Connecting food-insecure individuals to resources

Veggie Rx participant

Connecting food-insecure individuals to resources


  • Food insecurity affects 41 million Americans and is especially prevalent among children and the elderly. 
  • Food insecurity can impact a hospital’s bottom line. Hunger can exacerbate medical conditions and drive up hospitals’ patient care costs. 
  • There are various points of intervention, both clinical and nonclinical, that can shape a hospital’s approach to addressing food insecurity in the community. 
  • Hospitals are using best practices and innovative interventions to address food insecurity.
    • Conduct food insecurity screenings to identify hunger as a health need
    • Develop an accessible and reliable database of social resources
    • Implement an active referral system
    • Provide patients with supportive services, such as patient navigators
    • Reduce or remove language and cultural barriers
    • Address social determinants of health that are interconnected with food insecurity, such as housing and transportation
  • There are a number of local and national resources hospitals can access or share with food-insecure community members. This brief provides information on how hospitals can connect food-insecure patients and community members to local and federal resources. 

Food insecurity affects 41 million Americans and is especially prevalent among children and the elderly. Addressing food insecurity should be a priority for hospitals because hunger has enormous impacts on community health. Studies have consistently demonstrated that household food insecurity is associated with chronic disease, developmental delays in children, and poorer physical and mental health.

Food insecurity can also impact a hospital’s bottom line. Hunger can exacerbate medical conditions and drive up hospitals’ patient care costs.

A 2016 study found that hospitalization rates for hypoglycemia increase at the end of the month when household food money runs out. The cost of hospitalization was calculated at $17,564 —much higher than the estimated $657 it would cost to feed a family of four on the USDA Thrifty Food Plan for an entire month.

Hospitals can play a vital role in connecting patients to resources that address a household’s food needs to support patient health and wellbeing. There are various points of intervention, both clinical and nonclinical, that can shape a hospital’s approach. And most communities have existing resources that a hospital can leverage so alleviating hunger is not solely the responsibility of a single facility.

Food insecurity screening

One of the most important first steps a hospital can take to assist food-insecure individuals is to identify hunger as a need. Many hospitals, like Providence Medical Group in Oregon, have implemented a “screen and intervene” strategy that includes screening for food insecurity (for example, by using the Hunger Vital Sign two-question food insecurity screening tool), identifying food insecurity in patients’ electronic medical records, and connecting food-insecure individuals and families to food resources.

Programs and resources

The following programs and services are available in most communities. Hospitals should be aware of these programs as they will likely be the first place to start when referring food-insecure patients to resources.

  • Supplemental Nutrition Assistance Program (SNAP): SNAP (also known as food stamps) provides low-income families with benefits (on a card similar to an ATM debit card) to be used on food.
  • Temporary Assistance for Needy Families (TANF): TANF provides low- and very-low-income families with cash assistance to help meet basic needs.
  • Women, Infants, and Children (WIC): WIC provides low-income pregnant and postpartum women, infants, and children up to age five with services, including vouchers that can be redeemed for healthy foods at most major grocers, nutrition education, breastfeeding support, and referrals to other services.
  • Summer, afterschool, and weekend meal and supplemental food “backpack” programs give low-income children access to nutritious foods when school is not in session. Programs are funded by the U.S. Department of Agriculture (USDA) and administered by local organizations, including hospitals. Find your nearest site on the USDA website and check out this USDA toolkit on how to sponsor a site.
  • Soup kitchens and congregate meals: Congregate meals are meals served in community settings such as senior centers, churches, or senior housing communities. Soup kitchens and congregate meals are free or donation-based. The USDA provides tips and resources on how to start a congregate meal site.
  • Home-delivered meals: There are numerous services that offer home-delivered meals to vulnerable populations, such as Meals on Wheels, which delivers meals to food-insecure seniors. In Philadelphia, organizations partner with catering or dining services to prepare meals delivered by volunteers. Community Servings and Project Angel Heart are nonprofit food and nutrition programs that deliver medically tailored meals to individuals and families living with critical and chronic illness in Massachusetts, Rhode Island, and Colorado. Many food delivery efforts focus on seniors since this population often faces mobility issues.  
  • Food banks and pantries: Food banks partner with local nonprofit organizations to distribute food to families, seniors, and other individuals in need. Feeding America provides helpful information on how hospitals can develop partnerships with food banks or support the work of food pantries.
Women choose vegetables from the food bank
Participants of the Nutritional Options for Wellness (NOW) program get to know their neighbors while selecting fresh produce. (Access of West Michigan)

Best practices for hospital participation in food insecurity interventions

As more and more research emerges on the links between food insecurity and patient health, new interventions are being implemented and evaluated to address food insecurity in clinical and nonclinical settings. Consider these recommendations and best practices when developing a new intervention or seeking to improve existing programs:

Develop an accessible and reliable database of social resources

This is a basic and critical first step to connecting patients with resources. Hospitals should keep an up-to-date internal database and develop a mechanism (pamphlets, info sheets, or a website) for clinicians to share this information with patients.

