By Dorothy Brooks
Screening ED patients for food insecurity is not particularly difficult or time-consuming, but intervening to address the problem can be complicated by various factors. That’s what a group of researchers discovered when they delved into the issue with the help of an internal grant from the Indiana University (IU) School of Medicine Department of Emergency Medicine. The grant is directed toward resident-led research focused on promoting health equity.
The initial phase took place from July through October 2022 at Eskenazi Hospital, a public safety-net facility in Indianapolis. “In emergency medicine we have this great access to a cross-section of humanity that the rest of the healthcare system does not see,” explains Alexander Ulintz, MD, who was a third-year resident in emergency medicine at IU at the time of the study, but now is a clinical research fellow in the Department of Emergency Medicine at The Ohio State University in Columbus, OH. “Implicit in that is also the ability to do some interventions for folks who otherwise aren’t able to access other portions of the healthcare system.”
Seema Patel, MD, an emergency physician and a pediatrician, who was a fourth-year resident at IU at the time of the study and now is on staff in both the adult and pediatric EDs at Eskenazi Hospital, agrees with these sentiments, noting that emergency providers have a unique opportunity to identify patients with social needs and build trust with them. “The goal is really to figure out how to capture those patients and provide them with the resources they need, but also plug them back into the system so that they can continue to get the healthcare and resources that they need,” she says.
The researchers discussed some of their findings during a session at the annual convention of the American College of Emergency Physicians in Philadelphia in October 2023.
As part of the project, the investigators sought to determine whether they could screen ED adult patients for food insecurity effectively in the ED using the two-item Hunger Vital Sign screening tool (https://childrenshealthwatch.org/public-policy/hunger-vital-sign/). They then wanted to assess whether patients who screened positive for food insecurity would accept and use a $30 voucher that could be used at a nearby food market.
The researchers found that out of 377 patients who underwent the screening during the four-month study period, a total of 277 adult patients screened positive for food insecurity and 244 accepted the voucher. However, less than half of the patients who accepted the voucher (87) used it, and the median time it took to redeem the voucher was nine days.
Although the research shows that patients were largely agreeable to screening for food insecurity and accepting the vouchers, many were unable or disinclined to redeem the vouchers for food. It is not clear at this point what stopped the patients from redeeming the vouchers, but the researchers suspect that multiple barriers played a role.
Patel notes that while the researchers screened during business hours, it is possible that the hours of operation at the food market were too limited. “A lot of our patients are often in a rush to leave the emergency department because they have other things to do or they have to get home to their kids,” she explains. However, Patel cautions that it is important not to make too many assumptions about the role that stigma or other factors might have played.
The researchers plan to contact the patients who received the vouchers and learn why they did not redeem them. “We’re going to do some focus groups with patients and do that qualitative research piece to find out what the barriers were and how we can [more effectively] provide patients with these types of wraparound services,” explains Patel.
However, the early findings confirm there is patient trust in ED providers, says Ulintz. “Previous studies have found that families are actually more likely to disclose some of these vulnerabilities in the emergency department where you’re seeing somebody once and hopefully never again, as opposed to a primary care office where there may be feelings of shame or embarrassment when sharing this type of information with a provider you have known for a long time,” he says. “I think [the findings] confirm that we have access to these patients; they’re willing to tell us when they’re going through a hard time; and they’re willing to accept help from the ED.”
Tyler Stepsis, MD, the medical director of the ED at Eskenazi Hospital and a co-investigator on the project, tells EDM that the research is important because sometimes emergency providers are the only point of contact in a patient’s medical life. In such cases, it is essential for emergency providers to probe further. “It can help to uncover a lot more [need] than you might be assuming,” he says.
The researchers learned that interventions that work well in primary care settings may not be as effective in the ED. “One of the ways we got momentum for this project is that there was already food insecurity screening, and there already was this food market in place for select outpatient clinics within the Eskenazi health system,” shares Ulintz. However, the researchers recognize that the primary care patients differ in important respects from many patients who present to the ED. “I think what many people fail to recognize is that to get to a primary care appointment, there is already selection bias in that. You’ve already overcome so many barriers if you’re able to make it [to a primary care appointment] on a weekday during office hours,” shares Ulintz. “You’re able to take time off of work, and you have transportation, and [the visit] takes place with a language that you understand.”
Patients who present to the ED often face multiple barriers that prevent them from accessing primary care. “I think there just needs to be more attention paid specifically to how our emergency department populations differ [from primary care populations], and how we need to change our systems’ approach to addressing their needs,” states Ulintz.
Further, Ulintz believes the findings underscore the importance of including patients in the process when designing interventions. “We tested a hypothesis, and I think we confirmed a lot of the pieces of that, but we also found we need patients at the table to understand what the barriers are to redemption,” he says.
In the meantime, the researchers do have some insight to share with emergency medicine colleagues who understand there is a lot of unmet need with respect to food insecurity among their patients and would like to make improvements in their own settings.
First, the Hunger Vital Sign screening tool is just two questions and research credentials are not needed to screen patients as part of a normal routine, states Ulintz. “I think one helpful mantra for a lot of physicians is to remember that if you’re prescribing a medicine that needs to be taken with food, ask those two questions [from the screen], and make sure the patient has food,” he advises.
Most EDs have some access to food and can make sure patients at least have a meal while they are in the ED, adds Ulintz. However, he notes there also are other community-based resources that providers can tell their patients about. One commonly used resource is: https://www.findhelp.org/ (formerly Aunt Bertha). “You can put in a patient’s home address and it will help you find community-based resources that you can refer patients to. That’s something anyone in emergency medicine can do.”
Patel also encourages emergency medicine colleagues become better acquainted with local community organizations that address food insecurity. “These organizations already exist, and they are key tools that any ED can use, but it takes a little bit of extra research and extra attention to figure out what resources you can send your patients to, and how they work,” she says.
Screening ED patients for food insecurity is not particularly difficult or time-consuming, but intervening to address the problem can be complicated by various factors.
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