Outreach & Referral Systems

Introduction

The Food Access and Health Care consortium informally defines a strong outreach system to have the following components:

 

  • Information is easy to find and understand. Information includes federal, statewide, regional, and local details - presented in a way that is manageable for health care staff.  

  • Information is available to provide to patients in an easy-to-review way that it is immediately actionable. This includes having multiple formats and languages.

  • Health care staff who convey information to patients know where it is found and it is kept updated (ie people don’t have to keep re-looking everything up).

  • Health care practices identify / reach out to patients who would benefit from this information - see also our page on Food Insecurity screening and our Hunger Vital Sign explainer series.

  • Health professionals participate as trusted information sources in broader information campaigns about the role of food and diet in health.

In 2020-2021 we focused on systems for conveying information related to food access as part of COVID-19 response - including changing protocols for existing programs, new or expanded programs, options for people who were self-isolating or in quarantine after COVID-19 close contact, etc. 

 

For information from the November 2020 Community Roundtable focused on FQHCs and COVID-response resources, please see this link. 

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Food Access - Statewide Information Sources

These food access information resources can help with navigating to the best match for a referral, and also help health care offices keep their referral options up to date. The Vermont Department of Health / Vermont Nutrition Education Committee also provides this chart (2019) overviewing types of food assistance programs available.

  • Vermont 2-1-1 assists individuals in finding community resources, maintains a database of over 10,000 services in Vermont, and also provides information on service search & referrals to inform policy / resource development.

  • Vermont Foodbank including COVID-19 services. The Vermont Foodbank has over 200 member organizations, with their information listed online. The Foodbank also provides trainings throughout the year. They have a 3SquaresVT team that can help with enrollment as well.

  • Hunger Free Vermont helps ensure Vermont makes best use of available federal nutrition programs, such as SNAP. They support 10 regional Hunger Councils across the state and provide a number of food resources. See the next section on resources for outreach campaigns.

  • Help Me Grow provides resources for families with young children, including care coordination assistance.

  • Vermont Association of Area Agencies on Aging provides information on both community meal sites and Meals on Wheels, along with the older adults helpline Helpline at 1-800-642-5119.

  • Older Vermonters Nutrition Coalition - A coalition of Vermont non-profits working to ensure that all older Vermonters have what they need to be well-nourished. Their website provides information on programs for individuals as well as community organizations assisting with finding nutrition supports.

  • NOFA-VT provides information on local food-focused food security programs, including crop cash, options for using SNAP at farm stands and farmers’ markets, and subsidized CSA shares.

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Outreach Materials

Some Vermont programs provide materials to support outreach around food access, as well as diet and nutrition education. Examples include:

  • Vermont Food Help - A resource hub for 3SquaresVT materials, including an Outreach Campaign Toolkit developed by Hunger Free Vermont and the Vermont Foodbank.

  • Hunger Free Vermont - including resource overviews, SNAP / 3SquaresVT enrollment, school meals, and an older Vermonters resource guide.

  • VT Fresh - A program of the Vermont Foodbank that uses behavioral economics inspired strategies to help make the healthy food choice the easiest choice.

  • Expanded Food and Nutrition Education Program (EFNEP) - A program of UVM Extension and part of a national network of extension programs that support hands-on nutrition education. Includes both materials and a staff of nutrition educators available to work with income eligible parents, caregivers, expecting mothers, children and teens.

  • VT FEED (Food Education Every Day) - A national leader in the Farm-to-School movement, VT FEED integrates local food into the school cafeteria, classroom, and community. They have many resources available for supporting childrens’ healthy diets.

  • RiseVT also provides materials developed in community programs to help replicate successful pilots across the state, such as Dinner Together materials.  

 

See also the Data & Measurement page for sources of information that can help shape outreach campaigns. For example, the Vermont Department of Health provides information from the 3-4-50 Campaign that illustrates how diet interacts with chronic diseases in Vermont, as well as how our behaviors are changing over time. The Increasing Program Impact page also provides more examples of nutrition education materials.

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Examples of Food Directory Formats

In additional to general educational and outreach materials, there are examples of regional programs building directories for accessing food in their area. Below are examples of different types of materials to assist with navigating the food system - note that this list includes general food access and also local food availability, the intent is to show different possible formats.

Referral Systems & Information Exchanges

A care coordinator at a health care provider using food directories to help patients connect with food resources is one form of referral system - that is the basic structure behind much of the information on this page. A primary care provider connecting a patient with a specialist, providing notes on the condition prompting the referral, receiving treatment plan information back, and using that medical record to work with the patient towards health goals is another form of referral system. Some regions have started to blend these models into sophisticated community referral platforms that can share structured data back and forth between the health care sector and other service providers.

The Office of the National Coordinator for Health Information Technology (ONC) supports health information technology adoption and standards-based information exchanges. In 2021, they began to map the types of referral platforms being developed to facilitate connections between health care providers and community or social service resources. Early frameworks and a series of webinars summarizing the current landscape of this work are available online from the SDOH Information Exchange Learning Group.

The SDOH Information Exchange background document summarizes the potential this way:

The capacity to capture, exchange, analyze, use, and integrate individual-level and aggregated population-level health and social determinants of health (SDOH) data is a critical factor in supporting initiatives that address individuals’ social needs and health inequities. . . such systems can help identify social needs, coordinate services, measure outcomes, implement predictive analytics, conduct research, engage in collaborative community resource planning, and more.

