Implementing an electronic system to screen and actively refer to community based agencies for food insecurity in primary care

One of the most commonly experienced barriers to health is food insecurity, defined by the United States Department of Agriculture (USDA) as “a household-level economic and social condition of limited or uncertain access to adequate food”. Policymakers and health systems increasingly focus on food insecurity given the prevalence (affecting 12.3% of all households and 17% of households with children) and the impact on health. Food insecurity is associated with uncontrolled diabetes, obesity, toxic stress, maternal depression, pediatric hospitalization and iron deficiency. Consequently, multiple medical academies and national health care organizations recommend screening for and addressing food insecurity. In addition, a national movement toward population health management and value-based payment (VBP) models are catalyzing these efforts. In Massachusetts, these efforts are further stimulated by state health care policies, which mandate screening and intervention for food insecurity among patients in the Medicaid accountable care organization (‘Masshealth ACO’) program.