Inpatient Food Insecurity: A Call for Recognition, Investigation, and Intervention

Household food insecurity, common in families with young children, is associated with negative health consequences for all family members.1 There has been increasing recognition of a related but distinct condition affecting the parent or caregiver of a hospitalized child, termed inpatient food insecurity, hospital food insecurity, hospital-based food insecurity, or caregiver food insecurity.2–8Unlike situations in which caregivers may choose to miss a meal for other reasons (eg, child anxiety when caregiver leaves the bedside or not eating in front of a child who cannot eat), inpatient food insecurity implies the parent or caregiver is experiencing stress related to food or is skipping meals specifically owing to financial constraints.1 Studies have shown that inpatient food insecurity is common, likely underrecognized, and negatively impacts the medical care of hospitalized children.2,4–7 Improved detection and treatment of inpatient food insecurity may help families have more positive interactions with the health care system and ultimately improve patient outcomes.Inpatient food insecurity has the potential to affect patient care of a hospitalized child. Pediatric hospitalists and other inpatient pediatric specialists rely on caregivers to be part of the health care team, supporting their child and providing input that guides interventions, but it is difficult for caregivers to participate fully when their basic needs go unmet. Inpatient food insecurity may lead to a range of physical, mental, and emotional repercussions including hunger, fatigue, stress, and embarrassment during the child’s hospitalization.2,4,6,8,9 These symptoms impact their interactions with the medical team and ability to make medical decisions for their child.2 Inpatient food insecurity has been associated with longer length of stay and higher odds of readmission within 30 days of discharge.5 Recognizing and addressing inpatient food insecurity is necessary for pediatric inpatient providers and health care systems to provide family-centered, equitable care to hospitalized children.Standardized screening for health-related social needs such as food insecurity is commonly implemented in the pediatric inpatient setting. Inpatient food insecurity is increasingly described in the literature, but is inconsistently recognized in the health care setting, which may in part be because of screening practices. There is a validated and widely accepted clinical screening tool for household food insecurity; however, no such tool exists for inpatient food insecurity.10 Studies of inpatient food insecurity have used questions adapted from the US Department of Agriculture’s 18-item food security scale to reflect the inpatient hospitalization, but there is variability in the number of questions and how the questions have been modified.2–7,11 Additionally, there is not an established best practice in terms of ideal timing to administer the screen, and these variabilities make it difficult to compare studies and interventions. Screening early in a hospitalization may allow interventions to be implemented sooner and improve family-centered medical care. Conversely, screening early in a hospitalization may be less accurate because there may not be sufficient time for a caregiver to have skipped meals. Another consideration in screening for inpatient food insecurity should be which caregiver or caregivers should be screened because it may not always be a parent or guardian at the bedside or caregivers may be different at different points in a child’s hospitalization. Given these inconsistencies and lack of identified best practices, it is not surprising that the rate of inpatient food insecurity identified in existing literature has varied: as low as 8% in a cross-section of all hospitalized pediatric patients to 86% in a population of hospitalized children with Medicaid or no insurance.5,7 Differences in patient populations likely play a role as well. Studies suggest that inpatient food insecurity is more common among caregivers who identify as Black or African American, are unpartnered, have lower education levels, or are immigrants.2,3,6Importantly, although rates of inpatient food insecurity have varied, an incomplete overlap between household and inpatient food insecurity has been consistently described.2–5 Approximately one-third of caregivers who endorse inpatient food insecurity report that they have not experienced household food insecurity within the past 12 months.2–5 Furthermore, approximately one-third to half of caregivers who endorse household food insecurity did not endorse inpatient food insecurity.2–5 Therefore, although the presence of household food insecurity is associated with higher odds of experiencing inpatient food insecurity,2,3 screening for household food insecurity alone may miss a significant number of families experiencing inpatient food insecurity. This could lead to inadequate detection of and thus inadequate mitigation of inpatient food insecurity.Despite an increasing recognition of inpatient food insecurity, more work is needed. First and foremost, a validated and widely accepted clinical screening tool for inpatient food insecurity is needed that could be administered alongside the well-established tool used for household food insecurity. A common screening tool could be leveraged to build on prior work, expanding knowledge of the epidemiology of inpatient food insecurity and its impact on inpatient pediatric health care. There may also be a role for examining whether other health-related social needs (ie, transportation, lack of or inadequate health insurance) are similar in that they arise because of or are exacerbated by a child’s hospitalization.While efforts to establish best practices around inpatient food insecurity through research are ongoing, there are also opportunities to advocate for systemic change and design interventions to mitigate the problem. Health care systems must ensure that caregivers have access to affordable meals and receive education about resources available. Although studies of interventions in the literature are limited, those which involve providing meals or meal vouchers for caregivers of hospitalized children have been found to be effective.6–8 One potential intervention is offering reduced-price or free meals from the hospital cafeteria. Recognizing that many caregivers are reluctant to leave their child’s bedside, mechanisms should be put in place to have food for caregivers delivered to the patient room when possible. Additional programs that provide food directly, such as a dedicated health care-based food pantry for inpatient caregivers, direct meal provision by a philanthropic organization that is located either on site or near the hospital (eg, Ronald McDonald House Charities), and connection to the federal nutrition programs, have also been described, but their effectiveness has not been studied.3,6,8 Other interventions that could be trialed for feasibility and efficacy include provision of meals to families of hospitalized children through philanthropy with local restaurants or businesses, partnering with community food redistribution organizations or food pantries, and connection of families to a Supplemental Nutrition Assistance Program approved retailer located near the hospital.Although it is intuitive that providing meals to caregivers who are skipping meals because of cost during their child’s hospitalization would mitigate inpatient food insecurity,2,6,7 it is important to note that caregivers were open to this intervention even as some outpatient food security interventions have been associated with decreased uptake.9,12 In certain populations with known risk factors, such as patients with Medicaid or no insurance, a universal intervention may even be more appropriate than universal screening to decrease stigma. This approach has been described in a quality improvement project aimed at improving inpatient food insecurity in patients with Medicaid insurance.7As a component of a more comprehensive advocacy strategy, ensuring that the basic needs of caregivers are met should be recognized as an integral part of pediatric inpatient care and funded or reimbursed accordingly. Engaging stakeholders in hospital leadership to financially support caregiver meals with the lens of reducing disparities in hospitalized children has been effective in at least 1 hospital system in identifying ongoing, sustainable funding for meals for caregivers of hospitalized children.7 Other strategies could include a philanthropically maintained restricted fund or endowment, but admittedly this may not be a viable option for many institutions owing to limitations in donor bases or competing philanthropic priorities that could lead to challenges in large-scale implementation. Alternatively, caregiver meals for a parent or guardian could be included as part of the standard hospital facility fee or otherwise approved for reimbursement by payers as a routine component of pediatric hospitalization. Although payers may not be willing to make this change unless mandated by new public policies, it is important to remember that inpatient food insecurity has been associated with a longer length of stay and higher rate of readmissions. Payers could, therefore, benefit from the more cost-effective care that could be provided when inpatient food insecurity is addressed.Meeting the basic needs of the caregivers of hospitalized children promotes participation in a family-centered medical model and is part of holistic patient care. Further research will foster a more complete understanding of the scope and impact of inpatient food insecurity as well as best practices related to screening and response. Advocacy is needed to support this work and ensure the financial sustainability of proposed interventions. Recognizing and addressing inpatient food insecurity will help health care systems to optimize the quality of inpatient care and achieve more equitable outcomes.