Hunger Free Vermont, Hunger Vital Sign & The Bigger Picture

Find all supporting materials at the Hunger Vital Sign explainer series website.

This episode features an interview with Katy Davis, Community Health Initiatives Director at Hunger Free Vermont.

Part One of this series featured Children's HealthWatch - find their Hunger Vital Sign materials and background research here.

Audio Editing and Post-Production Provided By Evergreen Audio

Transcript

LABUN:

Welcome to episode number nine in our series of short explainers for the Hunger Vital Sign tool. I’m your host, Helen Labun. In this episode, we’re concluding our conversation with Katy Davis of Hunger Free Vermont. 

DAVIS:

My name is Katy Davis and I am the community health initiatives director at Hunger Free Vermont. Hunger free Vermont is a mission driven organization with the goal of ending the injustice of hunger and malnutrition for all Vermonters.

LABUN:

One of the things that Katy looks for is ways to make changes at scale - building from federal programs and bringing in tools, like Hunger Vital Sign, that are designed to become standard systems, used in a universal way throughout the state or country. 

DAVIS:

Hunger Free Vermont's work is really at the systems level, trying to expand and increase access to food and our main vehicle for that is really trying to encourage use of the federal nutrition program. Things like Three Squares Vermont, or what we call nationally SNAP, meals in school, meals in childcare. So really trying to provide technical assistance on how to best run those programs and how to increase participation. And I’m trying to focus on the universality of things. . . really trying to focus on dignity and reducing stigma in Three Squares Vermont. 

LABUN:

Note how, in this sense, standardization and accessing federal programs isn’t about rules and bureaucracy, it’s about making cultural shifts to signal that we’re all working on the big issue of hunger together, that it’s a universal concern, and many of us may need assistance at some point in our lives. That last point is particularly true in health care, where new diagnoses or medical events may change not only someone’s financial circumstances but also things like mobility, ability to cook, and dietary requirements - including possibly requiring complicated, specialized diets. Hunger Vital Sign screening holds a place for all of these conversations. 

DAVIS:

If everybody in the state is going into the doctor for either annual visits or if they need additional care and they're being asked these questions, these are conversations that are happening more and more. They're really personal. And, it can be really difficult to have them. And so, as you're building that relationship, we're in many ways changing the culture and the way that we think about ourselves when we need assistance, the way that we think about others. And I think there's a lot of kind of far reaching implications outside of health care that having this habitual conversation can really start to change the way that we think about food access and the way that we think about asking for help when you're struggling. And the way that we think about designing and devising programs to meet these needs.

LABUN:

We’ve also discussed practical ways that work on food insecurity screening in health care makes sense to an organization dedicated to ending hunger. Health care providers consider a broad range of preventive factors that support good health, including the quality of our diet. There’s also clear clinical evidence around how diet affects treatment for many health conditions. It makes sense, then, for health care providers to talk about food with their patients. Also, collecting food insecurity information in health care settings, especially primary care, can capture information from a wide cross section of a community. This community level data is especially useful because it’s iterative .  . .in other words, patients return regularly, so you can begin to evolve and improve programs, and get rapid feedback on whether you’re on the right track. Of course, this advantage of health care partnerships extends only as far as a region has invested in health care access for everyone. 

DAVIS:

. . .  The state of Vermont has really long done a good job of making sure that our folks with the lowest socioeconomic status have really had access to healthcare.

LABUN:

To recap this recap, opportunity abounds. 

But there are limits too. I remember talking to one of my college friends who went on to become a doctor treating hospital patients with advanced kidney disease. Somewhere around the summer of 2020 he said to me “I spend all day working as hard as I can to keep patients alive to see their family one more time, and now you expect me to also go to their corner convenience store and convince the owner to carry kale and apples instead of chips and soda, and then make sure people have the money to buy the kale, and that they want to cook and eat the kale, so that 20 years from now someone else might not be in the same situation as the patient I’m trying to save today? Even if I had the time, where would I find the emotional capacity?”  

