CE/CME

Food and Housing: Screening and Intervention

Welcome to the training on Food and Housing: Screening and Intervention provided by the Texas Health and Human Services Commission (HHSC) and the Texas Department of State Health Services (DSHS).

Credit Hours: 1.00 CE

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Goal

The goal of this training is to equip Texas Health Steps providers and other health care professionals to identify children and adolescents at risk for food insecurity and housing instability, to screen as part of routine preventive medical care and to connect patients and families to appropriate resources and interventions.

Target Audience

Texas Health Steps providers and other interested health care professionals.

Specific Learning Objectives

After completing the activities of this module, you will be able to:

  1. Examine the effects that food insecurity and housing instability can have on child and adolescent health and development.
  2. Employ recommended screening for food insecurity and connect patients and families to appropriate resources and interventions.
  3. Employ recommended screening for housing instability and connect patients and families to appropriate resources and interventions.

Please note this module expires on 9/1/2025.

This module was released on 9/1/2022.

Featured

Althoof, R., Ametti, M., & Bertmann, F. (2017).  The Role of Food Insecurity in Developmental Psychopathology. Preventive Medicine, 92, 106-109.

American Academy of Pediatrics. (2015). Policy Statement: Promoting Food Security for All Children. Pediatrics, 136(5), e1431-e1438.

American Academy of Pediatrics, Campaign for Dental Health. (2015). A Perfect Smile Comes at a Cost: How Poverty and Food Insecurity Cement Disparities in Oral Health.

American Academy of Pediatrics. (2008). Policy Statement: The Medical Home. Pediatrics, 110:184–186.

American Academy of Pediatrics. (2017). AAP policy statement: Providing Care for Children and Adolescents Facing Homelessness and Housing Insecurity. Pediatrics, 131(6), 1206-1210.

American Psychological Association. (2022). Effects of Poverty, Hunger and Homelessness on Children and Youth.

Bahn, R. A., Hwalla, N., & El Labban, S. (2021). Leveraging nutrition for food security: the integration of nutrition in the four pillars of food security. In C. M. Galankis (ed.), Food Security and Nutrition (pp. 1–32).

Bernal, J., Frongillo, E. A., Herrera, H., & Rivera, J. (2012).Children live, feel, and respond to experiences of food insecurity that compromise their development and weight status in peri-urban Venezuela. Journal of Nutrition, 142(7), 1343–1349.

Bhattarai, A., & Siegel, R. (2022). Inflation is Making Homelessness Worse. Washington Post, July 3.

Burke, M. P., Martini, L. H., Cayir, E., Hartline-Grafton, H. L., & Meade, R. L. (2016). Severity of Household Food Insecurity is Positively Associated with Mental Disorders among Children and Adolescents in the United States. The Journal of Nutrition, 146(10), 2019–2026. 

Bush School of Government and Public Service. (2015). Healthy Discussions: A community assessment and healthcare gap analysis of four border counties. Texas A&M University.

Calkins, K., & Devaskar, S. U. (2011). Fetal Origins of Adult Disease. Current Problems in Pediatric and Adolescent Health Care, 41(6), 158-176.

Center for Housing Policy and Children’s HealthWatch. (2015). Compounding Stress: The Timing and Duration Effects of Homelessness on Children’s Health.

Center on Budget & Policy Priorities. (2022). Federal Rental Assistance Fact Sheets, Texas.

Center on Budget & Policy Priorities. (2022). New Data: Millions Struggling to Eat and Pay Rent: Joblessness Continues to Affect Tens of Millions.

Center on Budget & Policy Priorities. (2018). Most Working-Age SNAP Participants Work, But Often in Unstable Jobs.

Centers for Disease Control and Prevention. (2022). Children Living in Households That Experienced Food Insecurity: United States, 2019-2020.

Centers for Disease Control and Prevention. (2022). Reproductive Health: Infant Mortality.

Centers for Disease Control and Prevention. (2022). Know the Facts: Protect Your Child from Lead Exposure.

Centers for Disease Control and Prevention. (2021). Childhood Lead Poisoning Prevention: At-Risk Populations.

Centers for Disease Control and Prevention. (2021). Disparities in Oral Health.

