Improving interdisciplinary communication to address food insecurity in primary care

Abstract

Food insecurity is a significant social determinant of health associated with chronic disease progression, increased healthcare utilization, and higher healthcare costs. Rural populations are particularly vulnerable due to geographic isolation, limited transportation, and reduced access to nutritious foods. Although primary care clinics increasingly screen patients for food insecurity, many lack standardized processes for connecting patients with community nutrition resources. At the project site, standard practice was informal referrals for positive screening of food insecure individuals, limiting interdisciplinary communication and the ability to track patient follow-up. This quality improvement project aimed to implement a standardized electronic health record (EHR)-based referral process to improve communication and care coordination for adult patients who screened positive for food insecurity during annual wellness visits or when establishing care in a rural primary clinic over a six-week period. Interventions included staff education, standardized workflow, EHR-based referral, and distribution of community food resource information to patients. The care coordinator contacted referred patients within one week to assess food resource utilization and ongoing needs. Process outcomes were evaluated through chart audits measuring staff education completion, referral placement for eligible patients, documentation of referrals, and care coordinator follow-up. The outcomes of the intervention were improved interdisciplinary communication, increased consistency in EHR documentation, and increased patient communication with care coordinator. This project highlights the role of standardized referral processes within primary care workflows to address food insecurity and strengthen care coordination in rural clinical settings.