Social Determinants of Health

Providers Focus on Food Insecurity

May 16, 2017 11:08 am

Recognizing that food insecurity has a direct impact on health, provider organizations are launching initiatives to address hunger in their communities.

When Mountain Comprehensive Health Corporation (MCHC), a federally qualified health center in rural Kentucky, started sending patients to farmers’ markets with vouchers to buy fresh fruit and vegetables two summers ago, 125 patients and their families were served.

In all, they lost 105 pounds, their glucose levels dropped by a cumulative 267 points, and their blood pressure levels improved by 25 percent.

“That was the catalyst to keep going the next year,” says Teresa Fleming, director of financial affairs.

So was the fact that more than 100 patients were on a waiting list, hoping that additional funds would allow the health center’s Farmacy program to grow. Funding was secured, and the program since has expanded at its original site and added farmers’ markets in two other counties.

“And for our next project, we are working on a community kitchen,” says Mike Caudill, MCHC’s CEO.

Food Security and Health

MCHC’s program is one of the many ways that provider organizations are addressing the link between poor nutrition and poor health among their patients.

Food insecurity, as defined by the U.S. Department of Agriculture, is a “household-level economic and social condition of limited or uncertain access to adequate food.”

According to Feeding America, a network of 200 food banks across the country, 42 million Americans lived in food-insecure households in 2015. That means 13 percent of all U.S. households experienced food insecurity at some point during the year.

Among households with children, 17 percent—one out of six—experienced food insecurity in 2015. Thirty percent of households with children headed by single women and 22 percent of those headed by single men were food-insecure.

Until recently, health system leaders shook their heads at the sad statistics but did not consider them directly relevant to their work. That is changing as leaders embrace the need for population health management, which means finding effective, efficient, and sustainable ways to improve the health of their patient population.

The role of food security in population health management increasingly is becoming clear. In 2015, researchers published a study of 62,000 Canadians that documented the connection between food security, health, and healthcare costs. 1 Among the findings:

  • Healthcare costs were 49 percent higher for households with low food security—in the form of reduced quality, variety, or desirability of diet but little or no indication of reduced food intake—compared with those that had sufficient food quality.
  • Healthcare costs were 121 percent higher for those with very low food security, defined as multiple indications of disrupted eating patterns and reduced food intake.

Addressing Root Causes

ProMedica, based in Toledo, Ohio, provides healthcare services in 27 counties in northwestern Ohio and southeastern Michigan. About six years ago, the system started working on an anti-obesity initiative in response to its community health needs assessment. As its trainers went out into the community to discuss obesity, they kept hearing reports of hunger.

Surprised by the finding, Randy Oostra, ProMedica’s president and CEO, said his first reaction was, “Wait a minute, this isn’t what we signed up for.”

But as he and ProMedica colleagues educated themselves about America’s food-insecurity statistics, Oostra began to see a direct line between food security and spiraling healthcare costs.

“We spend $3.2 trillion on health care and prescribe drugs that our patients will never be able to afford—and we don’t ask people about their basic needs,” he says. “To us, it seems like a lack of common sense.”

Beyond the fiscal consequences of ignoring patients’ food security, Oostra sees a moral imperative for provider organizations. Many health systems are not-for-profit, mission-based organizations that were established specifically to serve the poor and have grown to become major economic drivers in the communities they serve. “We are the anchor institutions in our communities—who better to start taking on these issues than us?” he says.

In 2015, ProMedica and the AARP Foundation co-founded the Root Cause Coalition, a nonprofit membership organization that addresses the root causes of health disparities by focusing on hunger and other social determinants of health. The coalition estimates that hunger contributes more than $130 billion a year to U.S. healthcare costs.

The coalition’s members—health systems, insurers, food banks, and others—are working together on research, advocacy, and education, including monthly webinars. 

Tackling the Problem at Home

Meanwhile, ProMedica is working to get a handle on food insecurity among its own patients.

“Last year we screened over 57,000 people for food insecurity,” Oostra says. “Very few social service agencies would have the ability to touch that many lives that quickly. So we think that, working with others, we really need to be in the center of this issue.”

ProMedica screens both inpatients and outpatients. It has embedded the Hunger Vital Sign—a two-question screening tool—into its electronic health record so that every patient is screened upon admission to the hospital. (Sidebar: Screening for Food Insecurity.)

A patient who screens positive for food insecurity receives a visit from a care team member to discuss community resources that may help, as well as a food “care package” at discharge.

ProMedica also screens patients for food insecurity when they visit primary care physicians. In the Toledo area, physicians write prescriptions that entitle food-insecure patients to visit a “food pharmacy,” located in a ProMedica office, to receive several days’ worth of food for their entire household. The prescription is linked to a patient’s medical record, so staff members at the food pharmacy can help patients choose healthy foods that support their specific nutritional needs. 