Centers for Disease Control and Prevention. (2021). Childhood Lead Poisoning Prevention: Populations at Greater Risk.

Centers for Disease Control and Prevention. (2014). Pediatric Environmental Health Toolkit.

Chang, C., Ceci, C., Uberoi, M., Waselewski, M., & Chang, T. (2022). Youth Perspectives on Their Medical Team’s Role in Screening for and Addressing Social Determinants of Health. Journal of Adolescent Health, 70(6): 928-933.

Chhabra, M., Sorrentino, A. E., Cusack, M., Dichter, M. E, Montgomery, A. E., & True, G. (2019). Screening for Housing Instability: Providers' Reflections on Addressing a Social Determinant of Health. Journal of General Internal Medicine, 34(7):1213-1219.

Child and Adolescent Health Measurement Initiative. (2021). Texas Fact Sheet, 2019: Strong Roots Grow a Strong Nation. The Johns Hopkins Bloomberg School of Public Health.

Children’s HealthWatch. (2019). Policy report: Pathways to Stable Homes: Promoting Caregiver and Child Health Through Housing Stability.

Children’s HealthWatch. (2011). Behind Closed Doors: The hidden health impact of being behind on rent.

Cincinnati Children’s Hospital Medical Center (2012). Infants At-Risk From Formula Stretching: Improved screening methods help doctors identify families with hunger issues.

Colonias in Texas. (n.d.). University of Wisconsin, Eau Claire.

Congressional Research Service. (2018). Homelessness: Targeted Federal Programs.

Cooksey-Stowers, K., Schwartz, M. B., & Brownell, K. D. (2017). Food Swamps Predict Obesity Rates Better Than Food Deserts in the United States. The International Journal of Environmental Research and Public Health, 14(11), 1366.

Cutts, D., Meyers, A. F., Black, M. M., Casey, P. H., Chilton, M., Cook, J. T. . . Frank, D.A. (2011). U.S. Housing Insecurity and the Health of Very Young Children. American Journal of Public Health, 101(8), 1508–1514.

DiMaggio, C., Brady, J., & Li, G. (2015). Association of the Safe Routes to School program with school-age pedestrian and bicyclist injury risk in Texas. Injury Epidemiology, 2(1), 15.

Episcopal Health Foundation, the Methodist Healthcare Ministries of South Texas, & St. David’s Foundation. (2019). Community Resource Referral Platforms: A Guide for Health Care Organizations.

Farrell, A. E., Dibble, K. E., Randall, K. G., & Britner, P. A. (2017). Screening for Housing Instability and Homelessness Among Families Undergoing Child Maltreatment Investigation, American Journal of Community Psychology, 60(1–2): 25–32.

Federal Reserve Bank of Dallas. (2015). Las Colonias in the 21st Century: Progress Along the Texas-Mexico Border.

Feeding America. (2021). 3 devastating effects of hunger on the body.

Feeding America. (2021). The Impact of the Coronavirus on Local Food Insecurity in 2020 & 2021.

Feeding America. (2019). Map the Meal Gap: Child Food Insecurity in The United States.

Feeding America. (2018). Understand Food Insecurity: What is Food Insecurity?

Feeding America. (2018). Hunger in America, Real Stories of Hunger: Emily’s Story (video).

Feeding America. (2018). Illuminating Intersections: Hunger and Health.

Feeding America. (2014). Hunger in America Study.

Feeding Texas. (2022). Learn About Hunger.

Food Research & Action Center. (2017). Hunger & Health: The Impact of Poverty, Food Insecurity, and Poor Nutrition on Health and Well-Being.

Galvin, G. (2018). On the Border, Out of the Shadows. U.S. News & World Report, May 16.

Gold, S., & Wagner, B. (2022). Acute care utilization and housing hardships in American children. Children and Youth Services Review, 136, 106447.

Gregory, C. A., & Coleman-Jensen, A. (2017). Food insecurity, chronic disease, and health among working-age adults. Economic Research Report, 235. U.S. Department of Agriculture, Economic Research Service.

Hall, L., & Nchako, C., (2022). A Closer Look at Who Benefits from SNAP: State-by-State Fact Sheets: Texas. Retrieved from Center on Budget and Policy Priorities website:

Harvard University, Joint Center for Housing Studies. (2021). The State of the Nation’s Housing, 2021.

