Improving Food Security in People with End Stage Kidney Disease

Fresenius Medical Care is launching a national initiative in the U.S. to identify and address food insecurity. Interdisciplinary teams of dietitians, social workers, nurses and physicians will take a structured and comprehensive approach to address food insecurity, an important health-related social need.

To advance health equity, the Centers for Medicare and Medicaid Services (CMS) continues to implement screening for health-related social needs (HRSN) across federal healthcare reporting and payment programs. Notably, the CMS End-Stage Renal Disease Quality Incentive Program (ESRD QIP) has new requirements for performance years 2024 and 2025 related to health equity.1 Each dialysis clinic in the U.S. is expected to demonstrate a commitment to health equity in 2024 and offer standardized screening for HRSN (e.g., food insecurity, housing instability, utility needs, transportation problems, and interpersonal safety) in 2025.2 To reduce health disparities, advance health equity, and fulfill the CMS ESRD QIP requirements, Fresenius Kidney Care (FKC) has developed its Health Equity Strategic Plan 2024–2026. The plan has four primary goals (Figure 1), including a focus on identifying and addressing HRSN.

As part of the organization’s expanded attention to social needs affecting health and well-being, FKC will launch a national quality improvement initiative across more than 2,600 clinics in the United States to assess for food insecurity and implement interventions to improve food security. Food insecurity was selected as the initial national quality improvement initiative focused on social needs due to its high prevalence, association with clinical outcomes, and available interventions and resources. Food insecurity may be one of the most critical social needs to address to improve health-related quality of life.3

In 2022, an estimated 12.8% of U.S. households were food insecure at some point in the year.4 Limited data exists on the prevalence of social needs such as food insecurity, housing instability, utility needs, transportation difficulties, and interpersonal safety among people with ESKD. In the state of Illinois, food insecurity was the most common social need reported among the more than 5,000 individuals with ESKD receiving care in FKC clinics screened for social needs (Figure 2)5 using the Accountable Health Communities Health-Related Social Needs (AHC HRSN) screening tool.6 More than 13% of individuals with ESKD screened positive for food insecurity, highlighting its importance.

Limited data exists on the prevalence of social needs such as food insecurity, housing instability, utility needs, transportation difficulties, and interpersonal safety among people with end-stage kidney disease (ESKD).

The Fresenius Kidney Care Food Security Quality Improvement Initiative

FKC will implement a national multi-year quality improvement initiative focused on improving food security for people on dialysis (Figure 3). The goal is to eliminate or lower the severity of food insecurity in the FKC population in the U.S. Addressing food insecurity in people living with ESKD requires an interdisciplinary approach involving dietitians, social workers, nurses, physicians, and community resources. The specific components of the food security initiative are: 

1) Screening and Identification: FKC dietitians will screen all adults receiving care in FKC clinics for food insecurity at least annually using the 6-Item Adult Short Form of the U.S. Household Food Security Survey Module (HFSSM).7 The 6-Item Adult Short Form of the HFSSM is a shortened version of the U.S. Department of Agriculture’s HFSSM and is designed to assess household food security, which refers to the availability and access to enough food for an active, healthy life for all household members.8 Responses to the survey provide insight into the presence and severity of food insecurity experienced by households and can identify individuals in need of food assistance.9

2) Assessment and Interventions: Among those who screen positive for food insecurity, the severity of food insecurity will be classified as low or very low food security based on the responses to the 6-Item Adult Short Form of the HFSSM. The dietitian will conduct a detailed assessment of dietary needs and habits, cultural preferences, and access to nutritious food. Once the assessment is completed, dietitians and social workers will collaborate to provide interventions to address food insecurity. Types of interventions may include medically tailored meals, prepared meals, food programs, and/or financial assistance. Medically tailored meals are specially prepared meals designed to meet the specific nutritional needs of individuals with chronic illnesses or medical conditions.10 These meals are carefully crafted by registered dietitians or nutritionists to provide the right balance of nutrients, vitamins, and minerals required to manage the individual’s health condition effectively.11 Prepared meals can include home delivery of pre-prepared meals designed for various dietary needs. These programs include Meals on Wheels, the Commodity Supplemental Food Program, and the Community Harvest Program and may be administered by government agencies, religious organizations, or community centers.12 For individuals who are food insecure and need access to groceries, several resources and programs can help. Resources include food pantries and community food programs such as community kitchens, food cooperatives, and community gardens. Financial assistance for patients who are food insecure can come from various sources, including government programs, nonprofit organizations, and community initiatives. These interventions include the Supplemental Nutrition Assistance Program (SNAP),13 Temporary Assistance for Needy Families (TANF),14 and emergency assistance programs through local governments that offer emergency financial assistance programs to individuals and families facing immediate financial crises. These programs may provide one-time cash payments or vouchers to help cover basic needs, including food. 

3) Reassessment and Follow-up: Among individuals identified as food insecure, the dietitians will reassess the severity of food insecurity every six months using the 6-Item Adult Short Form of the HFSSM, which will assess the effectiveness of interventions and ongoing needs.

Providing a structured approach with routine reassessment will allow for a comprehensive assessment of unmet needs and an assessment of the effectiveness of different interventions. The FKC interdisciplinary team has the expertise needed to effectively identify and lower food insecurity in individuals receiving care within FKC clinics. Addressing food insecurity using a standardized and holistic approach is paramount to improving the health and well-being of people living with ESKD.