Integrated Care Stories
Food and Nutrition Security
Kaiser Permanente achieves better outcomes through a combination of care coordination, comprehensive data collection and use, and aligned incentives that all promote affordable, high-quality care. This case study, part of our Integrated Care Stories series, highlights the benefits of Kaiser Permanente’s approach.
The challenge
Every year in the U.S., more than 45 million people – including 1 in every 5 children – experience food insecurity, which means they cannot reliably get enough affordable and nutritious food.1 Multiple factors can make it difficult to access healthy food, including low incomes, competing medical and housing expenses, and lack of transportation to grocery stores and markets. Food insecurity has considerable impacts on health. In addition to being incredibly stressful, food insecurity is associated with an increased risk of conditions like hypertension, type 2 diabetes, and heart disease.2 Research has also linked food insecurity with accelerated cognitive decline in middle-aged and older adults.3 For children and adolescents, even temporarily experiencing food insecurity is associated with delayed psycho-social development, behavioral issues, and reduced educational attainment and lifetime financial earnings.4
Federal food assistance programs — like the Supplemental Nutrition Assistance Program (SNAP) and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) — can bolster food access, improve health outcomes, and reduce health care expenditures. However, not all eligibl households are enrolled in these programs. Each year, about 80% of all eligible individuals participate in SNAP, but just 51% of eligible households with members born outside of the U.S. and 55% of eligible adults over 60 years old received SNAP benefits in 2022.5 Similarly, only about half (53.5%) of those eligible for WIC participated in the program in 2022.6 There are several reasons why people who are eligible for benefits do not participate, ranging from stigma to enrollment process challenges.7,8,9,10 These are critical missed opportunities, since increasing participation in SNAP and WIC can improve health outcomes and economic productivity while reducing health care expenditures.11
Additionally, the burden of food insecurity is not felt equally. People of color, older adults, people with disabilities, LGBTQ+ individuals, rural residents, and veterans experience food insecurity at higher rates, often exacerbating the other social and financial challenges these same groups are more likely to experience. To promote better health for all, it is critical
to connect those in need to government programs and community resources and work across sectors to address root causes of food insecurity. Health systems are uniquely positioned to facilitate these connections and support other entities in directing resources at the individual and community levels.
The integrated care and coverage solution
Some health systems and clinics ask patients about their access to food and may even share information about local food pantries and other resources during social health screenings, but this may not be enough to understand a patient’s barriers to access nor to connect patients to the supports they need.12,13 To address this, Kaiser Permanente is leveraging our integrated model to identify members with food insecurity and connect them with resources through public or private programs. In 2020 and 2022, we surveyed our members to ask about their most pressing social health needs and the ways Kaiser Permanente could support them in meeting those needs. Our members identified food security as a top priority and have since indicated that they want help with navigating resources available in their communities, including support with enrolling in public benefits.14
Kaiser Permanente’s social health screening identifies members who might be eligible for food assistance programs like SNAP. With this information, we connect with interested members through text messaging, email, and phone calls and have helped nearly 140,000 members apply for SNAP benefits since 2019. For those who are eligible and interested, we offer support throughout the application and enrollmentprocess. Each year, these efforts improve food security for thousands of our members and their families, which can also free up dollars to pay for expenses like housing and medications and help to infuse over $23 million into local economies.15
Kaiser Permanente also invests in programs and partnerships that address the larger social and structural factors, like poverty, that shape people’s ability to meet their basic needs. We regularly fund local food banks and community food distribution sites,16 such as the Food-to-Share Hubwe supported in 2024. The hub, located in Fresno, California, stores, processes, and distributes more
than 1 million pounds of food each year to those in need and help community members learn about nutrition and cooking skills. Through these and other efforts, Kaiser Permanente aims to increase food and nutrition security and improve health outcomes for people who may face the greatest barriers.17 Recognizing that economic security underlies food security, we aim to grow job opportunities and build wealth and economic security in the communities we serve.
Kaiser Permanente enhances small business development in our communities, promotes health care workforce development initiatives, supports affordable housing initiatives, and has directed over $1 billion a year for the last ten years to local suppliers.18 We also participate in coalitions that encourage other health systems to make similar investments.19
How Kaiser Permanente’s integrated care and coverage model supported this innovation
Connected, coordinated care teams: Members benefit from well-coordinated care in the Kaiser Permanente system. Clinicians can easily coordinate with one another and seamlessly refer patients to other team members — primary care doctors, specialists, lab technicians, pharmacists, and other healthcare professionals.
Kaiser Permanente integrates screening for food access into existing clinical workflows and patient intake assessments. We train both our care and service teams to identify a wide range of member needs, including coaching them on how to discuss these issues with patients in culturally sensitive ways. As a result, staff acrossthe care continuum are aware of food insecurity how to best screen for it, and how to coordinate referrals to resources within Kaiser Permanenteand beyond. We understand that food insecurity coexists with other health issues, so we have identified indicators that prompt our clinicians to ask about food access, availability, and affordability. For example, if patients at a higher risk for unmet social needs are not filling their prescriptions, they may lack reliable transportation or be experiencing issues that also make it difficult to access or afford food. Our pharmacy teams have connected more than 1,300 such patients across our regions to our Community Support Hub, where staff can help them access healthy food, economic support, and safe transportation. These supports also help patients stay on track with filling and taking their prescribed medications.
Research and quality improvement: We analyze care management processes and outcomes and use the results to continuously improve. We then share findings from this practice-based clinical research to benefit others beyond Kaiser Permanente. In addition, our care teams can access a constantly updatedclinical library, helping us stay abreast of new evidence-based approaches.
