Addressing Food Insecurity: Clinic-to-Community Treatment Models

Model 1: Comprehensive Clinical Model of Care

Overview: Patients with identified food insecurity are referred to a clinical team member with expertise in evaluating social needs, connecting to resources and following up with patients to ensure successful connection with community resources. Patient assessment and referral status is incorporated into a medical record. This interdisciplinary model of care takes three common forms.

Description Key Personnel or Partners Benefits Challenges Example(s)
Oversight by a clinical social worker, case manager, clinic nurse, or registered dietitian who builds trusting relationships with healthcare providers and patients by identifying and prioritizing social needs and facilitating connection to resources. Social worker, case manager, clinic nurse or registered dietitians  A focus on all social needs. Funding and infrastructure to have personnel in the clinic setting. Maternity Care Homes through Strong Start (link)
Trained volunteers use a computerized database to identify high quality resources for provider-referred patients. The volunteer liaisons work with patients to address unmet social needs until they are resolved. Volunteers  A focus on all social needs. Coordination and maintenance of volunteers. Bay Area Health Desk (link)
Community health workers conduct patient home visits. Community Health Workers Benefits individuals who may require more intense and personalized assistance.
A focus on all social needs.
Costlier than other forms of the model. Nurse-Family Partnership (link)


Model 2: Healthcare Provider Prescription for Food Resources Model

Overview: A healthcare provider collaborates with a community organization that will accept food “prescriptions” for referred patients. In contrast with the comprehensive model, this approach is less expensive and only focuses on unmet food needs.

Description Key Personnel or Partners Benefits Challenges Example(s)
On-site food pantries that provide immediate access to food and sometimes assistance with SNAP applications. Food banks and referral organizations A focus on food needs. Patient readiness and time to accept food and/or apply for SNAP benefits. Preventive Food Pantry, Boston Medical Center (link)
Food outreach (link)
The Food Pharmacy at ProMedica (link)
Prescription vouchers for free food, such as fresh produce, redeemable at a local food vendor or farmer’s market where patients can purchase additional food at a subsidized rate. Farmer’s markets or other food retail outlets A focus on food needs.  Individuals must travel to external locations. St. Christopher’s Foundation for Children Farm to Families (link)
Fresh Approach’s VeggieRx (link)
Food pharmacies that provide prescriptions for medically-tailored foods for patients with nutrition-related chronic diseases or medically-tailored food programs with nutrition counseling services for referred patients. Dietitian Focus on food needs.  Individuals must travel to external locations. Metropolitan Area Neighborhood Nutrition Alliance (link)
Community Servings (link)
Tulsa CARES (link)