Hatem, C. L., Young, L. C., Xue, Z., Reeser-Oyer, L., Lopez, T., & Hernandez, D. C. (2020). Food insecurity and housing instability during early childhood as predictors of adolescent mental health. Journal of Family Psychology, 34(6), 721–730.

Health Affairs Health Policy Brief. (2018). Housing And Health: An Overview of The Literature.

Institute for Children, Poverty & Homelessness. (2019). Addressing Hunger Among Homeless Children.

Johns Hopkins University. (2020). Poor Families Must Move Often, But Rarely Escape Concentrated Poverty.

Johnson, A. D., & Markowitz, A. J. (2018). Food Insecurity and Family Well-Being Outcomes among Households with Young Children. The Journal of Pediatrics, 196, 275-282.

Johnson, A. D., & Markowitz, A. J. (2018). Associations Between Household Food Insecurity in Early Childhood and Children's Kindergarten Skills. Child Development, 89(2), e1-e17.

Johnson, K. T., Palakshappa, D., Basu, S., & Seligman, H. (2021). Examining the bidirectional relationship between food insecurity and healthcare spending. Health Services Research, 56(5), 864–873.

Kingsley, G. T., Jordan, A., & Traynor, W. (2012). Addressing Residential Instability: Options for Cities and Community Initiatives. Cityscape: A Journal of Policy Development and Research, 14(3), 161-184.

Lee, C. Y., Zhao, X., Reesor-Oyer, L., Cepni, A. B., & Hernandez, D. C. (2021). Bidirectional Relationship Between Food Instability and Housing Insecurity. Journal of the Academy of Nutrition and Dietetics, 121(1), 84–91.

Ma, C. T., Gee, L., & Kushel, M. B. (2008). Associations between housing instability and food insecurity with health care access in low-income children. Ambulatory Pediatrics, 8(1), 50–57.

McLaughlin, K.A., Green, J. G., Alegria, M., Costello, E. J., Gruber, M. J., Sampson, N. J., & Kessler, R. C. (2012). Food Insecurity and Mental Disorders in a National Sample of U.S. Adolescents. Journal of the American Academy of Child & Adolescent Psychology, 51(12), 1293-1303.

Melchior, M., Caspi, A., Howard, L. M., Ambler, A. P., Bolton, H., Mountain, N., & Moffitt, T. E. (2009). Mental health context of food insecurity: a representative cohort of families with young children. Pediatrics, 124(4):e564–e572.

National Bureau of Economic Research. (2018). Child Age and Gender Differences in Food Insecurity in a Low-Income Inner-City Population. Working Paper 22988.

National Center for Homeless Education. (n.d.). The McKinney-Vento Definition of Homeless.

National Low Income Housing Coalition. (2022). Housing Needs by State, Texas.

National Low Income Housing Coalition. (2021). Out of Reach: Texas.

National Low Income Housing Coalition. (2018). The Gap: A Shortage of Affordable Rental Homes: No State Has an Adequate Supply of Affordable Rental Housing for the Lowest Income Renters.

Nolen, E. Cubbin, C.,  & Brewer, M. (2021). The effect of maternal food insecurity transitions on housing insecurity in a population-based sample of mothers of young children. AIMS Public Health, 9(1), 1–16.

O’Malley, J. A., Klett, B. M., Klein, M. D., Inman, N., & Beck, A. F. (2017). Revealing the prevalence and consequences of food insecurity in children with epilepsy. Journal of Community Health, 42(6), 1213-1219.

Pennsylvania State University, Center on Rural Education and Communities. (n.d.). Poverty, Housing Insecurity and Student Transiency in Rural Areas.

Pulcini, C. D. (2015). Hunger Screening: Pediatrician Trainees Challenge Providers to Feed the Need. American Academy of Pediatrics, AAP Voices, Dec. 17, 2015.

Raskind, I. G., Haardörfer, R., & Berg, C. J. (2019). Food insecurity, psychosocial health and academic performance among college and university students in Georgia, USA. Public Health Nutrition, 22(3):476-485.