Our integrated model allows us to work closely with our members to design interventions that address both individual- and community level barriers to accessing nutritious food. For example, our Social Health team used patient-centered methods, like member interviews and working with members to identify their barriers and goals, to design supports that help our members eligible for WIC enroll in the program, make the most of their benefits, and recertify (i.e. validate continued program eligibility) as needed. We also partnered with our members and care teams to develop supports across the WIC experience, including re-enrolling in WIC, using WIC effectively, and transitioning out of WIC to successfully access nourishing food. Our members shared that this type of coordination reduces their stress and helps them feel seen, heard, and well supported. Kaiser Permanente researchers also publish findings on food and nutrition insecurity to
help other health systems apply effective practices and outreach efforts. Our work helps other health systems realize the extent of food insecurity, including in some populations considered lower risk, and the importance of expanding screening efforts to identify those in need. For example, a food insecurity screening pilot at Kaiser Permanente Colorado determined that screening only those considered high-risk would have missed 50% of food-insecure older adults.20 This prompted a shift in how our care teams approachedscreening and led to the publication of research on this topic, helping to educate other health systems on the importance of taking more expansive approaches to promote equitable food access for older adults.
Kaiser Permanente also worked with Tufts University to develop a new screening tool for nutrition security, which is more specific than food security and relates to having access to nourishing foods that support well-being and prevent and manage nutrition-related diseases.21 Low nutrition security is closely linked to poor self-reported health and health outcomes, so Kaiser Permanente and other leading organizations are increasingly screening for nutrition security among patients and evaluating the impact of health services on nutrition security. The screener Kaiser Permanente helped to develop is used by researchers, universities, and health departments across the U.S.
Focus on individual and population health: Our mission and our long-term perspective motivate us to address individual and community drivers of health. We analyze member health trends to identify opportunities for improvement and support quality improvement and prevention. These investments in individual and population health help us retain members, and Kaiser Permanente benefits when those long-tenured members and the broader communities we serve realize positive health outcomes.
Kaiser Permanente’s food and nutrition security efforts are part of our broader approach to promote better, more equitable health outcomes by addressing root causes. Our Thriving Schools Initiative helps schools across the country access high-quality resources to support the physical and mental health of their students, staff, and teachers, regardless of each school’s ability to pay. The initiative also helps schools offer healthier foods and beverages, increase student participation in school meals and physical activity programs, and connect students and their families to food assistance and health resources. We build on this work by supporting enrollment in Summer EBT and funding organizations, like the Food Research Action Center (FRAC), that advocate for universal school meals and help school nutrition staff interpret changes to school nutrition standards.
We also work with coalitions and advocacy groups to support policies that increase food and nutrition security across communities. CityHealth, an initiative of the de Beaumont Foundation and Kaiser Permanente, encourages cities to implement evidence-based policies like healthy food procurement. This effort is designed to leverage city purchasing power to ensure community members have access to healthy choices in public facilities like schools, hospitals, government offices, parks, and
recreational centers.22 We support federal and state policies that sustain SNAP funding and increase SNAP participation, such as streamlining SNAP application processes. We also support policies that promote nutrition in SNAP, such as offering incentives to purchase produce. As changes impact how SNAP is funded and implemented, we remain committed to helping our members and state and community partners navigate the program’s evolution.
Extensive population-level data: With access to data across large numbers of patients over long periods of time, Kaiser Permanente tracks population health trends, and identifies and pursues opportunities to improve and eliminate disparities in care. Our extensive database and our research capacities allow us to serve as a helpful clinical and health services research partner to national agencies and academic institutions we serve realize positive health outcomes.
Kaiser Permanente is building up the evidence base on using Food as Medicine, an approach that uses food and nutrition to address the many diet-related, chronic diseases affecting millions of people in the United States. Part of our work is determining when it is beneficial to incorporate healthy food access and existing government programs, like SNAP and WIC, into our patients’ care plans. We developed a randomized clinical trial on medically tailored groceries – the first study of its kind – where patients with diabetes were provided with healthy food boxes and offered nutrition counseling sessions tailored to their health conditions. Patients who received the food boxes significantly reduced their blood sugar levels and were more than twice as likely to be food and nutrition secure than patients in the control group.23 Kaiser Permanente has also conducted studies on medically tailored meals, which are delivered to patients recently discharged from the hospital and proven
to improve health outcomes. These studies are helping us understand how certain nutrition-related interventions impact health outcomes and how to deliver those interventions most effectively.
In 2024, we launched the Food is Medicine Center of Excellence, which combines our food and nutrition clinical services, research, education, and community initiatives. The Center will help us align these efforts, expand member screening for food insecurity, expand nutrition training for health professionals, and create scalable approaches for providing evidence-based Food is Medicine programs. Leveraging our access to rigorous health data across diverse patient populations, Kaiser
Permanente serves as a research leader and hub for researchers across the academic, public, and private sectors. We regularly partner with universities, supporting events like the second annual national Food is Medicine Summit with the Friedman School of Nutrition Science and Policy at Tufts University in 2024 and 2025. The summit brought health system leaders, health care providers, patients, and policymakers together to discuss strategies to elevate the role of food and nutrition in improving health, including the need for more research on effective interventions in health care and community settings.
Kaiser Permanente’s value-based, integrated care and coverage model differs from much of the United States health care system, which relies on disconnected clinical practices paid through fee-for-service. These disconnected approaches typically result in highly fragmented care, a focus on quantity of services with less focus on ensuring high-quality care, and an emphasis on acute care rather than long-term investments in population and community health.
Kaiser Permanente achieves better outcomes through a combination of care coordination, comprehensive data collection and use, and aligned incentives that all promote affordable, high-quality care. This case study, part of our Integrated Care Stories series, highlights the benefits of Kaiser Permanente’s approach.