Providence Health & Services – Screen & Intervene Program

Portland, OR
January 2018

Overview
For many years, Providence Health & Services’ Community Health Division has recognized the connection between unmet social needs and the impact on health. The Division has led and supported several innovative approaches across Providence Oregon to address these needs. In 2013, in partnership with the Oregon Childhood Hunger Coalition and the Oregon Food Bank, Providence Oregon launched the Screen & Intervene Program. The program uses two nationally validated questions to screen children and their families for food security at well-child appointments. The program has been implemented at two Providence Medical Group Clinics that serve a high percentage of Medicaid and uninsured families, to understand if embedding screening and resulting intervention in the clinical setting was possible.

Since the adoption of the program, Providence Oregon created two programs to address those screened for food insecurity: the Community Teaching Kitchen and the Community Resource Desks. The Community Teaching Kitchen, located at Providence Milwaukie Hospital, is a one-stop shop for patients and those in the community who need assistance accessing healthy food. The program includes a food pharmacy that provides fresh healthy foods to patients and the community, a patient navigator to guide participants to resources, a dietician to assess and create diet plans for patients, and an on-site kitchen that educates patients on how to eat healthy at a low cost. In partnership with Oregon Food Bank and local food providers, the kitchen offers wraparound care for those deemed food insecure or who need to alter their diets due to illness or disease.

The Community Resource Desk is a program to help individuals connect to community resources to meet basic needs. Services are provided through a staffed desk in the lobby of Providence facilities; staff include full-time, on-site multilingual and multicultural resource specialists from community based organization Impact Northwest and Clatsop Community Action. The Community Resource Desks are open to everyone. Top services requested include housing, health insurance, and food.

Impact
Providence was one of the first health systems in Oregon to pilot the Screen & Intervene protocol; due to its success, we have expanded this model to other clinical sites. In the initial two years of the program, more than 2,000 families were screened; of those, 14 percent screened positive for food insecurity. In 2016, Providence Oregon Foundations provided $80,000 in funding for the Screen & Intervene Program.

In 2016, the Community Teaching Kitchen’s first year, more than 700 patients were referred for a combination of services including medical nutrition therapy, food insecurity, and classes. Providence Milwaukie Foundation provided $277,000 in funding for the Community Teaching Kitchen.

The Community Resource Desk Program has grown to four locations, serving 2,810 clients in 2016. The Community Health Division provided $230,000 to Impact Northwest and $50,000 to Clatsop Community Action Agency for their community collaborations.

Lessons Learned
Partnering with community based organizations is an impactful and effective way to assist patients and community members obtain resources and services to meet health related social needs. However, health systems faced challenges in when it comes to addressing social needs with community partners. An early learning for providence has been the difficulty sharing information due to HIPAA and other regulations. In response, Providence Oregon has created a HIPAA Solutions Work Group to develop legal solutions to share relevant information and client data with non-traditional partners, where necessary.

Future Goals
Future plans include expanding the Screen & Intervene work to other clinical sites, adding additional staff to the Community Teaching Kitchen, expanding the Community Resource Desk program to additional service areas, and integrating the program into the electronic medical record system.

Contact: Pamela Mariea-Nason
Executive, Community Health
Telephone: 503-893-6449
Email: jeri.stein@providence.org