The Hunger Vital SignTM

NCoP Member Center

The Hunger Vital SignTM National Community of Practice

Co-convened by Children’s HealthWatch and the Food Research & Action Center (FRAC), the National Community of Practice (NCoP) works to facilitate conversations and collective action among a wide-range of stakeholders interested in addressing food insecurity through a health care lens.

About the NCoP

Purpose

The overarching goal and purpose of the NCoP is to rapidly share leading best practices and data on food insecurity screening/intervention activities and strategies to scale what works. We hold quarterly virtual meetings to facilitate a collaborative forum and a venue where multiple stakeholders gather to disseminate research and best practices, incubate innovative ideas, and most importantly, collaborate in sub-groups to inform and influence large-scale policy and practice change resulting in evidence-based innovations to alleviate food insecurity and improve population health outcomes.

Subgroups

Policy – Projects that advance the policy landscape surrounding food insecurity screening and intervention

Coding – Projects that improve the compatibility of electronic medical records and coding language for food insecurity screening and intervention

Research – Projects and partnerships that enhance the evidence-base for food insecurity screening and intervention

Clinical Implementation – Engaging providers to increase implementation of food insecurity screening and intervention practices

Additional information on the NCoP is available under Resources

Hunger Vital Sign™ NCoP resources

From Progress to Peril: Food Insecurity Screening, Social Care Integration, and a Path Forward

This brief examines how recent federal and state decisions threaten a decade of advancements in integrating food insecurity screening and social care into healthcare, while outlining a robust roadmap to restore these critical, evidence-based efforts.

Food Insecurity Documentation and Coding in Health Care Settings: Identifying and Addressing Food and Nutritional Needs for Patients

Food insecurity affects millions of Americans and poses significant challenges for managing chronic disease. This policy brief provides comprehensive guidance on implementing standardized documentation and coding practices for food security screening, assessment, and intervention activities in an effort to positively impact the Social Determinants of health SDOH (the conditions in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes).

Expanding the Continuum: Referral Platforms for Comprehensive Care Coordination

This practical guide is designed for healthcare practitioners, community-based organizations, and anti-hunger advocates who want to incorporate successful strategies from the Accountable Health Communities (AHC) Model into their daily work. Rather than simply explaining what the model is, this guide focuses on how to implement its most effective components to address health-related social needs (HRSNs) in your community.

CMS Accountable Health Communities Model: Practitioner's Implementation Guide

This guide is designed to help healthcare providers, anti-hunger advocates, and community-based organizations navigate community referral networks to address health-related social needs (HRSNs), including food insecurity. Moving beyond basic platform descriptions, it offers practical insights into commonly used referral platforms, such as Unite Us and Findhelp, compares their features, and explores how they can be integrated into daily workflows.

FOOD AS MEDICINE SURVEY FINDINGS: How Anti-Hunger Organizations Partner With Health Care Providers to Address Food Insecurity

This report from The Food Research & Action Center (FRAC) presents findings from their survey to assess how state and local anti-hunger organizations are partnering with healthcare providers, practices, organizations, and systems to address hunger with an emphasis on learning about partnerships to connect households to the Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). This survey focused on learning about current models and activities that organizations are engaged in, as well as identifying challenges faced, and supports that would help to accelerate this work.

What Anti-Hunger Advocates Need to Know About Standardized Screening for Food Insecurity and Other Health-Related Social Needs

This brief examines recent standards-setting initiatives within the healthcare sector regarding screening for food insecurity and other health-related social needs. It offers recommendations for anti-hunger advocates to leverage screening efforts to improve the nutrition, health, and wellbeing of people struggling to put food on the table.

Electronic Medical-Record Based Referrals to Community Nutritional Assistance for Food-Insecure Patients

This paper briefly describes the integration of a food resource referral into the Hennepin County Medical Center's EMR at the hospital, outpatient clinics, and community primary are clinics for patients that screen positive for food insecurity using the Hunger Vital Sign. Authors found that this clinic-to-community linkage fits into clinicians' workflow with minimal disruption, efficiently connecting patients to the hunger relief system.

Hunger Vital Sign NCoP Professional Brief: Four opportunities for medical and health organizations to address food insecurity

This brief provides examples of work by leading medical and health organizations to support Hunger Vital Sign National Community of Practice members’ efforts to improve the food security of their patients at practice and policy levels — work that ultimately promotes positive health outcomes, addresses longstanding disparities in health, and reduces health care costs. Drawing on concrete examples, this brief describes the following four opportunities for medical and health organizations to engage their members in addressing food insecurity: 1) adopt; 2) assist; 3) advocate; 4) and advance the field.

Food is Medicine Massachusetts State Plan Case Study

The Massachusetts Food is Medicine Case Study, written by NCoP members, captures the lessons learned, takeaways, and process details of the MA FIM State plan. FIMMA’s case study motivates context-specific application of FIM interventions. This is a blueprint to inform future initiatives with evidence-based practices and an infrastructure to translate planning to implementation.