Restrepo, B. J., Rabbitt, M. P., & Gregory, C. A. (2021) The Effect of Unemployment on Food Spending and Adequacy: Evidence from Coronavirus-Induced Firm Closures. Applied Economic Perspectives and Policy, 43(1), 185–204.

Rich, R. (2013). The Great Recession. Federal Reserve Bank of New York.

Ryu, J. H., & Bartfeld, J. H. (2012). Household Food Insecurity During Childhood and Subsequent Health Status: The Early Childhood Longitudinal Study—Kindergarten Cohort. American Journal of Public Health, 102(11): e50-e55.

San Francisco Department of Public Health. (2019). Public Health Brief: Health Impacts of Family Housing Insecurity.

Sandel, M., Sheward, R., Ettinger de Cuba, S., Coleman, S. M., Frank, D. A., Chilton, M., . . .  Cutts, D. (2018). Unstable Housing and Caregiver and Child Health in Renter Families. Pediatrics, 141(2), e20172199.

Sheward, R., Bovell-Ammon, A., Ahmad, N., Preer, G., Ettinger de Cuba, S., & Sandel, M. (2019). Promoting Caregiver and Child Health Through Housing Stability Screening in Clinical Settings. Zero to Three Journal, 39(4), 52-59.

Sreeramareddy, C. T., & Ramakrishnareddy, N. (2018). Association of adult tobacco use with household food access insecurity: results from Nepal demographic and health survey, 2011. BMC Public Health, 18:48.

Texas Department of Housing and Community Affairs. (2020). State of Texas Low Income Housing Plan and Annual Report.

Texas Department of Housing and Community Affairs. (2015). 2020-2024: State of Texas Consolidated Plan.

Texas Health Steps, Anticipatory Guidance Provider Guide.

Texas Health Steps Periodicity Schedule.

Texas Health and Human Services Commission, Medical Transportation Program.

Texas Housers: Texas Low Income Housing Information Service. (2021). Texas ranks at the bottom for affordable and available housing for Extremely Low Income renters. This is what Congress must do to help.

Texas Tribune. (2018). As Texas grows, an affordable housing crisis looms. Here are six things to know.

Texas Workforce Commission. (2022). Housing Discrimination.

University of Wisconsin, Population Health Institute. (2020). 2020 County Health Rankings Key Findings Report.

U.S. Department of Agriculture, Economic Research Service. (2022). Frequency of Food Insecurity.

U.S. Department of Agriculture, Economic Research Service. (2022). Food Insecurity for Households With Children Rose in 2020, Disrupting Decade-long Decline.

U.S. Department of Agriculture, Economic Research Service. (2022). Definitions of Food Insecurity.

U.S. Department of Agriculture, Economic Research Service. (2021). Household Food Security in the United States in 2020.

U.S. Department of Agriculture, Economic Research Institute. (2021). Household Food Security in the United States in 2020. Economic Information Bulletin, 298.

U.S. Department of Agriculture, Economic Research Service. (2020). Key Statistics & Graphics.

U.S. Department of Agriculture, Economic Research Service. (2019). Understanding Low-Income and Low-Access Census Tracts Across the Nation: Subnational and Subpopulation Estimates of Access to Healthy Food.

U.S. Department of Agriculture, Economic Research Service. (2019). Food Access.

U.S. Department of Agriculture, Economic Research Institute. (2013). Food Insecurity in Households With Children: Prevalence, Severity, and Household Characteristics, 2010-11. Economic Information Bulletin, 113.

U.S. Department of Health and Human Services. (2022). HHS Poverty Guidelines for 2022.

U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2019). Healthy People 2020, Housing Instability.

U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2019). Healthy People 2020, Housing and Homes.

U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2019). Healthy People 2030, Social Determinants of Health.

U.S. Department of Housing and Urban Development. (n.d.). Rental Burdens: Rethinking Affordability Measures. (PD&R Edge article).

U.S. Governmental Accountability Office. (2020). Homelessness: Better HUD Oversight of Data Collection Could Improve Estimates of Homeless Population.

Whitaker, R. C., Phillips, S. M., & Orzol, S. M. (2006). Food Insecurity and the Risks of Depression and Anxiety in Mothers and Behavior Problems in their Preschool-Aged Children. Pediatrics, 118(3), e859-e868.

