“A striking prevalence” of food insecurity in South Jersey

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Accountable Health Communities launches across three counties
By Amy Yuen

Since launching our Accountable Health Communities (AHC) initiative on October 1, the Camden Coalition has been partnering with clinical providers across three counties in South Jersey to gain a fuller picture of the regional social barriers to health. As providers screen Medicare and Medicaid beneficiaries for five core health-related social needs during patient visits, they’re seeing one need that’s unexpectedly popping up the most in our region: food insecurity.

“The figures are preliminary, but our team at the Camden Coalition is seeing 68 percent of patients who have screened positive for a need say they lack consistent access to enough food to stay healthy,” said our AHC Program Manager Mingie Kang. “Providers are finding the prevalence so striking. Food insecurity affects anyone who has health issues, but it especially impacts individuals with chronic issues.”

Last year, the Camden Coalition was selected by the Center for Medicare & Medicaid Innovation as one of 32 organizations in the country to implement AHC, a five-year federal model created in 2016. In our initiative, clinical partners serving Camden, Burlington, and Gloucester counties are screening Medicare and Medicaid beneficiaries for five social needs related to health: food insecurity, housing instability, utility needs, interpersonal violence, and transportation. Those who screen positive for at least one of these needs are provided referrals to community service providers who can potentially address them — in the case of those experiencing food insecurity, for example, practices may link them to food pantries and soup kitchens, or newer innovations like food need screening and support programs. Patients who have visited the emergency department more than once in the last 12 months and who screened positive for at least one of the five factors will be offered personalized health and social service navigation.

Through the first two months, providers — including Cooper University Health Care, Jefferson Health Primary Care, Virtua Health, CAMcare, and Robin’s Nest — screened over 1,100 patients, of whom 222 qualified for navigation services and agreed to be contacted for follow up. “Our goal is to increase the number of clinical sites we partner with, as well as the number of screenings per site,” said Mingie. She and Senior Program Manager for Care Management Initiatives Andrew Katz have been providing weekly progress reports to each participating provider to foster their engagement with our initiative. “The patient data is showing them that there are a lot of health-related social needs out there. We’re focusing on encouraging providers to continue screening more patients to offer information about community resources.”

As more providers join our AHC initiative and more patients are screened, food insecurity may lose its lead position as the most frequently identified need among the five categories, but likely, it will stay near the top. According to Feeding America’s Map the Meal Gap, 9.9% of residents in Burlington and Gloucester counties and 12.2% of Camden County residents experienced food insecurity in 2016. The prevalence of food insecurity among local Medicare and Medicaid beneficiaries seems tied to a lack of knowledge of existing food resources in the community. “From our initial assessment, our navigators are finding that people often don’t know where the food pantries are and what services are out there for them,” said Mingie. It’s probable though that housing instability and a lack of transportation are also contributors to the high rate of food insecurity among patients, she said.

How patients with complex needs experience food insecurity

Going to a food bank may be a relatively easy fix for some Medicare and Medicaid beneficiaries who have food insecurity, but for people who experience complex health and social challenges, it can be an impractical solution. Many patients in our care interventions are constantly challenged when it comes to accessing food. “At the Camden Coalition, our goal as a care team is always to empower patients to utilize the resources that exist in the community. However, if they have physical barriers that prevent them from going out to use the resources, it makes things complicated,” said our Innovation Operations Clinical Manager Michelle Adyniec.

“Jackie” is a 42-year old Camden County resident enrolled in our core intervention program who faces obstacles that keep her from easily accessing most food resource programs. Her asthma, congestive heart failure, and weight make it extremely difficult for her to take public transportation to a food pantry, wait in line, and carry grocery bags back home on the bus. She’s had to move several times — from a shelter, then a nursing rehabilitation center, and now a residential hotel — and she’s had to reapply for food stamps and other benefits every time she moved to a different county.

To fill those crucial gaps, Michelle and her care team members have brought over food from food pantries. “If you have unstable housing, it can affect your access to transportation, your food stamps and benefits, and if you have a child, it can affect your DCP&P (Division of Child Protection and Permanency) case, among other things,” said Michelle. “Food insecurity is often a month-to-month challenge for a lot of folks because when you’re living on such low income, your budget is really tight. It’s a fragile social service web, and every week can bring a new, unexpected challenge that can unravel your safety net.”

Participants in our Camden Delivers and Camden RESET programs are especially at risk for food insecurity, Michelle added. “It’s frightening because pregnant women need good nutrition. Many women tend to share their food stamps with others in need around them, especially their significant other. When our RESET patients get out of jail, it’s really tough. It takes a while to get their food stamps reinstated, and there are a lot of other things they’re trying to do at the same time.”

Our care team has used different strategies to help our participants who can’t access food programs or experience gaps in their food stamp benefits, but they haven’t found an easy solution. “We were helping to get food for five people, while they were waiting for their food stamps to be approved. It became a logistical nightmare, not to mention stressful for everyone” said Michelle. “We had nowhere to keep the food cold, so we would have to get the food and immediately deliver it. It took a lot of work and coordination.” Currently, our care team is pursuing more sustainable solutions, including connecting patients like Jackie to adult day programs that provide meals.

Convening across sectors

Food insecurity is associated with some of the most common and costly health problems, including asthma, cancer, depression, and heart disease. Fortunately, more and more providers in Camden are recognizing the importance of discussing food access and nutrition with their patients. It’s one of the keys to addressing food insecurity in our region, but tackling the issue effectively will also require strong data, cross-sector convening, and shared learning.

That’s where our AHC advisory board comes in. The AHC advisory board — which was convened to oversee our initiative with the aim of transforming how whole person care is accessed and delivered in our region — met last month to begin reviewing the first set of data since our initiative’s launch. Organizations on the advisory board that address food insecurity in their work — including Food Bank of New Jersey, Cooper University Health Care, and Virtua Health — are playing a key role in shaping the conversation on regional needs.

“The advisory board represents different sectors and communities — clinical providers, social service providers, patients, caregivers, and state and local government,” said Mingie. “They’re eager to begin analyzing the gaps in food resources and other services, so they can assess community needs and create regional strategies. It’s exciting to be working with partners who want to systematically address both the needs of individuals and communities in a collaborative, data-driven way.”

*The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies. The project described was supported by Funding Opportunity Number CMS 1P1-17-001 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services.

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