Food Insecurity and Health: Overcoming Food Insecurity Through Healthcare-Based Interventions

The National Quality Forum (NQF), in collaboration with Humana Inc. has released its latest practical resource, a food insecurity and health implementation guide. Drawing from diverse expert input and patient experiences, NQF's latest Guide includes lessons learned, innovative and promising practices, as well as solutions to common barriers to address food insecurity in communities across the nation. The Guide provides healthcare organizations with a range of strategies to effectively intervene and assist individuals in their communities who may experience negative health outcomes from unstable access to food. Members of the NCoP served as contributors and reviewers of these measures.

The Hunger Vital Sign Identifies Household Food Insecurity among Children in Emergency Departments and Primary Care

This study aimed: (1) to examine the sensitivity and specificity of the 2-item Hunger Vital Sign against the 18-item Household Food Security Survey Module (HFSSM) in identifying young children in food insecure households in emergency department and primary care sites and (2) to examine associations between food insecurity and adverse health conditions. Results found that screening for food insecurity with the Hunger Vital Sign identifies children at risk for adverse health conditions in both primary care and emergency department sites, and can be used to connect families with resources to alleviate food insecurity.

An Overview of Food Insecurity Coding in Health Care Settings: Existing and Emerging Opportunities

Developed by NCoP member Sarah DeSilvey, FRAC and Children's Healthwatch (NCoP co-conveners), this report reviews existing and emerging opportunities to document food insecurity screening, assessment, intervention, and billing for each part of a patient visit using discrete codes and language from standardized EHR medical vocabularies.

PAS Presentations

This document features food insecurity and related posters and presentations from the 2019 Pediatric Academic Societies (PAS) Meeting. Search criteria included: food insecurity; social determinants of health; social need/risk; and screening (related to food insecurity and the social determinants of health). Work of NCoP members is highlighted in yellow and in bold.

Blue Cross Blue Shield Memorandum

Drafted by Sarah DeSilvey (NCoP member) and Children's HealthWatch (co-conveners of NCoP), this memo was sent to Blue Cross Blue Shield of Vermont on the importance of reimbursing for health risk assessment CPT codes 96160 and 96161. As a result of collaborative efforts, BCBS of VT (the largest private insurer in VT), now reimburses for these CPT codes, which include food insecurity.

IMANA Webinar

In April, 2019, the NCoP was featured in an Islamic Medical Association of North America (IMANA) Webinar titled "Ending Hunger Using the Hunger Vital Sign Tool." The following resource is the slide deck Richard Sheward (co-convener of the NCoP) used for the presentation. The slides introduce the HVS tool and the NCoP, the food insecurity screening and referral process, and other relevant resources.

MHCU Webinar

In September, 2019, Richard Sheward and Heather Hartline-Grafton (co-conveners of the NCoP) presented as subject matter experts on "Identifying & Addressing Food Insecurity in Healthcare Settings" during Moving Health Care Upstream's Policy Learning Lab Webinar. The following resource is a slide deck of this presentation.

Policy Learning Lab Compendium of Research & Technical Assistance Memos

In 2018, Children’s HealthWatch and FRAC (co-conveners of the NCoP) participated in Moving Health Care Upstream’s Policy Learning Lab, where they partnered as a subject matter expert in food insecurity and provided tailored resources and technical assistance to support four of the Policy Learning Lab teams. The following resource is the full MHCU Policy Learning Lab report, released in April, 2019. NCoP memos can be found on pages 37-63 in the following resource.

2025 Meetings

During this virtual meeting, The Hunger Vital Sign National Community of Practice welcomed presentations featuring exciting opportunities and innovations promoting WIC enrollment and retention. This recap newsletter includes links to the Webinar slide deck and recording, Q&A, and other updates.

During this virtual meeting, The Hunger Vital Sign National Community of Practice marked the release of a new report, which included an engaging panel discussion exploring how healthcare providers, community organizations, and technology platforms are collaborating to address food insecurity and other health-related social needs (HRSNs). This recap newsletter includes links to the Presentation slide deck and recording, Q&A, and other updates.

2024 Meetings

During this virtual meeting, The Hunger Vital Sign National Community of Practice welcomed presentations featuring exciting opportunities and innovations promoting WIC enrollment and retention. This recap newsletter includes links to the Webinar slide deck and recording, Q&A, and other updates.

During this virtual meeting, The Hunger Vital Sign National Community of Practice welcomed presentations featuring exciting opportunities and innovations promoting WIC enrollment and retention. This recap newsletter includes links to the Webinar slide deck and recording, Q&A, and other updates.