“We provide lots of healthy recipes and information on other community resources,” says Stephanie Cihon, ProMedica’s associate vice president for community relations, advocacy and grants. “And the patients are able to come back and see us once a month for up to six months before they need a new referral from their physician.”

Meanwhile, ProMedica is working on several innovative programs to increase the availability of food for those who need it. Those include:

A food reclamation program. Leftover food from Hollywood Casino Toledo and from ProMedica hospitals is packaged, frozen, and delivered to soup kitchens and homeless shelters. Since the program started in early 2013, it has collected enough food for more than 275,000 meals. (Leadership Blog: Food for Health: Taking Care of Our Patients’ Most Basic Needs.)

A full-service grocery market in a food desert, (i.e., a neighborhood that lacks access to healthy, affordable food). The Market on the Green is staffed by neighborhood residents who receive a year-long training program that provides work experience, financial coaching, and other education as needed. The market is part of the ProMedica Ebeid Institute for Population, which seeks to address the social determinants of health through programs focusing on hunger, nutrition, education, and job training. 

A mobile farmers market. Since 2013, ProMedica has been dispatching a “veggie mobile” that sells fresh fruits and vegetables to rural communities in one of the Michigan counties it serves. The market visits senior housing complexes, community centers, and other sites in food-desert neighborhoods. A registered dietitian rides along to provide nutrition counseling and education.

Summer meals for kids. Recognizing that only about 10 percent of children are eligible for the USDA’s Summer Food Service Program, ProMedica Toledo Children’s Hospital partnered with its food vendor to become a summer meal sponsor. More than 550 meals were provided to children in the hospital cafeteria last summer. 

Prescriptions for Food

In the Appalachian communities served by MCHC, the Farmacy program links patients who need food with farmers’ markets that provide it. Caudill, the CEO, considers it a community development program that addresses both food insecurity and economic challenges caused by the diminished mining industry.

“On the one hand, we saw this as a way of helping supplement the income of unemployed or underemployed miners who are involved in farming,” he says. “And on the other hand, we saw it as a way of helping patients, many of whom are unemployed miners, to afford fresh fruits and vegetables.” 

The program targets two groups of MCHC patients: pregnant women and patients with Type 1 diabetes, regardless of income; and patients with a chronic disease and income at or below 100 percent of the federal poverty level. The program works like this:

  • Eligible patients who wish to participate receive a Farmacy prescription from their MCHC provider.
  • Patients take the prescription to MCHC’s in-house manager, who verifies eligibility and explains the requirement to return to the clinic for monitoring.
  • The manager prepares the weekly voucher—$1 per day per family member (a family of four would receive a $28 voucher) and gives it to the patient.
  • Patients take the voucher to the farmers’ market manager, who exchanges it for an equal value of wooden tokens.
  • Patients use the tokens to buy fresh fruits, vegetables, eggs, and honey from farmers selling goods at the market.
  • Patients return to the clinic every two weeks for health measurements, including blood pressure, waist circumference, and blood-sugar level.

Based on the program’s success in 2015, MCHC received support from a local health plan and a grant from the federal government to expand the initiative.

“We provided over $117,000 in vouchers between the three counties last year,” Fleming says.

Pushing ahead, MCHC is partnering with a county extension office and local food groups to create a new nonprofit—Community Agricultural Nutritional Enterprises, Inc.—located in a former school cafeteria. The new organization will help farmers develop products, such as jellies and salsas, that can be sold at markets and grocery stores.

“And we’ll have an educational program to teach people how to preserve foods and to eat healthy,” Caudill says.

Lola Butcher writes about healthcare business and policy topics for several HFMA publications.

Interviewed for this article:  L.M. Caudill, CEO, Mountain Comprehensive Health Corp., Whitesburg, Ky.; Stephanie Cihon, associate vice president for community relations, advocacy and grants, ProMedica, Toledo, Ohio; Teresa Fleming, director of financial affairs, Mountain Comprehensive Health Corp., Whitesburg, Ky.; Randy Oostra, president and CEO, ProMedica, Toledo, Ohio.


1. Tarasuk, V., Cheng, J., de Oliveira, C., et al., “Association between household food insecurity and annual health care costs,” CMAJ, Oct. 6, 2015.

This study, which used the same scale for assessing food security that is used in the United States, provides a perspective that is impossible to get in this country. Unlike in U.S. research, this study examined healthcare costs from a central data source because of Canada’s single-payer health insurance system. The universal coverage also reduced the potential for selection bias related to health insurance status


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