paid off in better blood glucose control and lower health costs.
During the first 18 months, the participants' HbA1c levels decreased from an average of 9.6% before enrolling to 7.5% afterward, according to a program summary published April 10, 2018, in NEJM Catalyst. More recent data show that the average two-point HbA1c reduction has continued, based on a December 2018 analysis of 91 enrolled participants versus 119 patients who did not enroll in the free food program but met the criteria, including having uncontrolled diabetes.
Hospital leaders and physicians have long known that access to food, housing, and transportation significantly affects patients' ability to stay healthy. In a late 2018 speech, Health and Human Services Secretary Alex Azar cited federal data showing that malnutrition alone played a role in 12% of non-maternal hospital stays, comprising $42 billion annually in health care spending.
An analysis by Deloitte Center for Health Solutions, published in 2017 and based on a survey of nearly 300 hospitals and health systems, found that while 80% reported at least some screening for social needs, those efforts and related help were often focused on particular patient groups, such as high utilizers.
Increasing stakes on the value of care, including the shift toward bundled payments, may drive hospitals to focus more attention on this, according to Jay Bhatt, DO, senior vice president and chief medical officer at the American Hospital Association, which recently released a set of social determinants tools for clinicians.
“Hospitals and health systems are well positioned to address this in the sense that we use systematic approaches to address quality and safety, and those approaches can be applied to social determinants of health,” he said.
At Geisinger, helping diabetic patients to eat better has already avoided some hospital costs. Patients in the program had 70% fewer hospitalizations and 27% fewer ED visits compared to those not involved. Meanwhile, outpatient physician visits and other types of preventive care, such as eye and foot exams, increased, said Allison Hess, vice president of health at Geisinger Steele Institute for Healthcare Innovation.
The health system, which is also an insurer, has found the program to be cost-effective enough that the food support is continued even after patients complete the diabetes education. The food costs about $1,500 annually per patient, and research shows that a one-point reduction in HbA1C saves about $8,000 to $12,000 in health costs annually, Ms. Hess said.
Beyond medical treatment
In his speech, Mr. Azar suggested the possibility of governmental programs more directly reimbursing health systems for meeting patients' food shortages and other social needs. Rather than health systems only referring patients to other organizations, Mr. Azar said, “What if we gave organizations more flexibility so they could pay a beneficiary's rent if they were in unstable housing, or make sure that a diabetic had access to, and could afford, nutritious food?”
Clinicians and hospital leaders aren't waiting for his words to turn into changes in government funding.
In January, Kaiser Permanente announced several housing-related initiatives with community partners, including a commitment to house more than 500 adults ages 50 years and older in Oakland, Calif., who have at least one chronic condition. Last summer, Utah-based Intermountain Healthcare announced a three-year $12 million investment in the communities of Ogden and St. George. Their plan: to team up with community partners to try to ease housing, transportation, food insecurity, and other issues among Medicaid patients living there.
Asking patients about something as basic as their access to food can provide insights into far more than what's sitting in their cupboards, said Darren DeWalt, MD, FACP, chief of the division of general medicine and clinical epidemiology at the University of North Carolina (UNC) at Chapel Hill.
“When someone is food insecure, they're usually living check to check, and trying to decide, ‘Well, do I buy medications for my heart disease or do I get food for my children?’” Dr. DeWalt said. “Food insecurity causes people to make tradeoffs that are not in their individual self-interest or in society's interest.”
Dr. DeWalt coauthored a study, published April 2018 in Health Affairs, that looked at hospitalizations and other outcomes in two groups of homebound and chronically ill individuals—dually eligible for Medicare and Medicaid—who got home meal delivery for at least six months. In one group, the meals were tailored to their medical needs; the second group got a more general food delivery service. A third control group didn't get any meal delivery.
Both groups who received food delivery were less likely to visit the ED than the group that didn't. But only the tailored meal group saw a statistically significant decline in hospitalizations, with the rate roughly half of that for individuals who didn't get any meal delivery.
Identifying patient needs
At UNC, hospital clinicians are now running a pilot project, asking some patients about food insecurity, with the eventual goal of routinely screening all patients, Dr. DeWalt said. But when using the two-question screening, called the Hunger Vital Sign, they've learned that “some patients are kind of reluctant to say they need help because it can be embarrassing,” he said.
So now clinicians try to ask patients when they're in a private area, with few people nearby, so they are more likely to open up, Dr. DeWalt said.
When talking to patients about uncomfortable subjects, it's better to ask broader questions that require more than a “yes” or “no” answer, said Jennifer Lowry, MD, who directs the division of clinical pharmacology, toxicology, and therapeutic innovations at Children's Mercy Kansas City in Kansas City, Mo.
Over the course of nearly two decades, Children's Mercy Kansas City has conducted more than 1,000 home assessments through its Healthy Home Program, according to Dr. Lowry. The program, initially launched to help asthma patients, soon expanded to check out the homes of at-risk children who were getting cancer treatment or for some other reason were considered more vulnerable to infection, she said.
Nobody wants to admit that they have cockroaches, Dr. Lowry pointed out. Instead, she suggested asking, “What do you use to get rid of cockroaches?” Or, “What do you do when you see a mouse?” Similarly, the question shouldn't be if the patient's home has mold, but rather if there has been any trouble with roof or ceiling leaks, Dr. Lowry said.
Joy Victorine, a social worker who oversees transitional and community programs at St. Joseph Health, Humboldt County, in northern California, has seen firsthand the assumptions that can be made about vulnerable patients during the hospital discharge process. Over the course of the last decade, the nonprofit hospital has teamed up with local community organizations to provide short-term medical respite beds for homeless patients after they leave the hospital.
Ms. Victorine, who, along with a nurse, meets with patients shortly after they're transferred from the hospital to a respite bed, said sometimes a physician's discharge orders are not feasible. For instance, a physician may instruct patients to continue with their regular medications, but those medications might have been lost or stolen during hospitalization.
To avoid this problem, she recommends that hospitalists ask patients about their medication supply and access before discharge. “If there is doubt, write a renewal order for the medication. This is key especially if the patient does not have a regular doctor,” she said. Clinicians should also make sure that patients have access to all the necessary supplies; for example, along with an insulin prescription, they may need a glucometer, syringes, strips, and lancets.
Her program provided a total of nearly 2,000 medical respite days to homeless patients in 2018, according to data provided by Ms. Victorine. Assuming the hospital otherwise would have kept the patient in a hospital bed for a longer stretch, the cost savings was nearly $1.2 million for 2018.
They typically stayed no longer than three weeks, a limit that was set after it became apparent that some patients became so comfortable with their new respite home that they were reluctant to leave, Ms. Victorine said. But with other patients, it required many efforts, and repeated hospitalizations, to convince them to try a community medical respite bed after discharge, she said.
Asking tough questions about food insecurity and other social needs may be uncomfortable, Dr. DeWalt said. But someone on the hospital staff, whether it's a nurse or a social worker, should find out and make referrals so the physician has a heightened awareness of the food shortages, housing problems, or other daily challenges that their patients face, he said.
“It's important for hospitalists to understand that when this patient goes home, they don't necessarily have everything that you think they have,” Dr. DeWalt said. “And once you start to think about that, you think, ‘How can they have a good [health] outcome?’”