During this virtual meeting, The Hunger Vital Sign National Community of Practice explored and discussed opportunities for streamlined safety net program enrollment among families with young children. This recap newsletter includes links to the Presentation slide deck and recording, Q&A, and other updates.

During our Fall 2024 virtual quarterly meeting, FRAC presented findings from their recent Food As Medicine report and Project Bread (featured in the report) presented their work to connect patients to SNAP and other health-supporting nutrition resources by partnering with healthcare providers. This recap newsletter includes links to the Presentation slide deck and recording, Q&A, and other updates.

2023 Meetings

During this virtual meeting, The Hunger Vital Sign National Community of Practice welcomed presentations on two timely aspects of food security screening and measurement. First, Dr. Emilia De Marchis, MD MAS., family practice doctor and Assistant Professor of Clinical Family and Community Medicine, at the University of California San Francisco, described what anti-hunger advocates need to know about recent healthcare sector standards-setting initiatives that include screening for food insecurity and other Health-Related Social Needs. Second, Dr. Ana Poblacion, Ph.D., MS, Research Scientist and Director of Multisite Operations, at Children’s HealthWatch, shared an overview of the newly developed and validated Abbreviated Child and Adult Food Security Scale for use in clinical and research settings. This recap newsletter includes links to the Webinar slide deck and recording, Q&A, and other updates.

2022 Meetings

Children’s HealthWatch, FRAC, and the Hunger Vital Sign National Community of Practice worked in partnership with several stakeholders, including the Boston Organization of Nutritionists and Dietitians of Color, University of Colorado Medical Center, Cystic Fibrosis Foundation, Greater Boston Food Bank, Boston Public Health Commission, 360girls&women, Center for Health Law and Policy, Harvard Medical School, RTI. International, Highmark Health, Bi-State Primary Care Association, Inter-Island Health Collab (Martha’s Vineyard and Nantucket), and individual people. This document summarizes major themes organized by questions 1-5 as outlined in the Toolkit for Partner-Led Convenings and expressed by stakeholders captured by the focus group’s sessions. Click here to read the proceedings (summary and notes) from the listening session.

During this virtual meeting, The Hunger Vital Sign National Community of Practice discussed recent rulemaking by CMS, and the publication of preliminary lessons from the CMS Innovation Center’s Accountable Health Communities (AHC) Model, marking a new phase of bringing food insecurity screening to scale nationally. This conversation covered the recent Hospital Inpatient Quality Reporting guidance from CMS for SDOH screening, Global Malnutrition Composite Score, and CMS’ request for information to support future changes. We also introduced a new resource profiling the research behind food insecurity within the AHC Model. This model was cited by CMS in its recent decisions, and a recent explainer series attempts to deepen understanding of social risk screening tools at the healthcare practice level while also gathering feedback on specific practice questions around implementation. This recap newsletter includes links to the Webinar slide deck and recording, Q&A, and other updates.

2021 Meetings

Recap of virtual meeting held March 25, 2021. This meeting featured a presentation and discussion with Marlysa Gamblin, MPP, founder of the Racial Equity & Hunger National Learning Network and GamblinConsults, and former Senior Domestic Policy Advisor for Racial and Gender Divides at Bread for the World Institute. During the presentation, Marlysa provided a brief overview of racial equity and introduced the Racial Equity Scorecard for Policy and Programs with examples and conversation around how it can be applied to our work, including evaluating nutrition programs, such as SNAP. The following resource includes links to the Webinar slide deck and recording, Q&A, member updates, and discussion notes.

Recap of virtual meeting held June 22, 2021. Following up on our December panel presentation, “Policy in Action: Efforts to Enroll Medicaid Beneficiaries in SNAP”, this meeting presentation took a deeper dive into SNAP and WIC enrollment gaps. A panel featured presentations on the Colorado Blueprint to End Hunger on maximizing enrollment of Medicaid members in SNAP and WIC, FRAC’s new analysis on the SNAP Gap, and from the Center on Budget and Policy Priorities on strengthening ties between WIC and Medicaid. This meeting featured The following resource includes links to the Webinar slide deck and recording, Q&A, member updates, and discussion notes.

Recap of virtual meeting held September 24, 2021. This meeting featured a presentation from Dr. Ana Poblacion on a new, abbreviated food insecurity scale. Based on items from the established US Household Food Security Survey Module (HFSSM), Dr. Ana Poblacion described how she and her colleagues are developing a sensitive, specific, and valid food security scale to identify levels of severity of food insecurity in both adults and children in the household. This meeting also included member subgroup discussions and key policy updates. This recap newsletter includes links to the Webinar slide deck and recording, Q&A, member updates, and discussion notes.

2020 Meetings

Recap of the annual in-person NCoP meeting, held on February 29, 2020, at the National Anti-Hunger Policy Conference in Washington, D.C. The following resource includes a list of attendees, meeting notes, member updates, and a summary of current member projects.