Project Bread, a Massachusetts-based anti-hunger organization, developed a Hospital Handbook for clinicians and staff. This resource provides up-to-date, brief information in an accessible format. Eat San Francisco’s web-based database of healthy food resources for the San Francisco area is another great example of a community resource.  

Implement an active referral system

Active referrals have been demonstrated to be far more effective than simply providing patients with a list of resources or a hotline. Instead of requiring patients to follow up on their own, hospitals should obtain authorization from patients to allow outside organizations (such as community resource navigators or pantries) to follow up with patients directly.

Kaiser Permanente Colorado integrated a referral form into patients’ electronic medical record, which patients sign to authorize Hunger Free Colorado, an anti-hunger nonprofit, to contact them directly. This change increased the percentage of referred patients who received resources from 5 to 78 percent.

Provide patients with supportive services, such as patient navigators

Patient navigators are employed by hospitals and work with patients onsite to provide supportive services, such as help applying for benefits (SNAP, TANF, WIC, etc.), helping patients locate food banks or even accompanying them to pantries, navigating transportation barriers, and offering other support. Patient navigators can also assist patients in meeting other needs, such as housing, medical insurance, or Medicaid assistance.

For example, Memorial Hermann Memorial City Medical Center’s emergency department provides patients with navigators or “promotores de salud,” bilingual, state-certified community health workers trained in peer-to-peer counseling.

Navigators, who are trained to provide support in a linguistically and culturally appropriate manner, screen patients for food insecurity and assist them in securing resources. In a 2013 study, the use of navigators was shown reduce the use of the emergency room by patients seeking non-emergency care at Memorial Hermann.

Reduce or remove language and cultural barriers

Interventions should consider the unique barriers patients may face due to different cultural preferences, religious beliefs, or language barriers. For example, accessing programs and services like SNAP or WIC can be difficult for patients who do not speak English or are not familiar with social services. Barriers can be minimized by translating materials, providing interpreters, training staff in cultural competency, and designing culturally-appropriate interventions.

Boston Medical Center (BMC) issues food-insecure patients a food prescription, which is captured in their electronic medical record and forwarded to the Preventative Food Pantry. At the pantry, staff compile each patient a bundle of medically and culturally appropriate foods, including fresh produce and meat. The BMC pantry serves approximately 7,000 patients every month.

Address social determinants of health that are interconnected with food insecurity, such as housing and transportation

Health Leads, a Boston-based nonprofit, is helping hospitals implement interventions that connect patients to community-based resources such as food, transportation, and housing. Health Leads works across the country by placing undergraduate volunteers in hospitals to connect patients with social needs to local resources.

2-1-1 is a free, confidential referral and information service that connects people to a specialist who will help them find local health and human services. The 2-1-1 dialing code is available to over 250 million Americans (83 percent of the U.S. population), covering all or part of 49 states. Hospitals can work with their local 2-1-1 organization, such as San Diego 2-1-1, to support their efforts and utilize their referral service.

Unite Us developed software for hospitals to track and coordinate care across all social determinants of health. Unite Us provides technology solutions and technical support to provide a centralized system to record social needs and referrals in electronic medical records and connect patients to service providers, community resources, and employment opportunities.

CSA pick-up at South Valley Economic Development Center, one of the La Cosecha distribution sites.
CSA pick-up at South Valley Economic Development Center, one of the La Cosecha distribution sites in New Mexico (Healthy Here PR at CWA Communications) 

Recommendations and examples of hospital food insecurity interventions

While food insecurity screening is increasingly becoming a standard part of patient care, a number of hospitals have launched interventions that provide patients with immediate emergency food resources or work to connect them with longer-terms resources for alleviating food insecurity. Below is a list of recommended practices and examples of hospitals implementing these interventions for their patients.

Sharp Grossmont Hospital, Calif. (Provide in-house patient navigators/referrals to community organizations)
Hospital and program example

Pledge signer iconSharp Grossmont Hospital

San Diego, Calif.

Care Transitions Intervention (CTI) program


Piloted in 2014, CTI connects vulnerable patients to community resources. The program provides 30-day post-discharge coaching and referrals to hunger relief organizations, transportation, medical equipment, and other social supports. Program participants also receive nutritionally tailored food, and/or direct referral to the San Diego Food Bank. 


The CTI program has reduced readmission among vulnerable populations at Sharp Grossmont from 20% to 10%. CTI averages 20 food bank referrals per month. From September 2015-March 2015, the program connected 67% of participants with the Emergency Food Assistance Program, 22% to Senior Food Program, 71% to Food Distribution, and enrolled 7 in CalFresh (SNAP). 

ProMedica Health System, Ohio (Provide food assistance on-site)
Hospital and program example

Provide food assistance on-site  (produce prescription programs, food pharmacy programs, on-site food pantry)

ProMedica Health System

Toledo, Ohio

Food Farmacy


Food-insecure patients are referred to a social worker or hospital patient care navigator to assist in connecting to resources, provided with a one-day food supply, and referred to the hospital’s Food Farmacy for healthy, nutritious, diagnosis-specific foods. Admission is free and prescribed by the physician once every 30 days for 6 months intervals. ProMedica incorporates food insecurity screening in their EMR system.


