Implementing a Clinical-Community Partnered Intervention to Address Food Insecurity Among High-Risk Veterans

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Background: Nearly 25% of Veterans are estimated to be food insecure (FI), experiencing limited or uncertain access to nutritionally adequate and safe foods. FI has been associated with a wide range of adverse health outcomes as well as increased healthcare costs and utilization. Concerningly, FI is frequently under- recognized in clinical settings including VHA. Prior research has shown that clinicians and other care team members often feel ill equipped to address FI even once identified. As such, there is a critical need to determine how to most effectively connect FI Veterans with relevant services and community resources in order to address Veteran FI and its downstream consequences. Gaps Addressed (Knowledge and Practice): In October 2017 the VA launched a national FI clinical reminder intended to screen all Veterans receiving care in the VHA. In the first 24 months of screening, the reminder identified over 77,000 Veterans across the country that reported FI. Little is known, however, about the variation in screening across VA sites; how sites respond when a Veteran screens positive for FI; or what VHA practices following a positive screen best improve Veteran food security status, Veteran experiences of care, and health outcomes. This proposed application would address these knowledge gaps. Innovativeness: Although VHA has begun to address social determinants of health more broadly, efforts to address FI are still in their nascency. This proposal, and the future area of research it will foster, is innovative because it seeks to develop novel VA-community partnerships that address key social determinants of health contributing to adverse health outcomes. This proposal further innovates through its emphasis on multi-level stakeholder engagement including strong Veteran engagement, and seeking Veteran-centered approaches to addressing food insecurity. Specific Aims: My long-term career goal is to become national leader in developing, evaluating, and implementing effective interventions to address Veteran FI and other social determinants of health. Through this CDA-2 application, I will build upon my prior training in family medicine and health services research to acquire advanced skills in implementation science, intervention design, and mixed methods evaluation. I propose the following research aims: Aim 1: Examine variation across VA sites nationally in implementation of the FI clinical reminder and characterize implementation experiences and community referral processes; Aim 2: Understand Veteran experiences of FI and their interactions with VA and community resources following a positive FI screen; Aim 3: Develop and pilot test an intervention model to optimize screening and referral processes for connecting FI Veterans to relevant VA and community resources. Methodology: This proposal employs a multistage mixed methods framework with integrated analyses across aims. Next Steps: When completed, this proposed work will evaluate current approaches to Veteran FI and identify and pilot strategies to integrate VHA-community partnered interventions to address FI into clinical practice. Findings will lay the foundation for a future IIR to conduct a multi-site trial of an intervention model. Further, the proposed research and training will help launch my career as an independent physician-investigator committed to providing a rigorous, scientific basis for reducing Veteran FI and related social determinants of health in a way that is Veteran-centered, maximizes patient autonomy, and optimizes health outcomes.