As a follow-up to engage with those who were unable to attend the annual in-person meeting in February, a virtual planning call took place April 2, 2020 to allow for all HVS NCoP members to participate in our 2020 strategic planning. The following resource includes meeting notes and member updates in response to COVID-19.

Recap of virtual meeting held June 3, 2020. This meeting featured a presentation by Kevin Fitzpatrick, PhD, professor at the University of Arkansas on preliminary research findings documenting post-COVID prevalence of food insecurity in the US and by region. The following resource includes links to the Webinar slide deck and recording, Q&A, member updates, and discussion notes.

Recap of virtual meeting held September 16, 2020. This meeting featured a presentation by Diane Whitmore Schazenbach, PhD, Director of the Institute of Policy Research at Northwestern University, on the rise of food insecurity during the COVID-19 pandemic using recent Census Household Pulse Survey data as well as the effect of Pandemic EBT (P-EBT) on measures of food hardship. The following resource includes links to the Webinar slide deck and recording, Q&A, member updates, and discussion notes.

Recap of virtual meeting held December 10, 2020. This meeting featured a conversation among experts about existing opportunities, efforts underway, and potential avenues to ensure all Medicaid beneficiaries eligible for SNAP are enrolled in the program. efforts to enroll Medicaid beneficiaries in SNAP. The following resource includes links to the Webinar slide deck and recording, Q&A, member updates, and discussion notes.

2019 Meetings

Recap of the annual in-person NCoP meeting, held on February 23, 2019, at the National Anti-Hunger Policy Conference in Washington, D.C. The following resource includes a list of attendees, meeting notes, member updates, and a summary of current member projects.

Recap of virtual meeting held May 21, 2019. This meeting featured a presentation of SIREN’s recent Community Resource Referral Platforms guide by Yuri Cartier, with a follow-up discussion lead by Lynn Knox of the Oregon Food Bank. The following resource includes the downloadable guide and SIREN presentation slides, links to the Webinar slide deck and recording, presentation notes, member updates and discussion notes, and member Q&A.

Recap of virtual meeting held August 15, 2019. This meeting featured a presentation by Kristin Sukys and Jean Terranova of the Massachusetts Food Is Medicine State Plan, a two-year statewide initiative that explored the need for and access to nutrition interventions in the Commonwealth, and provides fifteen actionable policy recommendations to increase access to food is medicine interventions. The following resource includes the downloadable MA Food Is Medicine State Plan and Executive Summary, links to the Webinar slide deck and recording, and member updates and discussion notes.

Recap of virtual meeting held November 7, 2019. This meeting featured a presentation by Tricia McGinnis and Anna Spencer of the Center for Health Care Strategies, who discussed the landscape of waivers available for state agencies to address food insecurity through Medicaid and partnerships with CBOs. The following resource includes links to the Webinar slide deck and recording, Q&A, member updates, and discussion notes.

2018 Meetings

Recap of the quarterly meeting held in May 23, 2018. This meeting introduced a newly released issue brief developed by the NCoP (primarily member Sarah DeSilvey) titled “An Overview of Food Insecurity Coding in Health Care Settings: Existing and Emerging opportunities”, and discussed opportunities to document food insecurity in the medical record. The following resource includes links to the Webinar slide deck and video recording, meeting notes, member and project updates, and additional resources.

Recap of the quarterly meeting held August 22, 2018. This meeting featured a presentation from Danielle Jones on the EveryONE Project. The following resource includes links to the Webinar slide deck and video recording, and additional resources.

Recap of the virtual meeting held November 18, 2018. This meeting featured a presentation from Wendy Davis, Stanley Weinberger, and Chris Pellegrino from the Vermont Child Health Improvement Program (VCHIP) on “Improving Food Insecurity Screening in Vermont Health Care Settings”. The following resource includes the downloadable VCHIP presentation slides, links to the Webinar slide deck and recording, presentation notes, and member updates and discussion notes.

2017 Meetings

Recap of the quarterly meeting held December 7, 2017. This meeting featured a presentation of “Community Health Detailing: Tap the Power of Community to Improve Care for Food-Insecure Families” by Rishi Manchanda, Founder and President of HealthBegins. The following resource includes links to the Webinar slide deck and video recording, guest presentation slides, meeting notes, member and project updates, document of NCoP “goals, priorities, and accomplishments”, and additional resources.

2016 Meetings

The following resource includes links to documents discussed at the quarterly meeting held in December 2016. These include relevant journal articles, Malnutrition Quality Collaborative Workgroup Meeting 1 & 2 slides, draft letter to the AAFP, Hunger to Health Coalition sign on letter, and additional resources.

2017 Meetings

Membership

To join the Hunger Vital Sign™National Community of Practice, click here or contact Richard.Sheward(at)bmc.org.

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