A Nurse-Led Intervention to Address Food Insecurity in Chicago

The World Health Organization (2018) defines the Social Determinants of Health (SDOH) as conditions in which people are born, grow, live, work and age that impact their health. These social determinants are mostly responsible for health inequities, or unfair and unavoidable differences in health status seen within and between countries (WHO, 2018). For the purpose of this article, we consider food insecurity, one SDOH, and describe a nurse led initiative designed to address this concern in one of Chicago’s underserved communities.

Food insecurity is a growing health concern in the United States. Food insecurity is a growing health concern in the United States. As defined by the United States Department of Agriculture (USDA), food insecurity is “the lack of consistent access to enough food for an active, healthy life” (Feeding America, 2018, para 2). There is often a misconception wherein people believe food insecurity means not having any food at all, but in reality, food insecurity refers to more than just not having food. Food insecurity relates to access, quality, and availability (Feeding America, 2018). This article offers a brief overview of food insecurity and describes The Rush Surplus Project, developed in 2015 by concerned nurses within the Rush healthcare system to address the issue of food insecurity in surrounding communities on the west side of Chicago, Illinois. This project decreases hospital food waste by donating food to local shelters for redistribution to individuals in need. We will offer implications for nursing and health systems concerned by food insecurity and conclude with a summary detailing next steps in progress at Rush University Medical Center.

Brief Overview of Food Insecurity

Levels of Food Security
... in reality, food insecurity refers to more than just not having food. The Figure depicts the four distinct levels associated with food security (Feeding America, 2018). The top level, High Food Security, encompasses households that have no concerns with supply and access to food. The next level, Marginal Food Security, includes households which have encountered issues and anxiety related to the accessibility of food, but when they do have food it is of great quality with many options. These two levels are considered food secure. The next level, Low Food Security, includes households with poor quality and variety in food options, but the ability to eat adequate amounts of food on a routine basis. The lowest level, Very Low Food Security, includes people within the household who did not have enough money or resources to obtain food and this affected their diet and the amount of food they were able to consume throughout the year. Segments of the population in these final two categories fall into the food insecure category.

Figure. Levels of Food Security

(Feeding America, 2018). [View full size]

Prevalence
In 2016, approximately 41.2 million Americans were identified as food insecure. In 2016, approximately 41.2 million Americans were identified as food insecure (Feeding America, 2018). These Americans were unable to get food due to unforeseen circumstances. According to Gundersen (2013), food insecurity rates have been at an all-time high, in part, dating back to the Great Recession starting in 2008. As a result, people have not been able to completely recover from this classification. There is a paucity of data to describe the magnitude of food insecurity because prior to 2008, food insecurity was not measured or classified in such a measurable manner (Gundersen, 2013).

Seniors... in particular, find themselves as food insecure. At the start of the Great Recession, the total number of children in America who were food insecure increased by 30%, and remained elevated (Gundersen, 2013). The economy has improved since the Great Recession, but there still continues to be a high number of individuals who are food insecure. Seniors (people 60 years old or older) in particular, find themselves as food insecure. Since 2015, approximately 5.4 million seniors have been identified as food insecure. Locally in Illinois, about 15% of Seniors are classified as food insecure, as reported by America’s Health Rankings (Feeding America, 2018). Specifically, in Cook County, Illinois, there are over 729,000 individuals, or 1 in 5 families, who suffer from food insecurity (Feeding America, 2018).

National Initiatives
Classification of the number of individuals identified as food insecure continues to rise and is of growing concern throughout the nation. Classification of the number of individuals identified as food insecure continues to rise and is of growing concern throughout the nation. One might ask, what is being done to help address such a national issue? While there are programs that take the food waste from organizations and donate it to local shelters or food pantries for distribution, this seems hardly enough to address this continued growing concern.

Many individuals and families have enrolled in the Supplemental Nutrition Assistance Program (SNAP), a federally funded program to provide resources for participants to purchase food in specific stores. The type and amount of benefits an individual can receive from SNAP are based on household and overall monthly income. For example, an individual with a lower income, living in a family unit with three other dependent individuals (whether they are children or seniors) would potentially qualify for this program based on the income they receive. Each state has a different policy and guidelines regarding how much assistance people can receive. Additionally, expenses people have to deal with beyond rent can lead to a need for additional help from SNAP benefits.

Organizations, governments, and individuals across the country waste an estimated 30-40% of the American food supply (Schroeder & Smaldone, 2016). Many initiatives have emerged to reduce waste, including diverting excess edible food to hunger relief efforts. The next section will describe an exemplar of a program to address food insecurity at the local level.

