It’s a project two years in the making, but it’s finally off the ground and improving the lives of patients at A.F. Williams Family Medicine Center. Project champion Heather Bleacher, MD, has been leading an internal committee that’s dedicated to gaining a better understanding of the social determinants of health impacting their patients. (Pictured left to right: Autumn Kuehl, LCSW and Heather Bleacher, MD)
“Two years ago, I sent an open invitation to everyone at the clinic to gauge interest in getting more involved with our community,” she explained. “I got a great response from a group of nurses, physicians, medical assistants and behavioral health providers who were all interested in finding ways to expand how we care for our patients outside of the clinic.”
The team’s primary goal was to find ways to connect patients with resources that can improve the social factors that prevent optimal wellness. After many meetings and revisions to the practice’s workflow, in March 2017 the clinic started screening its patients for food insecurity.
“We are all well aware that medical care is a small fraction of what constitutes a person’s health. If we’re not paying attention to things outside of medical care, we’re missing an opportunity to help our patients. This program gives us a way to see the whole picture,” Dr. Bleacher said.
Corey Lyon, DO, DO, FAAFP, medical director of A.F. Williams, agrees. "You don't know what your patients really need to achieve health unless you ask," he said. "So much more goes into a patient's health than the care we provide in the exam room."
Within nine business days, roughly 52 patients identified as having food needs.
“No one expected the numbers to be so high,” Bleacher said. “We thought maybe a few people a day might self-identify, but that’s not how it’s working out.”
Autumn Kuehl, LCSW, calls the patients who complete the screening and request a follow up call about their food insecurity.
“When needs are identified, I work with patients to connect them with existing community resources. For example, with the patient’s permission I can send a referral to an organization like Hunger Free Colorado,” said Kuehl. “Hunger Free Colorado then reaches out to the person usually within 24 hours. Their organization screens for eligibility for federal programs and enrolls if eligible. If they aren’t eligible or already have benefits, they are referred to local food pantries. We then receive monthly reports of the interventions from Hunger Free Colorado.”
Kuehl said that so far, patients seem to feel positive about the program.
“A big thing we try to do is reduce the stigma that’s felt by people who are food insecure,” she said. “Many of the people I talk to say things like, ‘I’m embarrassed to ask for help.’ I try to make sure they understand that there’s no shame in needing assistance, and there are existing programs in the community that can help.”
The program has also challenged the assumptions of the A.F. Williams team. “Food insecurity doesn’t just hit our Medicaid patients. We’ve had just as many patients with private insurance identify as food insecure,” said Kuehl.
Both Dr. Bleacher and Kuehl credit the entire team for their hard work in getting the program off the ground and in the team’s day-to-day commitment.
“Screening definitely adds more work to the plates of our already very busy staff,” said Dr. Bleacher. “Everyone on our team is already working to the top of their licenses. The extra work of screening is challenging for them to fit into their days, but everyone’s attitude seems geared toward figuring out how to make it work. It’s one of the reasons I love working at A.F. Williams.”
“A program like this really requires buy-in from everyone in order to be effective,” said Kuehl. “As a social worker, it means a lot to me that our clinic is doing this simply because it’s the right thing to do.”
“Working with Hunger Free Colorado has been great. They have a statewide database of all food resources, from free meals to pantries to screenings for SNAP and WIC. Having a ready partner was a big driver in getting our program off the ground,” said Dr. Bleacher.
“It’s great that we’re not recreating the wheel,” said Kuehl. “Having our clinic connected to these community resources also lends some credibility—the people I speak with seem to think, if A.F. Williams trusts this organization, then I can, too.”
A.F. Williams is also partnering with Aurora Interfaith Community Services.
“Most food pantries limit how often a person can come in. We have several patients who are experiencing homelessness and are not able to refrigerate food,” explained Kuehl. “The partnership with Aurora Interfaith Community Services allows A.F. Williams patients to go to the pantry as frequently as they need, which has been a tremendous help for our patients who aren’t able to keep more than a few days’ worth of food.”
“In the future, we’ll be asking our patients about more than just food insecurity. We know that transportation, general financial strain, intimate partner violence, health literacy, and social isolation have negative health consequences. We want to understand where our patients are coming from so we can integrate the information into preventive and wellness care,” said Dr. Bleacher. They are also looking at ways to measure and evaluate the program’s effectiveness.
More than anything, Dr. Bleacher is thankful for the perseverance and dedication of the A.F. Williams staff.
“We couldn’t have gotten this off the ground without them. The current health care system isn’t built for programs like ours. We’re trying to fit a round peg in a square hole. But we’re not going to let that stop us from doing the right thing for our patients.”
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