Assessment40504

1

Preliminary Care Coordination Plan for Food Insecurity in a Florida Community Care Setting

Preliminary Care Coordination Plan for Food Insecurity in a Florida Community Care Setting

Care coordination is essential for effectively managing patients in community settings (Bryant, 2023). After budget cuts relocated dedicated case management staff to the inpatient environment, the nurse manager asked me, a staff nurse in a community care center, to assume the care coordination role. This preliminary plan focuses on food insecurity, a critical social determinant of health that affects physical wellness, psychosocial stability, and cultural dignity among community residents (Bryant, 2023). The plan analyzes the health concern and associated best practices, establishes specific goals, and identifies Florida community resources that support a safe and effective continuum of care.

Analysis of Food Insecurity and Best Practices for Health Improvement

Food insecurity is the limited or uncertain access to adequate food because of insufficient resources (Baker et al., 2024). In Florida, Feeding Florida estimates that 2.9 to 3.2 million residents experience food insecurity, including more than 800,000 children. National data show that 13.7% of U.S. households were food insecure in 2024, with higher rates among households with children, single-parent families, and racial and ethnic minority groups (U.S. Department of Agriculture, 2025). The condition produces cascading effects that nurses must address through coordinated, person-centered interventions (Bryant, 2023).

Physically, chronic food insecurity drives both undernutrition and the paradoxical coexistence of obesity. Households often rely on inexpensive, calorie-dense, nutrient-poor foods, elevating risk for type 2 diabetes, hypertension, cardiovascular disease, and compromised immune function. Children may experience delayed growth and increased infection risk. Adults with chronic conditions frequently choose between medications and food, leading to nonadherence and preventable acute care use. Best-practice screening with the validated two-item Hunger Vital Sign enables early identification; an affirmative response to either item signals risk and warrants referral (Baker et al., 2024).

Psychosocial consequences include elevated stress, anxiety, depression, and feelings of shame that discourage help-seeking. Caregivers experience heightened parental stress, while older adults face isolation when mobility limits access to congregate meals. Best practices integrate trauma-informed approaches, destigmatizing language, and linkage to mental health resources alongside food assistance. Evidence shows that direct provision of food and monetary assistance significantly reduces food insecurity prevalence; sustained impact, however, requires ongoing navigation and follow-up rather than one-time referrals (Norris et al., 2023).

Cultural considerations are especially important in Florida’s diverse population, which includes substantial Hispanic, Haitian, African American, and immigrant communities. Preferred staple foods, preparation methods, religious dietary restrictions, and language preferences influence the acceptability of assistance and the effectiveness of nutrition education. Immigrant and mixed-status households may fear that benefit enrollment will affect immigration status. Best practices therefore emphasize culturally congruent food offerings, language-accessible materials, engagement of trusted community leaders, and dignity-centered choice. Underlying assumptions include that patients will disclose needs when screened respectfully and that community resources remain accessible. Points of uncertainty include fluctuating federal benefit levels, transportation barriers in rural counties, and variable pantry capacity during peak demand such as hurricane season.

Specific Goals to Address Food Insecurity

Clear, measurable goals guide coordination and allow evaluation of progress. First, within 30 days of a positive Hunger Vital Sign screen, 90% of identified patients will complete a structured referral to at least one federal nutrition program (SNAP or WIC) or a local Feeding Florida partner agency, with documentation of application status or enrollment. Second, within 60 days, 75% of patients with chronic conditions such as diabetes or heart failure who screen positive will receive brief, culturally tailored nutrition counseling focused on cost-effective meal strategies and will demonstrate improved self-reported access to nutritious food on follow-up. Third, over six months, the care coordination caseload will achieve a measurable reduction in food-related emergency department visits among enrolled patients by facilitating consistent access to emergency food boxes, mobile pantry schedules, and senior meal programs. These goals prioritize immediate stabilization of household food supply while building longer-term self-sufficiency.

Available Community Resources for Continuum of Care in Florida

A robust continuum of care depends on seamless linkage from clinical screening to community supports. Federal nutrition programs form the foundation. The Supplemental Nutrition Assistance Program (SNAP), administered through Florida’s Department of Children and Families via the MyACCESS portal, provides monthly electronic benefits for groceries. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) serves pregnant, postpartum, and breastfeeding individuals and children under age five through county health departments. For adults aged 60 and older with limited income, the Commodity Supplemental Food Program (CSFP) distributes monthly USDA food packages through designated partners.