Medical Definitions

The medical definitions in this course were obtained or adapted from the American Academy of Pediatrics, Centers for Disease Control and Prevention, Children (a Swiss journal), Congressional Research Service, the federal Substance Abuse and Mental Health Services Administration, Harvard University, Healthy People 2030, Nemours Children’s Health System, Texas Secretary of State, U.S. Department of Agriculture and the U.S. Department of Health and Human Services. 

Continuing Medical Education

The Texas Department of State Health Services, Continuing Education Service is accredited by the Texas Medical Association to provide continuing medical education for physicians. 

The Texas Department of State Health Services, Continuing Education Service designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Nursing Continuing Professional Development

The Texas Department of State Health Services, Continuing Education Service is accredited as a provider of Nursing Continuing Professional Development by the American Nurses Credentialing Center’s Commission on Accreditation.

Texas Department of State Health Services, Continuing Education Service has awarded 1.00 contact hours of Nursing Continuing Professional Development.

Social Workers

The Texas Department of State Health Services, Continuing Education Service, the continuing education provider, ensures that the education provided is directly related to the practice of social work; and that the individuals presenting the information have the necessary experience and knowledge in the topics presented. The Texas Department of State Health Services, Continuing Education Service has awarded 1.00 hours of credit.

Certificate of Attendance

The Texas Department of State Health Services, Continuing Education Service has designated 1.00 hour(s) for attendance.

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Resources

Appendix of Resources

Note: This Appendix has one section for health-care providers resources and another section of resources for children and families. Both are divided into two topics: food insecurity and housing instability.

Appendix of Resources for Health-Care Providers

Food Insecurity:

American Academy of Pediatrics. (2015). Policy Statement: Promoting Food Security for All Children. Pediatrics, 136(5), e1431-e1438.

American Academy of Pediatrics, Campaign for Dental Health. (2015). A Perfect Smile Comes at a Cost: How Poverty and Food Insecurity Cement Disparities in Oral Health.

American Academy of Pediatrics and the Food Research & Action Center.

Screen and Intervene: A Toolkit for Pediatricians to Address Food Insecurity.

Baylor University. Baylor Collaboration on Hunger and Poverty, which uses “research, policy and practice to cultivate evidence-based solutions to the challenges of food and economic injustice.”

CIE Toolkit for health-care providers who want to deliver coordinated, person-centered care to address social determinants of health to improve population health.

Every Texan (formerly the Center for Public Policy Priorities), offers a Food Security web page with information about food assistance programs.

Feeding America. Food Insecurity in Texas online map, searchable by county.

Feeding America. Find Your Local Food Bank.

Feeding America. Video: Illuminating Intersections: Hunger and Health. (3 minutes)

Feeding Texas, the largest hunger-relief organization in Texas.

Findhelp.org, social care website that allows users to search for local food, housing and other resources by entering a Zip code.

Food Research & Action Center. Transition Recommendations: “This is the Time to Heal in America,” and It Begins With Addressing Hunger.

Texas Health and Human Services Commission provides information about:

  • SNAP Food Benefits  (in Spanish)
  • Texas Food Bank Network Provider, a list of food banks that can assist with filling out SNAP applications. (in Spanish)
  • Texas Legal Services Center can provide legal aid for civil legal issues such as accessing SNAP or other benefits for families of modest means (generally with income under 200% of the federal poverty level). Contact TLSC at 512-477-600 or:

Texas Rio Grande Legal Aid (TLRA) provides SNAP or other benefits assistance to families of modest means in 68 Southwest Texas counties, including those surrounding Austin, San Antonio, Corpus Christi, Laredo and El Paso. Toll-free at 1-833-329-8752, or:

Legal Aid of Northwest Texas (LANWT) provides SNAP or other benefits assistance to families of modest means in for 114 North Texas counties, including those surrounding Dallas, Lubbock, Amarillo and Midland. Contact LANWT toll-free at 1-888-529-5277, or:  https://internet.lanwt.org/gethelp and counties covered

Lone Star Legal Aid (LSLA) provides SNAP or other benefits assistance to families of modest means in for 72 East Texas Counties, including those surrounding Houston. Contact LSLA at 1-800-733-8394, or:

Texas Health Steps, Anticipatory Guidance Provider Guide.