Addressing Food Insecurity
Food insecurity is a key SDOH that influences the health and well-being of individuals... Food insecurity is a key SDOH that influences the health and well-being of individuals, especially high-risk populations. For example, individuals who are food insecure are unable to live healthy lifestyles because they are unable to afford nutritious foods for their diets. The lack of an adequate supply of nutritious food can lead to psychological stress, poor health outcomes, and chronic health conditions. Schroeder and Smaldone asserted that the inability to live a healthy lifestyle is not only a characteristic of being food insecure, but also a consequence of it (Schroeder & Smaldone, 2015). Further, adults experiencing food insecurity are at greater risk of developing hypertension, high cholesterol, and type II diabetes (Seligman et al., 2015).

The American Hospital Association (AHA) (2017) has called upon its members to get involved in addressing food insecurity. Hospitals and health systems have begun to address this issue by using their own resources to ameliorate this growing concern. Some hospitals provide meals, while others provide food to individuals in the community (AHA, 2017). The AHA (n.d.) provides guidance for hospitals and health systems who wish to address food insecurity for patients and targeted communities. A detailed description of these resources is located on their webpage entitled, Community Health Initiatives at the American Hospital Association.

The Rush Surplus Project

Historical Overview
... a task force of three nurses at ROPH explored the idea of packaging food that would be wasted or discarded in our hospital. The Rush Surplus Project was created in 2015 by a team of area nonprofit leaders participating in Dominican University and Oak Park River Forest Community Foundation’s “Community Leadership Program.” Members of the team represented several area institutions including Rush Oak Park Hospital (ROPH), Oak Park Day Nursery, Oak Park and River Forest High School, Thrive Counseling Center, and Oak Park River Forest Food Pantry. One challenge for healthcare workers is to relieve hunger. To address this responsibility, a task force of three nurses at ROPH explored the idea of packaging food that would be wasted or discarded in our hospital. These nurses challenged themselves to look beyond just helping patients to stay out of the hospital with medication and other treatments by also asking patients “Do you have enough food at home?" Table 1 further explains the mission and vision for this program.

Table 1. The Rush Surplus Project

The Rush Surplus Project seeks to simultaneously reduce food waste and food insecurity throughout Cook County, IL through the development of a replicable and sustainable model to redistribute unserved cafeteria food to local families and individuals in need, while simultaneously operating as a model of service efficiency and environmental sustainability. The Rush Surplus Project is an innovative way to reduce commercial food waste and increase the amount of safe, nutritious food for those in our community who struggle with hunger. Notably, this project answers the call to action issued by the AHA (2017).

As implementation began, ROPH and the food pantry became partners, identifying the physical, human, and financial resources to initiate the project start. As implementation began, ROPH and the food pantry became partners, identifying the physical, human, and financial resources to initiate the project start. ROPH recruited members of the hospital staff to repackage unserved, prepared food from the hospital cafeteria while the food pantry drew from its sizable pool of volunteers to transport the meals for distribution twice a week to clients. By the end of 2015, the program had expanded to include West Cook YMCA as a recipient agency. In spring of 2016, The Rush Surplus Project received funding from the Entrepreneur Leaders in Philanthropy Fund, a giving group of the Oak Park-River Forest Community Foundation, as part of the Big Idea Grant Competition ("The Big Idea," 2018). Funds received from this grant were used to expand the program to additional donor institutions and recipient agencies and to support the work of building a replicable model. By winter of 2016, The Rush Surplus Project added three more receiving sites: Riveredge Hospital, Oak Park River Forest High School, and Dominican University. These donors were connected to Mills Park Tower, Youth Outreach Services, and New Moms, agencies serving low-income families or individuals.

Evolution and Expansion
Rush University Medical Center (RUMC) is an academic medical center located in Chicago, Illinois, with a patient bed capacity of 664. The hospital facilities are for adults and children, along with an attached 61 bed rehabilitation center. In 2017, Practice Greenhealth, a nonprofit promoting environmental stewardship in healthcare, collaborated with Chicago-based Feeding America (2018), a hunger-relief organization, to encourage hospitals and healthcare facilities nationwide to donate excess resources to food banks. Food insecurity and chronic homelessness are prevalent in under resourced communities on the West Side of Chicago, all within our area of service. Conservative estimates indicate that on a daily basis, 6,200 individuals in Chicago are homeless. Findings from Feeding America’s Map the Meal Gap survey revealed that there are approximately 729,020 food insecure individuals in Cook County alone (Feeding America, 2018). With awareness of these statistics, the creators of The Rush Surplus Project expanded the project to RUMC due to the increased need. In order to expand the project successfully, new partners in the community were created.

In sum, The Rush Surplus Project seeks to match those who have extra-prepared food with those in need of food. In sum, The Rush Surplus Project seeks to match those who have extra-prepared food with those in need of food. This can take different forms, including setting up a system for an organization to internally redistribute food or, as is more often the case, transferring food to another organization that can distribute the food to individuals and families in need. In all cases, the focus is on repackaging unserved prepared foods from area cafeterias into meals in individual or family-size portions. The meals come to the recipient organization ready for distribution to clients. We attribute our success to the unwavering commitment of each program partner for ensuring high quality implementation. Each partner has thus far exceeded the desired expectations needed for program success.