The original quote used more colorful language. But, point well taken. It’s not just about time and it’s not just about caring what happens. Making necessary changes in the food system requires expertise. It requires all types of expertise -- how well someone performed in medical school doesn’t have anything to do with how much we trust them with kale recipes. It requires community knowledge. It requires policy change. And sometimes it straight up requires regulatory authority over the food system. 

DAVIS:

I think, you know, medical providers are used to having to do it all.

LABUN:

Solving hunger - it’s not a place where medical providers are going to do it all. 

DAVIS:

I think there's definitely apprehension assuming that, when you start screening, you need to be able to jump into the deep end of the pool right away. And I think that's just unrealistic. It’s an unfair expectation to put on anyone as a medical provider. And that one of the opportunities that the Hunger Vital Sign really does afford is to develop deeper connections with community organizations and understand what types of services are being provided out in the community and who can help support folks finding what they need.

And there's certainly a lift in terms of all pieces and implementing the screen. But I think in terms of the referral and response there's a lot of people in communities across the state and across the country who have been dedicated to making sure folks can get connected to social services of all kinds. And that includes food access too. And so this is an opportunity to elevate their skills and to, you know, really open the doors a little bit wider and have it be more of a community medical response as well.

LABUN:

In episode seven, Katy talked about one of these collaborations with the University of Vermont Children's Hospital, implementing Hunger Vital Sign screening as part of a larger project to address food security for patients and their families. This project connected to several systems in health care that can help replicate successful models and provide a structure for connecting with diverse partners. Many of these systems fall under the category of quality improvement projects, and consistent data - the kind of information that’s collected with a standard tool like Hunger Vital Sign - helps practices in different places learn from each other.  

DAVIS:

We were part of a national group that was trying to implement similar quality health improvement projects at their hospital. So we had opportunities to learn from them and figure out what data we should be trying to look at and figure out, you know, how do we actually get patient voice involved? How do we actually understand what delivery of the Hunger Vital Sign feels like? And really try to set some benchmarks and understand what's happening and what direction we need to be moving in.

LABUN:

Another structure for the Children’s Hospital was their Community Health Needs Assessment, which is a process taking place every three years to build strategies for addressing critical community health needs.

DAVIS:

It was really the community health needs assessment that pushed and was the impetus for really digging into the work around implementing the hunger vital sign at the children's hospital. And it's been a wonderful experience as a community partner to be a full member at the table. 

LABUN:

Community partners have their own systems for collecting input - and this engagement is a lot of work. Bringing everyone to the table when input is needed, in a way where participants feel their perspective is valued, with a conversation structured so that the information gathered can be put into practical use . . . it’s not only a true skill set but also something that relies on trust built over time. Similarly community groups may have the experience in engaging their constituencies, but lack experience on the medical side to build a conversation that effectively engages health care systems. It’s an opportunity for mutual benefit. 

DAVIS:

Being able to get the right people at the table, I think has been one of the biggest challenges. And making sure that it's not just top down decision making, but the folks who are actually going to be part of the process have a voice. If you don't do that, then it plays into the way that you approach asking the questions and delivering the screen, because you're already frustrated by the myriad of things that's associated with it. So that can be a real struggle. I often when I run up against things, if it's a data question or a health, a medical record question, I'll often try to point them to other people that I've worked with who have actual medical experience and understand the data systems better than I do. And I think that does a nice job of building new connections for medical providers and shows that I don't do things that I'm not actually qualified to do

LABUN:

One thing we’ve emphasized in this Hunger Vital Sign series is that the risk screen is only a first step - but a powerful first step. And community partners can help take these steps in many ways. We’ve discussed their potential role in creating an effective screening process, providing connections to non-medical services for referral - and, of course, providing the services themselves, making the screening system more effective by helping it become more universally used, and building community data into advocacy for policies that bring us closer to the goal of eliminating food insecurity. 