The ProMedica Food Farmacy has served more than 3,600 households since opening in April 2015. Among the 4,000 individual Medicaid patients who completed screening and food pharmacy referral, there was a 3% decrease in emergency visits, a 53% reduction in readmission rates, and a 4% increase in primary care visits.

Massachusetts General Hospital, Mass. (Provide assistance with applying for benefits)
Hospital and program example

PGH member icon Massachusetts General Hospital

Boston, Mass.

Food for Families program


Food for Families screens patients for food insecurity and provides services including: helping eligible patients enroll in SNAP and WIC programs, connecting patients to in-house food pantries, and enrolling in a 6-week healthy cooking course in collaboration with Cooking Matters.


In 2015, Food for Families screened 851 individuals, provided in-person consultations to 223 people, and provided in-person SNAP application assistance to 105 participants.

Arkansas Children’s Hospital (Provide assistance with applying for benefits)
Hospital and program example

PGH member iconArkansas Children’s Hospital 

Little Rock, Ark.

onsite WIC clinic


In 2015, Arkansas Children’s launched an on-site WIC clinic (open every Friday) that helps patients apply for benefits such as SNAP and WIC. 


Since the WIC clinic launched in 2015, over 700 visits for assistance have been made.

Kaiser Permanente Colorado (Provide assistance with applying for benefits)
Hospital and program example

PGH member icon Pledge signer iconKaiser Permanente Colorado

Denver, Colo.

Hunger Free Colorado


Kaiser staff screen and actively refer food-insecure patients to Hunger Free Colorado. With patient consent, the hospital provides Hunger Free Colorado with patient contact information so they can conduct outreach instead of patients having to connect with services. Hunger Free Colorado helps patients apply for and receive food benefits and resources. 


The program has referred more than 1,800 Kaiser patients to Hunger Free Colorado. After initiating active referrals, Hunger Free Colorado increased connections to services by a factor of 14.

Arkansas Children’s Hospital (Host summer meals or other federally funded feeding programs)
Hospital and program example

PGH member icon Arkansas Children’s Hospital 
Little Rock, Ark. 

sponsor for USDA meals program


Arkansas Children’s partnered with the USDA to provide a free, healthy sack lunch to any child on the hospital campus. It is one of the only hospitals to provide meals year-round. Arkansas Children’s is reimbursed for the cost of meals and some staff time.


In 2016, Arkansas Children’s Hospital handed out 21,165 free lunches and has provided more than 76,000 since the program began in 2013.

Seattle Children’s Hospital, Wash. ( Host summer meals or other federally funded feeding programs)
Hospital and program example

PGH member iconSeattle Children’s Hospital 

Seattle, Wash.

Kids Café


In 2017, Seattle Children’s partnered with Food Lifeline to launch Kids Café at their Autism Center. Kids Café brings wholesome snacks and meals to children at community sites such as health care facilities, libraries, and Boys & Girls Clubs.

The program is reimbursed by the federal government for the cost of food. Food Lifeline, which rescues surplus food from farmers, restaurants, grocery stores, and food manufacturers supplies the food and administers the program. Other community partners, such as Seattle Children’s Hospital, provide space and supervision for the children while they eat.   


The program ran from July through September, 2017 and served 10 children each day. Patients enrolled in the Autism Center’s Early Intervention Program were eligible for Kids Café. While the program at the Autism Center will not continue, Seattle Children’s Hospital is considering hosting new sites.  

Kadlec Medical Center, Wash. (Support/partner with local hunger organizations)
Hospital and program example

Kadlec Medical Center

Richland, Wash.

Project Homecoming


Project Homecoming, a partnership with Meals on Wheels, was launched in 2016 to address the nutritional needs of senior patients. Patients who screen positive for food insecurity are provided with meals (delivered by Meals on Wheels) for 30 days after hospital discharge. Kadlec reimburses Meals on Wheels for the cost of meals and nutritional supplements for patients. Patients are also provided with nutrition education information.


In 2016, Project Homecoming enrolled 29 patients. Enrolled patients’ readmittance rate was 3.4% compared to 5.5% for patients not enrolled in the program.

Kaiser Permanente, Calif. (Address social determinants of health connected with food insecurity)
Hospital and program example

PGH member icon Pledge signer iconKaiser Permanente 

Southern California

Health Leads 


In partnership with Health Leads, Kaiser Permanente piloted a call center that contacts patients in the top 1% of predicted health care utilization, according to their illness burden. Trained Kaiser staff screen patients for needs including housing and food and enroll patients in the Health Leads program. Enrolled patients are contacted every two weeks to check on progress and connect them to resources.


In 2016, Kaiser enrolled 186 patients. Of patients screened, 74% enrolled in the Health Leads program. Kaiser is evaluating the program’s success in connecting patients to resources and working on improving community-hospital alignment.

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