The Rush Surplus Project has provided direct hunger relief to thousands of food insecure individuals since inception. Since 2015, The Rush Surplus Project has provided over 700 nutritious meals each month, or approximately 8,400 meals per year (Rush Surplus Project Database, 2018). This directly benefits 8,400 individuals in the greater Chicago area—a huge impact on individual lives.

The Rush Surplus Project reduces environmental waste by reducing local food waste and environmental harm. For each meal saved, we have reduced landfill by approximately 1 pound; a reduction in waste of 8,400 pounds over the course of the year (Rush Surplus Project Database, 2018). The Rush Surplus Project has also encouraged volunteerism in our community—and volunteerism strengthens community bonds. Each month, the volunteers experience a meaningful and authentic way to serve in a program committed to food security, environmental sustainability, and community collaboration.

Interventions for Nursing
Individuals wishing to start a similar program should first check with their local health department for guidance... Individuals wishing to start a similar program should first check with their local health department for guidance on food handling, regulations, and handling donations. Likewise, nurses wishing to start a similar program may wish to ask the following questions:

• What data is available to help guide the decision to initiate a food surplus program?
• What is the actual targeted population?
• Is there support system-wide to support a food surplus program?
• Which members of the interdisciplinary team are critical to launching and sustaining such an effort?
• What evaluation metrics are needed in designing a food surplus program?
• What resources (internal and external) are available to assist in this endeavor?

...there are numerous implications for safe food handling as part of a food surplus program. In addition, there are numerous implications for safe food handling as part of a food surplus program. Table 2 is adapted from the Rush Surplus Project Handbook (Grenier, 2015) to highlight the guidelines utilized when packaging and distributing food. Additional helpful information can be found from local and public health departments.

Table 2. Rush Surplus Project Guidebook Excerpts

Source: Rush Surplus Project Guidebook (Grenier, 2015).

Implications for Nursing and Health Systems

Nurses should consider screening for food insecurity as part of routine nursing assessments. Food insecurity continues to be an issue that offers nurses a unique opportunity for engagement within the community. As noted previously, when individuals are food insecure, they are less likely to be successful in maintaining a healthy lifestyle. Nurses should consider screening for food insecurity as part of routine nursing assessments. Nurses will then need to coordinate these efforts with other disciplines to ensure that appropriate resources and follow up measures are in place.

Addressing food insecurity can have a great impact on the patient experience and patient outcomes. If food insecurity is managed and addressed, perhaps people may feel more empowered and willing to make improvements in their lifestyle choices.

Summary and Next Steps

Overall, food insecurity is a national problem that continues to grow. The Rush Surplus Project strives to minimize food waste from our institutions and utilize it in a positive way to help decrease food insecurity in the community. The decrease in food insecurity is only a first step in solving just one SDOH. Imagine the possibilities if all of the social determinants of health had solutions.

Currently, RUMC is preparing to open their own food pantry; the Food is Medicine initiative targets inpatients who screen positive for food insecurity. Patients will be screened for food insecurity upon admission, using a SDOH screening tool. The Food is Medicine Program will help to ensure that patients designated as food insecure have food to take home upon discharge, and ensure that they are provided resources to continue to meet their needs.

Food insecurity is something that can be conquered with the help of many stakeholders internal and external to the healthcare delivery system. In closing, food insecurity is a challenge faced by a growing number of people. Although it may be challenging to admit, it is important for people to acknowledge that they are food insecure in order to receive the resources and help available to them. Food insecurity is something that can be conquered with the help of many stakeholders internal and external to the healthcare delivery system. The Rush Surplus Project is an emerging model has demonstrated benefits to those in need and is rewarding for nurses throughout the Rush healthcare system.

Acknowledgement

We would like to extend sincere gratitude to Janice Phillips, PhD, RN, CENP, FAAN, Director of Nursing Research and Healthy Equity, Rush University Medical Center and Angelique Richard, PhD, RN, CENP, Chief Nurse Executive, Rush University Medical Center, for continued support and guidance through implementation and expansion of this project. We would also like to thank all of the individuals who have volunteered time helping to package and deliver the food.

Authors

Jennifer Grenier, DNP, RN-BC
Email: Jennifer_m_grenier@rush.edu

Dr. Grenier has been a Rush nurse for the past 19 years, starting as a nursing assistant, and now as a Director of Nursing for Inpatient Rehab. She received a Doctorate of Nursing Practice in Systems Leadership from Rush University in 2017. She is the founder of the Rush Surplus Project and has been working hard to expand the project to other organizations.

Nicole Wynn, MSN, RN-BC
Email: Nicole_h_wynn@rush.edu

Ms. Wynn has been a Rush nurse for six years, starting as a new graduate nurse, and currently as the Assistant Unit Director of a post-surgical care unit specializing in Spine Surgery and Ear Nose and Throat surgeries. She is currently enrolled at Rush University, working towards a doctorate in Transformative Leadership. She has been part of the Rush Surplus Project since its inception in 2015.