Some possible advantages of building a more advanced platform for connecting patients with community resources:

  • Helps care coordinators stay engaged with patients, following up to make sure they have received the resources they need.

  • Helps care coordinators build a complete resource package with patients, for example pairing referrals to a food access program with referrals to nutrition education or transportation assistance.

  • Allows for medically-tailored food assistance through having a secure way to share health information and connect food access information back to a medical record (“medically tailored” meaning connection to an individual patient’s clinical treatment / prevention plan - as contrasted with non-tailored programs designed for basic nutrition security).

  • Supports better analysis of gaps in available resources by having a structured way to aggregate information across a region.

  • Supports analysis of the health impacts of programs, again through ability to aggregate structured data and also ability to look at the range of services patients are receiving - for example, would be able to show how food access support was combined with medication management or clinical nutrition services.

  • Removes the administration, technological, and human resources burden from individual programs creating referral systems, or systems to collect data for analysis, by building a common infrastructure.

Creating these systems is a major undertaking and much of the work remains in an “innovation” phase. Here are some examples from around the country:

A closely related topic is “Z-Codes” and other taxonomies for SDOH data. For more information on this topic, the following resources offer a starting point:

Next Steps

Communications systems for health care practices connecting patients with food access resources was the first area of focus in early planning stages. Due to timing, much of this work focused on understanding information sharing structures during the COVID-19 disruptions, as reflected in the 2020 Community Roundtable materials.

The Vermont Sustainable Jobs Fund received funding in 2021 - 2022 to create a food security strategic plan that included emergency preparedness. Therefore, FAHC did not perform additional analysis of our work during the early phases of COVID-19, but rather provided materials to the food security planning group to include in their assessment and recommendations. The final report was not yet available at the time of this posting.

We identified that FAHC participants were particularly interested in learning more about how to navigate the intersection of food access and transportation barriers. FAHC contracted with Farm to Plate in 2021-2022 to review this concern and make recommendations for next steps. The final report was not yet available at the time of this posting.

Bi-State has applied to the Federal Office of Rural Health Policy for Network Development Grant funding that could support FAHC follow-up on next steps after the above reports are complete.

FAHC included SDOH Information Exchanges and closed loop referral systems, such as the ones outlined in the previous section, in our organizational structure review in summer 2022. We determined that an effective information exchange infrastructure would require public investment for statewide coverage. The primary reasons why we assessed these systems as being out of scope for FAHC were:

  • Many of the interfaces will be with state social service systems.

  • Patients move across service territories – especially if we are connecting patients to services after a hospital stay, or connecting to specialty services such as medical nutrition therapy. 

  • Systems come with high costs in IT, data management, construction – and they need to be interoperable. 

  • Much of the downstream cost savings will not be attributable to a single hospital region, or even necessarily to the health care sector, making it unlikely individual members of FAHC-participating organizations would initiate a large scale project.

  • This is an allowable 1115 waiver investment with federal match (Medicaid) and the White House has indicated future federal funding may become available to states.

However, we identified several projects started by FAHC with immediate potential:

  • Reviewing options for closed loop referrals within relevant medical services - for example through exploring Registered Dietitian / Primary Care Provider communications within Bi-State’s FQHC pilot programs and through the 2023-2024 Department of Financial Regulation review of Medical Nutrition Therapy utilization patterns.

  • Piloting closed loop communications for referral to program participation - this use case is different from a single service connection. It tracks progress across a prescribed course of activity, may include demonstrating learned skills, self-reported behavior change, or other benchmarks, and often includes HIPAA-compliant options for sharing program communications / announcements with participants.

    • Current focus is Self Management Programs / MyHealthyVT; CSA & Health care programs are a potential future application. See, for example, West Virginia Health Connection.

  • Continuing collaboration with local food programs to provide information on HIPAA and health care communications, such as in previous seminars on the topic.

Bi-State has applied to the Federal Office of Rural Health Policy for Network Development Grant funding that could support these efforts.

If another phase of Network Development is funded, we identified potential for incorporating FAHC strategic planning results and stakeholder engagement into future efforts to design structures for sharing information on access to community resources:

  • Providing feedback from end users / primary audiences - for example, our Food Insecurity Screening Systems survey suggests that at health care practices the most frequent engagement with resource directories is by a care coordinator providing direct patient assistance in navigation. Understanding how care coordinators use directories as part of guiding patients (and how they would like to do so) could provide valuable insight into directory design. This design might include both a virtual directory and tools for communicating next steps with patients.

    • See, for example, work done by hiCOlab on patient-centered resource design. FAHC is supporting a proof of concept project in 2023 to integrate resources offered by community-based health care partners (CSAs) using a similar patient co-design approach.

  • Developing strategies to ensure that clinical considerations are integrated (where appropriate) into directory platforms - Food Is Medicine Massachusetts offers one example of this work through coordinating with a clinical advisory group on how structure community food program profiles. Platform interoperability between Health IT and social services IT is another example of supporting integration.

    • A related consideration is how a community referral platform supports non-profit organizations in billing for relevant services, should payment become available.

  • Improving the implementation of food insecurity screening systems / social risk screening systems that help direct patients to community referrals (see separate recommendations).

See also outreach recommendations related to the FAHC 3SquaresVT pilot found in the Federal Nutrition Programs section.

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