Unmet health-related social needs are common amongst older US adults and impact both quality of life and health outcomes. One of the ways that unmet health-related social needs impact health is through malnutrition, an imbalance in a person's intake of energy and/or nutrients. Lack of reliable access to a sufficient quantity of nutritious food is a specific health-related social need that can be assessed rapidly and, when unmet, is a direct risk factor for malnutrition and may be indicative of a broader range of unmet health-related social needs. We conducted a cross-sectional study to characterise malnutrition and food insecurity amongst older adults receiving emergency department (ED) care using brief, validated measures and to assess the burden of a broader range of health-related social needs amongst these patients. Patients were asked about their need for and willingness to receive a range of social services.The study was conducted in an academic ED serving a racially and socioeconomically diverse population in the Southeastern United States. A convenience sample of noncritically ill adults aged 60 years and older was approached between November 2018 and April 2019. Study patients (n = 127) were predominantly non-Hispanic white (67%), community dwelling (91%) and urban residents (66%) with 28% screening positive for malnutrition risk, 16% for food insecurity and 5% for both. Of those at risk for malnutrition, 25 (69%) reported ≥2 unmet health-related social needs and 14 (38%) were receptive to social services. Amongst food insecure patients, 18 (90%) reported additional unmet health-related social needs and 13 (65%) were receptive to receiving social services. In conclusion, a brief set of questions can identify subgroups of older ED patients who are food insecure or at risk for malnutrition. Individuals who screen positive for food insecurity have a high burden of unmet health-related social needs.
Food insecurity is prevalent among older adults, negatively impacts health, and may increase healthcare utilization. Emergency Departments (ED) are an important site of care for older adults. However, the feasibility of screening for food insecurity in EDs is unknown. We assessed the feasibility of implementing a screening and referral process to identify and address food insecurity among older adults in the ED and then monitored progress to overcome barriers to implementation. We developed a semi-structured interview (SSI) guide using the Consolidated Framework for Implementation Research. Prior to implementation, ED staff with diverse clinical backgrounds participated in SSIs. SSIs were analyzed using rapid analysis. Before and during implementation, we engaged hospital leadership to refine the screening and referral process. During implementation, we identified barriers through periodic reflections with staff, observing screenings, and reviewing Electronic Medical Record (EMR) data. Staff agreed that food insecure older adults would benefit from community services. Nursing Assistants (NA) were identified as key implementers. ED leaders expressed concerns about regulatory compliance, EMR integration, and NA scope of work, which were addressed. During implementation, barriers included competing priorities, lack of knowledge, and discomfort with the topic of food insecurity. Stakeholder input and reviewing EMR data led to adaptations including modifying criteria for referral and embedding training into NA orientation. Leadership and staff supported food insecurity interventions but identified several concerns. Steps to facilitate implementation included identifying staff to screen, EMR integration, and building staff efficacy. Reviewing screening data and soliciting stakeholder feedback enabled ongoing adaptations that strengthened implementation.
Food insecurity is prevalent among older adults, negatively impacts health, and may increase healthcare utilization. Risk factors include poverty, lack of transportation, and social isolation. Community-based services may mitigate food insecurity and other social risk factors. However, identifying those at risk and connecting them to services can be challenging. We implemented a screening and referral program in an Emergency Department (ED) to identify older adults facing food insecurity and connect them to a local Area Agency on Aging (AAA), which arranged and tracked delivery of community-based services. ED nursing assistants used the Hunger Vital Sign screener to assess food insecurity in patients aged 60 years and older. ED Care Managers (CMs) saw all who screened positive and made referrals to the AAA. The AAA conducted an intake assessment and arranged services. Patients were contacted three months after their ED visit to evaluate health, quality of life, and satisfaction with services. Of 423 patients screened over 7 months, 45 (11%) reported food insecurity. Of those, 25 were referred to the AAA. Patients were not referred to the AAA due to CM inability to make a referral (7), declining services (4), or other reasons (11). The AAA reached 21 patients and 9 received at least one service. Of those, 5 were reached for follow-up and reported satisfaction with services. The most frequently requested service was Meals on Wheels (10). Food insecurity is common among older ED patients. An ED-AAA partnership is feasible and connects older adults to beneficial services in their communities.
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