A last point on the policy piece - in Episode Seven, Katy talked about using local data to create a path forward for universal school meals. Another advantage of partnering with groups like Hunger Free Vermont, which apply a broader anti-hunger lens to initiatives like Hunger Vital Sign screening, is they can see ways to leverage funds, data, and programs across sectors. So, for example, if screening patients for food insecurity leads to more referrals for SNAP enrollment, then that affects federal calculations of funds for school meal programs, and that in turn makes universal school meals more possible for Vermont.   

She knows those kinds of connections. 

DAVIS:

I think from a data perspective, actually having a sense of what the picture looks like for Vermont would be really amazing, and I think there's a lot of opportunity there to, you know, advocate for different waivers that could expand the federal programs in different ways. If only we knew that this population of folks who fall into this category and this geographic area had needs that were going unmet, what are those needs? We can then dig more into some of the why, if we know a bit more about the who and then either expand things for the federal programs or really hone in like with local or state money to be able to fill some of those gaps. Because I think that's part of how can we more fully leverage the funds that are coming into the state? 

LABUN:

Another point that we explored in the earlier episodes is how use of Hunger Vital Sign has evolved over the years as both research and implementation have added to its utility. A key change took place several years ago when Epic made food insecurity screening a standard part of its electronic health record, or EHR, platform.

You may not have noticed the national celebrations to commemorate this occasion, but trust me when I say that a small yet dedicated portion of the population felt very celebratory. What this meant was that health care practices had an easy, structured way to record patients food insecurity risk, allowing them to track how this risk interacted with health care services and health outcomes at the individual patient level, and to combine this data to see how food insecurity played out in patient groups across their practice - including learning whether programs designed to reduce food insecurity had a significant impact. 

There are opportunities to make more structural changes like this one to improve health care practices’ ability to collaborate with community organizations. 

DAVIS:

One of the pieces that there's a lot of momentum for are kind of wraparound referrals. So really having automated systems where, at your physician's office or at the hospital, the referral can be put in that automatically goes to a community partner or automatically goes to some Institute where services can be provided. So automating that piece of it, I think, something that we're gonna see a lot more, especially as access to technology continues to increase. 

LABUN:

Connecting records systems reflects how complicated the process can be to address the health care needs of patients with food access barriers. There might be a primary care provider, one community service organization connecting a patient with resources for food, another organization providing transportation to food programs, another health care practice with a registered dietitian providing medical nutrition services, and perhaps a fourth organization providing skills training and coaching to help patients learn to prepare a specialized medical diet.  

Another area of work is in the services themselves following a risk screen, including what services are covered by health care payers. We’ve talked about how federal nutrition safety nets offer a first step - but those don’t cover everyone and they aren’t designed to provide food that matches particular medical needs or to integrate with medical services like nutrition therapy. Should there be more standard options for next steps? And what kind of data would we need to collect to map out that strategy? 

DAVIS:

One of the things that I've noticed in the difference between Vermont and other states is, you know, there's many attributes to being a small state. However, not having economies of scale really hobbles us in some ways. Cuz you know, when I talk to folks in other states who are working on other initiatives, the shared number of people makes the idea of insurance claims and a different kind of billing codes make a lot more sense than it does here in the state of Vermont. So I think there's benefits to being a small state and, you know, in the fact that we have a really low uninsured rate, folks have relationships with their primary care providers. That really is a beautiful story in many ways. And then there's other ways where some supports are only available in places where they just have more people. And that makes more sense. Their services are different. And so I think there's pros and cons on both sides.

LABUN:

Have we said enough times that Hunger Vital Sign screening is the first step down a very long path and the opening to a very long conversation?

Well, it’s true.

And we’ll surely explore that conversation more in future episodes of Policy in Plainer English.

Before the next installment, be sure to check the resources and links in the show notes and at PlainerEnglish.org.