Improving Food Security: MyHealth Access Network’s Accountable Health Communities Route 66 Consortium

Improving Food Security:
MyHealth Access Network’s Accountable Health Communities Route 66 Consortium

by Candace Pape-Macedo, Senior Manager of SNAP Programs


August 24, 2021

Food insecurity isn’t always easy to spot, but we see its impacts all around us.
An inability to consistently meet basic nutritional needs impacts child development1, academic achievement2, workforce performance3, military recruitment and service (national defense)4, family stability and adverse childhood experiences5, individual resilience6, dental health7, emotional8 and psychological9 wellbeing, chronic disease prevention and management10, overall health, and more.

Pioneer organizations are joining the fight against hunger to create a better tomorrow for more Oklahomans. One great example of this is MyHealth Access Network’s Accountable Health Communities Route 66 Consortium.

Armed with the knowledge that food insecurity can mask underlying health conditions and prolong hospital stays11, hinder medication adherence and complicate disease management12, contribute to higher utilization of emergency department services13, exacerbate existing conditions14, and raise health care costs15, the project blends effective screening procedures with tools to make it easier for medical professionals to identify food needs and connect patients to impactful resources.

How It Works
MyHealth uses a mobile social needs screening that includes two questions to identify food insecurity and offers an immediate resource referral with a local option like a food pantry along with information about the Supplemental Nutrition Assistance Program (SNAP). Positively screened patients receive electronic notification of the closest food pantry from a Community Resource Inventory of nearly 5,000 resources. In addition, notification recipients are invited to visit the project’s SNAP information webpage, call the toll-free SNAP Application Assistance Hotline for help submitting a SNAP application over the phone in about 30 minutes, or visit the Hunger Free Oklahoma grocery webpage for more information and tips for applying online.

For this project, Medicare and Medicaid beneficiaries who have two or more emergency room visits in the last 12 months are referred to a navigation program. These individuals receive follow-up calls to assist in connecting with community agencies that can help meet their identified social needs. Project navigators from the Tulsa and Oklahoma City County Health Departments are trained to assist patients that may need additional support to complete a SNAP application and get their food needs met.

The Impact
Working with five health systems with 117 sites comprised of clinics, emergency rooms, and urgent care centers, as well as three care coordination sites, the MyHealth Accountable Health Communities project has seen increasing success. Since launching in August of 2018, the project has offered over 2 million social needs screenings to patients seen in Oklahoma and identified more than 97,000 social needs.

Making Food Insecurity Screening Routine
Knowing that food security status can change rapidly, hospitals, clinics, and health systems across the country are beginning to incorporate food insecurity screening as part of patient intake procedures and care. Thanks to this project, participating medical professionals in Oklahoma can now systematically screen and connect patients to food resources statewide with little time required from the clinical staff, which is more important than ever with the increasing demands on healthcare staff due to the Covid-19 pandemic. The project in its final year has demonstrated that community-healthcare partnerships can help screen and connect thousands of Oklahomans to food resources. We look forward to this becoming a sustainable practice in Oklahoma and appreciate the MyHealth Route 66 Consortium’s ongoing commitment to creating a hunger-free Oklahoma.

Learn More
To learn how your organization can join the fight against hunger by receiving SNAP application assistance training, SNAP outreach material, or information on other food resources for your community connect with Hunger Free Oklahoma here. For more information on the MyHealth Accountable Health Communities project please reach out to MyHealth Access via

1. Food Insecurity, Health, and Development in Children Under Age Four Years

2. Too Hungry to Learn: Food Insecurity and School Readiness

3. Feeding Our Human Capital: Food Insecurity and Tomorrow’s Workforce

4. Breaking Point- Child malnutrition imperils America’s national security;%20filename=%22Breaking%20Point:%20Child%20malnutrition%20imperils%20America%27s%20national%20security.pdf%22

5. Childhood Adversity and Adult Reports of Food Insecurity Among Households With Children

6. What are the Psychological Effects of Hunger on Children?

7. The association between food insecurity and dental caries among U.S. adults: Data from the National Health and Nutrition Examination survey

8. Food insecurity and emotional health in the USA: a systematic narrative review of longitudinal research

9. The Long‐term Health Consequences of Childhood Food Insecurity

10. Food Insecurity, Chronic Disease, and Health Among Working-Age Adults

11. Food insecurity screening: Health care’s role in identifying food insecurity

12. Food Insecurity and Medication Adherence in Low-Income Older Medicare Beneficiaries With Type 2 Diabetes

13. Emergency Medicine News, Special Report: Food Insecurity Can lead straight to the ED

14. The Intersection between Food Insecurity and Diabetes: A Review

15. Food-Insecure Households Likelier to Have Chronic Diseases, Higher Health Costs


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