Food Insecurity—Addressing Basic Resource Needs in Health Care Settings


John F Steiner, MD, MPH

Perm J 2018;22:18-239 [Full Citation]
E-pub: 10/22/2018

Editor’s Note

In my practice in a safety-net clinic I care for uninsured patients, most of whom must regularly weigh the difficult decision as to how best to use their few dollars: Medications? Food? Gas/transportation? Even the very act of getting to a clinic can be a challenge. Understanding this critical—and often life-threatening—decision-making process is essential to total health care. To best care for this population of patients, health care organizations must develop a strategy to deal with this commonly forgotten problem.

Through the Kaiser Permanente (KP)research groups, various KP Regions have developed programs to respond to this need and continue to review the success of these programs and options for additional or improved programs.

The Permanente Journal is pleased to present this supplemental issue featuring work from KP researchers and their academic colleagues and collaborators on the role of basic resource needs in patient care. This special issue represents the support and importance The Permanente Journal gives to this important health care initiative. We value our partnership with the KP research groups, and this special supplement is a reflection of that relationship. We thank John Steiner, MD, MPH, for his partnership and for his leadership in bringing together these talented researchers to create this collection of peer-reviewed articles to improve the health and welfare of the patients we serve.

--Lee Jacobs, MD
Associate Editor-In-Chief

Charles Albert Tindley (1851-1933) was a prominent pastor in Philadelphia and a prolific composer of gospel hymns, including the lyrics that later became the civil rights anthem, "We Shall Overcome." Another of his hymns, "We’ll Understand It Better By and By," includes a few simple verses that address a day-to-day reality for his African American congregation at the beginning of the 20th century.1 

We are often destitute

Of the things that life demands,

Want of food and want of shelter,

Thirsty hills and barren lands …

Food insecurity, inadequate or unaffordable housing, and other basic resource needs remain too common in the US to this day.2,3 

As the articles in this Supplement to The Permanente Journal emphasize, public- and private-sector organizations that finance health care and clinical systems that deliver care are increasingly convinced that addressing the social determinants of health is a pathway to better health. The papers by Gusoff et al (page 22) and Solomon and Kanter (page 48) take the “macro” perspective, summarizing the current thinking of funders, regulators, and professional organizations about the need to recognize a wide array of social determinants in health care systems. These articles also provide guidance to frontline clinicians and delivery systems about how to address those needs.

Most papers in this supplement, by design, take a “micro” perspective. Out of the expansive array of social determinants,4 these papers focus on 1 or more of 5 basic resource needs (housing, food, transportation, and resources to pay for utilities and medical costs). Steiner and colleagues (page 53) propose a 5-step continuum of care that can help clinical delivery systems develop and improve their ability to address these basic resource needs, and can help evaluators and researchers assess the success of these efforts. The majority of the papers address the first 3 of these 5 steps: the need for thoughtful planning of new programs (page 17; page 71), the use of valid measures of basic resource needs to assess needs at the individual (page 33; page 40; page 63) and community level (page 28; page 58), and the development and testing of interventions to connect patients to community resources (page 6; page 63; page 71). Among these interventions, Hsu et al (page 6) showed improvements in satisfaction among patients and the primary care team, whereas both Friedman and Banegas (page 63) and Stenmark et al (page 71) found that many individuals had needs that were not mitigated by these programs. None of the articles describe efforts to spread their programs within their original health care system or to other settings. In this, they reflect the broader state of the literature and the nascent state of most programs.

Policy directives and statistical tests are not the only way to conceptualize these programs, however. As both Tindley’s hymn2 and Sundar’s narrative (page 78) show, art and story are uniquely able to bring lofty pronouncements and population-based evaluations back to the level of an individual who struggles to meet her basic human needs.

Structuring the health care system to identify and mitigate basic resource needs is a hard problem. By their very nature, hard problems require multidisciplinary solutions that cross conventional domains of responsibility and bureaucratic reporting lines. As these papers suggest, collaboration within health care systems to identify patients with basic resource needs requires the engagement of operational leaders, clinicians, office staff, information technology professionals, population health specialists, social workers, and patient navigators. These systems must also collaborate with the skilled and committed leadership and staff of the community organizations that ultimately provide basic resources to address these needs.

Some of the studies in this Supplement are small and few are definitive, but all reflect the efforts of dedicated professionals to evaluate approaches to addressing the basic resource needs that Reverend Tindley so eloquently captured more than a century ago. We hope that these articles speak to our intended audience of leaders, clinicians, and staff who have recognized the need to address social determinants of health and will design and conduct the programs to do so.

How to Cite this Article

Steiner J. Food insecurity—addressing basic resource needs in health care settings. Perm J 2018;22:18-239. DOI:

1.    Tindley CA. We’ll understand it better by and by [Internet]. Grand Rapids, MI:; c 1906 [cited 2018 Sep 20]. Available from:
    2.    Food security in the US in 2017 [Internet]. Washington, DC: Economic Research Service, US Department of Agriculture; 2017 [cited 2018 Sep 20]. Available from:
    3.    The State of the Nation’s Housing 2018 [Internet]. Cambridge, MA: Joint Center for Housing Studies of Harvard University; 2018 [cited 2018 Sep 10]. Available from:
    4.    Social Determinants of Health [Internet]. Washington, DC: Health People 2020; updated 2018 Sep 10 [cited 2018 Sep 10]. Available from:

Keywords: food insecurity, resource needs, social determinants of health



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