Texas Health Steps Periodicity Schedule.

Texas Health Steps. Child Health Clinical Record Forms.

Texas Medicaid Provider Procedures Manual (TMPP).

U.S. Department of Agriculture, Food and Nutrition Service, list of stores accepting SNAP food purchases online.

U.S. Department of Agriculture, Food and Nutrition Service, Pandemic Electronic Benefit Transfer (P-EBT) card information for children to purchase food who previously would have received free or reduced-price meals through the National School Lunch Act.

Housing Instability:

American Academy of Pediatrics. (2017). Policy statement: Providing Care for Children and Adolescents Facing Homelessness and Housing Insecurity. Pediatrics, 131(6), 1206-1210.

CIE Toolkit for health-care providers who want to deliver coordinated, person-centered care to address social determinants of health to improve population health.

Texas Health and Human Services Commission. Programs for People who are Homeless or at Risk of Becoming Homeless. (in Spanish)

Texas Health Steps, Anticipatory Guidance Provider Guide.

Texas Health Steps Periodicity Schedule.

Texas Health Steps. Child Health Clinical Record Forms.

  • Texas Legal Services Center can provide aid for civil legal issues such as housing challenges for families of modest means (generally with income under 200% of the federal poverty level). Contact TLSC regarding families in major metropolitan area at 512-477-600 or:

Texas Rio Grande Legal Aid (TLRA) provides housing challenge assistance to families of modest means in 68 Southwest Texas counties, including those surrounding Austin, San Antonio, Corpus Christi, Laredo and El Paso. Toll-free at 1-833-329-8752, or:

Legal Aid of Northwest Texas (LANWT) provides housing challenge assistance to families of modest means in for 114 North Texas counties, including those surrounding Dallas, Lubbock, Amarillo and Midland. Contact LANWT toll-free at 1-888-529-5277, or:  https://internet.lanwt.org/gethelp and counties covered

Lone Star Legal Aid (LSLA) provides housing challenge assistance to families of modest means in for 72 East Texas Counties, including those surrounding Houston. Contact LSLA at 1-800-733-8394, or:

Texas Medicaid Provider Procedures Manual (TMPP).

Urban Institute. Video: Housing Instability. (30 minutes)

U.S. Department of Housing and Urban Development. Continuum of Care (CoC) Program.

U.S. Department of Housing and Urban Development. Homeless Information: Texas.

Lead Exposure:

Patients and Families

Food:

Feeding America. Find Your Local Food Bank.

Feeding Texas, the largest hunger-relief organization in Texas.

Findhelp.org, social care website that allows users to search for local food, housing and other resources by entering a ZIP code.

Texas Health and Human Services Commission provides information about:

U.S. Department of Agriculture, Food and Nutrition Service, list of stores accepting SNAP food purchases online.

Housing:

  • 2-1-1 Texas hotline operated 24/7 by the Texas Health and Human Services Commission. Offers a Housing Choices—Finding a Place to Live web page with an array of housing programs for families in need.
  • Findhelp.org, social care website that allows users to search for local food, housing and other resources by entering a ZIP code.
  • U.S. Department of Housing and Urban Development. Offers a Housing Counseling Services online directory of HUD-approved housing counseling agencies, searchable by ZIP code. Offerings vary by agency, but usually include counseling about homelessness, rentals and mortgage delinquency.
  • U.S. Department of Housing and Urban Development. Rental Assistance web page.
  • Tenants’ Rights Handbook offered by the Texas Young Lawyers Association and the State Bar of Texas.
  • Texas Homeless Network, a nonprofit working to make homelessness rare, brief and non-recurring.
  • Texas Homeless Network, Emergency Housing Vouchers.
  • TexasLawHelp.org, the statewide legal aid website for Texas. It offers free legal help and information about public housing, eviction, foreclosure and other housing aid.
  • Texas Tenant Advisor website, offered by the Texas Low Income Housing Information Service.
  • U.S. Department of Housing and Urban Development & U.S. Department of Health and Human Services. Texas website, with resources for affordable and accessible housing as well as supportive services in Texas.

Transportation:

  • Texas Health and Human Services Commission, Medical Transportation Program. May provide non-emergency transportation to patients and families to get to a medical or dental checkup or to a drug store.