Enhancing Referrals to the Supplemental Nutrition Assistance Program through Clinical Integration of a Standards-Based Decision Support System

Abstract

Background The Supplemental Nutrition Assistance Program (SNAP) is one of the most successful national programs to reduce poverty and improve health outcomes, but millions of Americans who qualify still do not have access to SNAP, and limited data are available to determine how referrals to the program can be completed successfully.

Objectives We aimed to design and develop a standards-based digital care coordination platform to support closed-loop social services referrals between patients and social and health care providers and demonstrate the feasibility to screen, diagnose, plan, and complete interventions with selected patients in real settings.

Methods We partnered with community members to design the platform through Community Engagement Studios and with a Federally Qualified Health Center, Local Mental Health Authority, and Food Bank to determine the features and workflow requirements of the platform design. We customized currently available systems to use Fast Healthcare Interoperability Resources (FHIR) Application Programming Interfaces (APIs) that could exchange information in real time across providers and participants.

Results The platform was successfully demonstrated through a pilot where patients were recruited in clinical settings and referred to a Food Bank that provided SNAP application assistance to study participants. We translated the requirements of the platform to national standards and required workflows of providers and patients. Study participants were notified electronically of the specific steps to follow to complete their SNAP applications while receiving support from specialists from the Food Bank.

Conclusion The pilot demonstrated the feasibility of collecting granular social service referral information that can be used to better address gaps in social care. The pilot also highlighted the importance of further coordination on the usage and harmonization of needs assessment nationally and that current digital systems are still not ready to fully utilize national Social Determinants of Health data standards.

Keywords

Social Determinants of Health - clinical decision support - Application Programming Interface - population health - Health Information Exchanges

Protection of Human and Animal Subjects

This study was performed in compliance with federal regulations regarding personally identifiable health information, the University of Texas at Austin's Information Security Office (ISO) testing and review policies, and the University of Texas at Austin's Institutional Review Board (IRB) for Human Subjects Research (Study Number 2022-12-00003436). Our system is a social services referral decision support system only and does not offer support in the diagnosis or treatment of patients.

