Federal Nutrition Programs
Introduction:
At the base of food & health care work are the federal government programs that provide for essential access to food. These programs are primarily within the U.S. Department of Agriculture (USDA), with a state agency that supports state-level implementation.
USDA is responsible for providing a safety net for millions of Americans who are food-insecure and for developing and promoting dietary guidance based on scientific evidence. USDA works to increase food security and reduce hunger by providing children and low-income people access to food, a healthful diet, and nutrition education in a way that supports American agriculture and inspires public confidence. (USDA Food & Nutrition Services)
Federal nutrition programs include:
Supplemental Nutrition Assistance Program or SNAP (in Vermont known as 3Squares VT) and enhanced SNAP (for example in disaster or pandemic relief)
WIC - Women, Infants and Children - Vermont link is here.
Commodity Supplemental Food Program (CSFP) - provides monthly food to income-eligible older adults (see more from VT Foodbank)
School Lunch program - read more about school lunches from Hunger Free VT (including summer programs and after school food)
Older Americans Act (OAA) Nutrition Programs - Administered by the Administration for Community Living (not the USDA), these federal funds go to states to then support individual programs.
States, federal grants, health care funding and charitable funding often matches these core programs to enhance their impact - providing matching dollars for SNAP benefits spent at farmers markets, adding funds for fresh produce, supporting school backpack programs to ensure children have food for the weekend, for example. Health care funding complements, but does not replace, foundational federal nutrition programs.
See also the Produce Prescriptions page for more examples.
Federal nutrition programs often include access to nutrition education. Nutrition education focused programs are covered on our Nutrition Services page.
In September, 2021, the Bipartisan Policy Center released an extensive report with policy recommendations for building from the current food and nutrition support infrastructure and lessons learned during COVID-19 to better support nutrition security. The 2022 White House Conference on Hunger, Nutrition, and Health contained options for change as well, and the USDA released a complementary report on actions within their administrative authority that they intended to take to improve federal nutrition strategy.
Within conversations about federal nutrition programs is a question of whether the USDA should define both “food security” and “nutrition security” within its goals. The definitions section of our food insecurity screening page addresses this conversation.
Role in Screening and Referral:
Federal investment in nutrition programs has helped shape food insecurity screening and referral within a health care context. Some key points:
USDA research on household food security provides the starting points for much of the later research on measuring food access needs in a health care setting. See the Hunger Vital Sign series### for a detailed explanation of how this works.
Because of the wide availability of food assistance programs of different types (including with nutrition education and, in some cases, RD-advised nutrition tailoring), health care practices screening for food insecurity will always have starting options to offer patients for next steps.
Related to this wide availability, research on the health impacts of food access interventions often use federal nutrition program enrollment as a starting point, allowing research to be compared across geographies. (See, for example, the overview of research into health care & SNAP on pg. 49 of the 2022 Aspen Institute report).
Some potential sources of friction around integrating federal nutrition programs into a health care setting include:
The USDA tends to use income-based eligibility requirements for program participation, and may, in fact, prohibit using any other criteria. Health care practices are more likely to use patient self-attestation around food access barriers and risk factors for diet-related health conditions.
The application process for federal nutrition programs can be complicated and take many iterations to sort out, so care coordinators at health care practices may have limited capacity to provide direct application assistance (see later sections).
In many states, including Vermont, databases on participation in nutrition benefits do not connect to health care databases with information such as screening positive for food insecurity. This disconnect is legal, technical, and also privacy related -- so not simple to resolve (see also our notes on SDOH Information Exchanges).
Pilot programs for integrating food access and health care are often grant funded, and the burden of managing grants across USDA, HHS, private philanthropy and other sources that often have non-compatible evaluation criteria can discourage practices from participating.
SNAP Outreach & Enrollment:
In 2021, FAHC began to review opportunities to improve health care practices’ engagement 3SquaresVT outreach and enrollment. Two FAHC members, Hunger Free Vermont and Vermont Foodbank, are actively involved in implementing statewide outreach programs for 3SquaresVT (3SVT). We observed that 3SVT has a unique role to play in health care providers’ response to the impacts of food insecurity in their community:
It is a federally-funded entitlement program, providing access to support for food purchases as long as a household meets eligibility criteria. The stable availability can be important with health-related goals, such as managing chronic conditions.
It is the most flexible food access program, recognized at most conventional retail outlets along with local options such as farmers’ markets, and so fits most easily into patients’ regular daily routines and individual dietary needs.
Other federal nutrition programs are often built from the SNAP foundation, such as Nutrition Incentives, farmers’ market Crop Cash, and nutrition education programs.
Research on the health impacts of food insecurity often focuses on SNAP recipients, showing positive outcomes in measures like ED utilization, engagement in primary and preventive care, and total cost of care savings.
As noted above, there are also challenges for health care practices that want to assist patients in accessing these federal benefits:
Eligibility is based primarily on income, not on common screening metrics like food insecurity, diet quality, or risk of developing diet-related disease.
Enrolling can require 1:1 assistance, which takes time, and also gathering certain pieces of information, which are unlikely to be brought to a health care appointment.
Enrolling and accessing benefits takes time to process, presenting sequencing challenges if a health care practice is attempting to build from this food access program to offer additional healthy options and also assist patients who do not qualify for 3SVT.
There are Vermont organizations that can help with 3SVT outreach & enrollment, including assistance with:
Designing outreach materials – see for example vermontfoodhelp.com.
Designing general outreach campaigns that emphasize health benefits.