The Feeding Florida network unites nine Feeding America member food banks that serve all 67 counties through more than 2,400 partner agencies (Feeding Florida, n.d.). These food banks operate community pantries, mobile grocery units, senior box programs, and children’s feeding initiatives. Residents locate their regional food bank at feedingflorida.org or by calling the statewide assistance line. The nine member food banks are Second Harvest of the Big Bend, Feeding Northeast Florida, Second Harvest Central Florida, Feeding Tampa Bay, All Faiths Food Bank, Treasure Coast Food Bank, Harry Chapin Food Bank, Feeding the Gulf Coast, and Feeding South Florida. Additional resources include The Emergency Food Assistance Program (TEFAP), congregate and home-delivered meals under Older Americans Act programs, Summer Break Spot sites for children, and Fresh Access Bucks, which doubles SNAP purchasing power for fresh produce at participating farmers markets. Florida 211 serves as a centralized information and referral hub for local pantries and related supports.

Effective continuum of care requires active navigation rather than passive referral lists. Care coordinators should maintain updated contact information, schedule warm hand-offs when possible, and conduct follow-up contacts to confirm patients successfully accessed resources. Collaboration with social workers, community health workers, and registered dietitians strengthens the multidisciplinary response and addresses co-occurring needs such as transportation or housing instability.

Conclusion

Food insecurity threatens the health and dignity of community residents across physical, psychosocial, and cultural dimensions. By implementing validated screening, establishing measurable goals, and forging reliable connections to Florida’s network of federal programs and Feeding Florida partner agencies, the nurse care coordinator promotes a safer and more effective continuum of care. Sustained success depends on culturally respectful engagement, proactive navigation, and ongoing evaluation so that patients move from crisis assistance toward greater food security and improved health.

References

Baker, S., Gallegos, D., Rebuli, M. A., Taylor, A. J., & Mahoney, R. (2024). Food insecurity screening in high-income countries, tool validity, and implementation: A scoping review. Nutrients, 16(11), 1684. https://doi.org/10.3390/nu16111684

Bryant, S. G. (2023). Screening for social determinants of health in transitional care patients and partnering with the faith community to address food insecurity. Professional Case Management, 28(5), 235–242. https://doi.org/10.1097/NCM.0000000000000613

Feeding Florida. (n.d.). Find your food bank. https://www.feedingflorida.org/

Florida Department of Health. (n.d.). Food access programs. https://www.floridahealth.gov/individual-family-health/injury-prevention-wellness/food-access/

Norris, K., Jilcott Pitts, S. B., Reis, H., & Haynes-Maslow, L. (2023). A systematic literature review of nutrition interventions implemented to address food insecurity as a social determinant of health. Nutrients, 15(15), 3464. https://doi.org/10.3390/nu15153464

U.S. Department of Agriculture, Economic Research Service. (2025). Food security in the U.S.: Key statistics & graphics. https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/key-statistics-graphics/

1

Preliminary Care Coordination Plan for Food Insecurity in a Florida Community Care Setting

Preliminary Care Coordination Plan for Food Insecurity in a Florida Community Care Setting

Care coordination is essential for effectively managing patients in community settings (Bryant, 2023). After budget cuts relocated dedicated case management staff to the inpatient environment, the nurse manager asked me, a staff nurse in a community care center, to assume the care coordination role. This preliminary plan focuses on food insecurity, a critical social determinant of health that affects physical wellness, psychosocial stability, and cultural dignity among community residents (Bryant, 2023). The plan analyzes the health concern and associated best practices, establishes specific goals, and identifies Florida community resources that support a safe and effective continuum of care.

Analysis of Food Insecurity and Best Practices for Health Improvement

Food insecurity is the limited or uncertain access to adequate food because of insufficient resources (Baker et al., 2024). In Florida, Feeding Florida estimates that 2.9 to 3.2 million residents experience food insecurity, including more than 800,000 children. National data show that 13.7% of U.S. households were food insecure in 2024, with higher rates among households with children, single-parent families, and racial and ethnic minority groups (U.S. Department of Agriculture, 2025). The condition produces cascading effects that nurses must address through coordinated, person-centered interventions (Bryant, 2023).

Physically, chronic food insecurity drives both undernutrition and the paradoxical coexistence of obesity. Households often rely on inexpensive, calorie-dense, nutrient-poor foods, elevating risk for type 2 diabetes, hypertension, cardiovascular disease, and compromised immune function. Children may experience delayed growth and increased infection risk. Adults with chronic conditions frequently choose between medications and food, leading to nonadherence and preventable acute care use. Best-practice screening with the validated two-item Hunger Vital Sign enables early identification; an affirmative response to either item signals risk and warrants referral (Baker et al., 2024).

Psychosocial consequences include elevated stress, anxiety, depression, and feelings of shame that discourage help-seeking. Caregivers experience heightened parental stress, while older adults face isolation when mobility limits access to congregate meals. Best practices integrate trauma-informed approaches, destigmatizing language, and linkage to mental health resources alongside food assistance. Evidence shows that direct provision of food and monetary assistance significantly reduces food insecurity prevalence; sustained impact, however, requires ongoing navigation and follow-up rather than one-time referrals (Norris et al., 2023).