Publikationsverlauf

Eingereicht: 27. Dezember 2023

Angenommen: 14. Oktober 2024

Accepted Manuscript online:
15. Oktober 2024

Artikel online veröffentlicht:
19. Februar 2025

• References

• 1 Keith-Jennings B, Llobrera J, Dean S. Links of the supplemental nutrition assistance program with food insecurity, poverty, and health: evidence and potential. Am J Public Health 2019; 109 (12) 1636-1640
• 2 Mabli J, Jim O, Lisa D, Laura C, Betsy S. Measuring the effect of supplemental Nutrition Assistance Program (SNAP) participation on food security. Washington, DC: Department of Agriculture, Food, and Nutrition Service; 2013
• 3 Schanzenbach D, Bauer L, Nantz G. The Hamilton Project: Twelve Facts about Food Insecurity and SNAP. The Brookings Institution; . Accessed April 28, 2024 at: https://www.brookings.edu/wp-content/uploads/2016/07/THP_12Facts_SNAP.pdf
• 4 Center on Budget and Policy Priorities. Safety net more effective against poverty than previously thought; 2015. Accessed November 11, 2023 at: http://www.cbpp.org/research/poverty-and-inequality/safety-net-more-effective-against-poverty-than-previously-thought
• 5 Center on Budget and Policy Priorities. SNAP is linked with improved nutritional outcomes and lower health care costs; 2018. Accessed November 11, 2023 at: https://www.cbpp.org/research/snap-is-linked-with-improved-nutritional-outcomes-and-lower-health-care-costs
• 6 United States Department of Agriculture. Definitions of food insecurity. Accessed April 28, 2024 at: https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-u-s/definitions-of-food-security/
• 7 United States Department of Agriculture. How many people lived in food-insecure households?. Accessed April 28, 2024 at: https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-u-s/key-statistics-graphics/
• 8 Associated Press. Food insecurity shot up last year with inflation and the end of pandemic-era aid, a new report says. Accessed November 12, 2023 at: https://apnews.com/article/hunger-food-us-increase-inflation-pandemic-report-49fe26f083583d6efa66c6509657a741
• 9 Carpenter A, Kuchera AM, Krall JS. Connecting families at risk for food insecurity with nutrition assistance through a clinical-community direct referral model. J Nutr Educ Behav 2022; 54 (02) 181-185
• 10 Cartier Y, Fichtenberg C, Gottlieb L. Community resource referral platforms: a guide for health care organizations. SIREN Network; 2019. https://sirenetwork.ucsf.edu/sites/default/files/wysiwyg/Community-Resource-Referral-Platforms-Guide.pdf
• 11 Stenmark SH, Steiner JF, Marpadga S, Debor M, Underhill K, Seligman H. Lessons learned from implementation of the food insecurity screening and referral program at kaiser permanente Colorado. Perm J 2018; 22: 18-093
• 12 National Committee for Quality Assurance (NCQA). Implementing a community referral platform: recommendations from a real-world implementation experience qualitative findings. Accessed November 23, 2023 at: https://www.ncqa.org/wp-content/uploads/2021/02/20210205_Implementing_a_Community_Referral_Platform_Lessons_Learned.pdf
• 13 Rousseau JF, Oliveira E, Tierney WM, Khurshid A. Methods for development and application of data standards in an ontology-driven information model for measuring, managing, and computing social determinants of health for individuals, households, and communities evaluated through an example of asthma. J Biomed Inform 2022; 136: 104241
• 14 Reisman M. EHRs: the challenge of making electronic data usable and interoperable. P&T 2017; 42 (09) 572-575
• 15 Burke T. The health information technology provisions in the American Recovery and Reinvestment Act of 2009: implications for public health policy and practice. Public Health Rep 2010; 125 (01) 141-145
• 16 Chen M, Tan X, Padman R. Social determinants of health in electronic health records and their impact on analysis and risk prediction: a systematic review. J Am Med Inform Assoc 2020; 27 (11) 1764-1773
• 17 Office of the National Coordinator for Health IT (ONC). 2021 LEAP in Health IT Projects. https://www.healthit.gov/topic/2021-leap-health-it-projects . Accessed at: November 11, 2023
• 18 Health Level Seven International (HL7). FHIR accelerator program: gravity project. Accessed November 28, 2023 at: https://www.hl7.org/about/fhir-accelerator/
• 19 The Gravity Project. Gravity use case package. Accessed November 11, 2023 at: https://confluence.hl7.org/display/GRAV/Gravity+Use+Case+Package
• 20 Valdez CR, Garay R, Vasquez M. et al. Expansion of the community engagement studio method: deepening community participation in health care innovation. Prog Community Health Partnersh 2023; 17 (03) 515-522
• 21 Protocol for responding to and assessing patients' assets, risks, and experiences (PRAPARE). What is PRAPARE. Accessed August 17, 2024 at: https://prapare.org/what-is-prapare/
• 22 Khurshid A, Oliveira E, Nordquist E, Lakshminarayanan V, Abrol V. FHIRedApp: a LEAP in health information technology for promoting patient access to their medical information. JAMIA Open 2021; 4 (04) ooab109
• 23 Khurshid A, Hautala M, Oliveira E. et al. Social and health information platform: piloting a standards-based, digital platform linking social determinants of health data into clinical workflows for community-wide use. Appl Clin Inform 2023; 14 (05) 883-892
• 24 Health Level Seven International (HL7). Fast Healthcare Interoperability Resources SDOH Clinical Care Implementation Guide. Accessed November 23, 2023 at: https://www.hl7.org/fhir/us/sdoh-clinicalcare/
• 25 The Gravity Project. Social risk terminology value set. Accessed November 23, 2023 at: https://confluence.hl7.org/display/GRAV/Social+Risk+Terminology+Value+Sets
• 26 Burdick TE, Kessler RS. Development and use of a clinical decision support tool for behavioral health screening in primary care clinics. Appl Clin Inform 2017; 8 (02) 412-429
• 27 Jenssen BP, Karavite DJ, Kelleher S. et al. Electronic health record-embedded, behavioral science-informed system for smoking cessation for the parents of pediatric patients. Appl Clin Inform 2022; 13 (02) 504-515