Training health care provider staff in related topics, including hunger in Vermont, referral systems for food assistance, and providing direct enrollment assistance.
Providing 1:1 assistance to patients who request help with 3SVT enrollment.
Analyzing patient data against known gaps in current statewide enrollment to help focus outreach and successfully engage patients at risk of food insecurity.
Offering insights from previous 3SVT outreach campaigns to build a strategy that will be effective and make best use of statewide resources for 3SVT support.
FAHC divided its goals around 3SVT into four general areas:
Informing outreach materials tailored to a health care practice setting (in coordination with the Vermont Food Help design process).
Facilitating appropriate referrals for assistance with 3SVT applications.
This focused on referrals outside of the health care practice, Hunger Free Vermont & Vermont Foodbank already offer trainings for health care providers who want to offer 1:1 assistance to patients.
Engaging local Federally-Qualified Health Centers (FQHCs) in regional 3SVT outreach campaigns coordinated through the state’s outreach grant partners.
Using available health care data to shape targeted outreach from health care practices to demographics the state has identified as being high priorities for data-driven outreach approaches.
In 2021, FAHC began a collaboration with OneCare Vermont, Hunger Free Vermont, and the Vermont Foodbank to pilot a project using the SDOH data analytics services from n1 Health. With data analysis, and using the information sharing pathways set up through the ACO structure, we could support targeted 3SVT outreach for patients at Community Health Rutland.
The pilot focused on two priority groups for statewide outreach:
Vermonters with income in the 135 - 185% of federal poverty level bracket, who are SNAP eligible but not enrolled in Medicaid.
Vermonters in households with everyone over the age of 60 and no earned income, who may be eligible for the 3 Squares in a SNAP program.
The data reviewed by n1 Health highlighted patients who were at risk of food insecurity, likely to respond to telephone engagement, and likely to be within the target demographics. For general outreach support, n1 Health also provides enhanced contact information for verifying correct contact details. Rutland could then adjust this information further with practice-specific filters, for example removing patients already receiving care management services and prioritizing patients due for an appointment reminder. This led to a prioritized list of patients to contact for discussing the benefits of 3SVT.
The outreach systems supported by Hunger Free Vermont and the Vermont Foodbank helped FAHC develop next steps for Community Health Center staff to assist potentially eligible patients with enrollment.
The pilot project is structured to work with patient outreach & engagement systems in place at a health care practice. For example, in Rutland the outreach focused on phone calls to patients either in follow up to appointments or who are due for an appointment. Other health care practices might use digital outreach or other phone call systems. This pilot is complementary to food insecurity screening. Unlike a general screening protocol, this pilot focused on active outreach targeted to a specific assistance program.
FAHC Next Steps:
At the close of the FAHC strategic planning period, the data-based pilot project in Rutland had not yet completed its full 6 months. After 6-months, n1 Health, Bi-State Primary Care Association, and OneCare Vermont will review the results of the data-driven outreach with all partners. Key outcomes to evaluate will include:
Changes in Rutland-region 3SVT enrollment trends (because enrollment takes 30 days to process and the enrolled list can’t be compared to patient outreach lists, the trend observation is indirect).
Changes in inquiries received by community partners (e.g. Area Agencies on Aging, Community Action Programs)
Efficacy in data analysis for prioritizing patient contacts - signaled by ability to narrow contact lists to a manageable size, percent of calls successfully completed, and patients who respond with positive interest.
Positive impact on patient engagement in primary care
Partners will also review the work done to prepare this pilot project for scaling statewide:
Establishing HIPAA-compliant information & data flows that can be applied to all ACO network partners.
Working through data transfer technical details and formatting to a usable structure for frontline staff doing outreach.
Creating template materials for referrals, talking points, resource connections
Designing an integration of n1 data analytics and statewide outreach goals that can match existing communication systems at health care practices. Bi-State facilitates this tailoring with federally-qualified health centers (the focus of the pilot).
Offering a small honorarium to Community Health Rutland to present on their observations from the pilot phase.
One potential barrier to expansion is that this project asks for data collection, coding, and analysis work from frontline staff who have not previously needed these skills. This theme has appeared in other elements of the FAHC planning work. Testing food-interventions in a health care setting, evaluating their health and cost impacts, tracking patients as they move through the system, identifying resource gaps. . . these are all complicated analytical tasks.
The strategic planning by FAHC observed this emerging data literacy challenge, but did not develop broad recommendations. Partner organizations work on data collection, management, and analysis with their members; preliminary conversations suggested that existing health care associations & technical assistance providers had their own plans in this regard and did not consider a Network-based approach to be a priority at this time. Bi-State is addressing the data topic specifically in a food-based intervention context through the Healthy Rural Hometown Initiative pilot program.
Community Health Rutland has also discussed running a more general outreach campaign and offering staff trainings on hunger in Vermont. This effort can increase broader social understanding for 3SVT, reinforce messages from the direct patient outreach, and reach people adjacent to potential beneficiaries (for example, children of older Vermonters). To support the next phase of outreach, FAHC developed initial concept sheets through review of current documents, past market research, and interviews with health care practices.
Notes on options for general outreach via health care practices
Rutland region overview of planned outreach by community partners
Hunger Free Vermont and the Vermont Foodbank are the lead FAHC partners working on 3SVT outreach and enrollment, including next steps for the concept sheets linked above. In 2023, Bi-State Primary Care Association will join the statewide working group on 3SVT Outreach. In 2022, Bi-State applied for a Network Development Grant that, if funded, would provide additional support for pursuing nutrition-related outreach projects through FQHCs.