Cultural considerations are especially important in Florida’s diverse population, which includes substantial Hispanic, Haitian, African American, and immigrant communities. Preferred staple foods, preparation methods, religious dietary restrictions, and language preferences influence the acceptability of assistance and the effectiveness of nutrition education. Immigrant and mixed-status households may fear that benefit enrollment will affect immigration status. Best practices therefore emphasize culturally congruent food offerings, language-accessible materials, engagement of trusted community leaders, and dignity-centered choice. Underlying assumptions include that patients will disclose needs when screened respectfully and that community resources remain accessible. Points of uncertainty include fluctuating federal benefit levels, transportation barriers in rural counties, and variable pantry capacity during peak demand such as hurricane season.

Specific Goals to Address Food Insecurity

Clear, measurable goals guide coordination and allow evaluation of progress. First, within 30 days of a positive Hunger Vital Sign screen, 90% of identified patients will complete a structured referral to at least one federal nutrition program (SNAP or WIC) or a local Feeding Florida partner agency, with documentation of application status or enrollment. Second, within 60 days, 75% of patients with chronic conditions such as diabetes or heart failure who screen positive will receive brief, culturally tailored nutrition counseling focused on cost-effective meal strategies and will demonstrate improved self-reported access to nutritious food on follow-up. Third, over six months, the care coordination caseload will achieve a measurable reduction in food-related emergency department visits among enrolled patients by facilitating consistent access to emergency food boxes, mobile pantry schedules, and senior meal programs. These goals prioritize immediate stabilization of household food supply while building longer-term self-sufficiency.

Available Community Resources for Continuum of Care in Florida

A robust continuum of care depends on seamless linkage from clinical screening to community supports. Federal nutrition programs form the foundation. The Supplemental Nutrition Assistance Program (SNAP), administered through Florida’s Department of Children and Families via the MyACCESS portal, provides monthly electronic benefits for groceries. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) serves pregnant, postpartum, and breastfeeding individuals and children under age five through county health departments. For adults aged 60 and older with limited income, the Commodity Supplemental Food Program (CSFP) distributes monthly USDA food packages through designated partners.

The Feeding Florida network unites nine Feeding America member food banks that serve all 67 counties through more than 2,400 partner agencies (Feeding Florida, n.d.). These food banks operate community pantries, mobile grocery units, senior box programs, and children’s feeding initiatives. Residents locate their regional food bank at feedingflorida.org or by calling the statewide assistance line. The nine member food banks are Second Harvest of the Big Bend, Feeding Northeast Florida, Second Harvest Central Florida, Feeding Tampa Bay, All Faiths Food Bank, Treasure Coast Food Bank, Harry Chapin Food Bank, Feeding the Gulf Coast, and Feeding South Florida. Additional resources include The Emergency Food Assistance Program (TEFAP), congregate and home-delivered meals under Older Americans Act programs, Summer Break Spot sites for children, and Fresh Access Bucks, which doubles SNAP purchasing power for fresh produce at participating farmers markets. Florida 211 serves as a centralized information and referral hub for local pantries and related supports.

Effective continuum of care requires active navigation rather than passive referral lists. Care coordinators should maintain updated contact information, schedule warm hand-offs when possible, and conduct follow-up contacts to confirm patients successfully accessed resources. Collaboration with social workers, community health workers, and registered dietitians strengthens the multidisciplinary response and addresses co-occurring needs such as transportation or housing instability.

Conclusion

Food insecurity threatens the health and dignity of community residents across physical, psychosocial, and cultural dimensions. By implementing validated screening, establishing measurable goals, and forging reliable connections to Florida’s network of federal programs and Feeding Florida partner agencies, the nurse care coordinator promotes a safer and more effective continuum of care. Sustained success depends on culturally respectful engagement, proactive navigation, and ongoing evaluation so that patients move from crisis assistance toward greater food security and improved health.

References

Baker, S., Gallegos, D., Rebuli, M. A., Taylor, A. J., & Mahoney, R. (2024). Food insecurity screening in high-income countries, tool validity, and implementation: A scoping review. Nutrients, 16(11), 1684. https://doi.org/10.3390/nu16111684

Bryant, S. G. (2023). Screening for social determinants of health in transitional care patients and partnering with the faith community to address food insecurity. Professional Case Management, 28(5), 235–242. https://doi.org/10.1097/NCM.0000000000000613

Feeding Florida. (n.d.). Find your food bank. https://www.feedingflorida.org/

Florida Department of Health. (n.d.). Food access programs. https://www.floridahealth.gov/individual-family-health/injury-prevention-wellness/food-access/

Norris, K., Jilcott Pitts, S. B., Reis, H., & Haynes-Maslow, L. (2023). A systematic literature review of nutrition interventions implemented to address food insecurity as a social determinant of health. Nutrients, 15(15), 3464. https://doi.org/10.3390/nu15153464

U.S. Department of Agriculture, Economic Research Service. (2025). Food security in the U.S.: Key statistics & graphics. https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/key-statistics-graphics/