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2022 MIPS Improvement Activity IA_AHE_9: Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols


Activity Description

Create or improve, and then implement, protocols for identifying and providing appropriate support to: a) patients with or at risk for food insecurity, and b) patients with or at risk for poor nutritional status. (Poor nutritional status is sometimes referred to as clinical malnutrition or undernutrition and applies to people who are overweight and underweight.) Actions to implement this improvement activity may include, but are not limited to, the following:

  • Use Malnutrition Quality Improvement Initiative (MQii) or other quality improvement resources and standardized screening tools to assess and improve current food insecurity and nutritional screening and care practices.
  • Update and use clinical decision support tools within the MIPS eligible clinician’s electronic medical record to align with the new food insecurity and nutrition risk protocols.
  • Update and apply requirements for staff training on food security and nutrition.
  • Update and provide resources and referral lists, and/or engage with community partners to facilitate referrals for patients who are identified as at risk for food insecurity or poor nutritional status during screening.

Activities must be focused on patients at greatest risk for food insecurity and/or malnutrition—for example patients with low income who live in areas with limited access to affordable fresh food, or who are isolated or have limited mobility.

Activity ID Activity Weighting Sub-Category Name
IA_AHE_9 Medium Achieving Health Equity


Reduce food insecurity and improve nutritional outcomes for at-risk patients.


Evidence of screening for food insecurity and malnutrition risk and implementing protocols to support patients who are identified as at risk. Include both of the following:

  1. Protocols for identifying at-risk patients created or improved – Documentation of screening tools—preferably standardized tools that have been tested in underserved communities—applied within clinician workflow and information stored within health information systems; AND
  2. Implementation Plan and Results – Documentation of the plan to advance support to patients who have been identified as having the greatest risk for food insecurity and/or malnutrition, with specific rationale for the interventions selected and documentation of the results achieved.

Example: A practice selects and adapts two standardized tools for screening patients for food insecurity and malnutrition into their electronic health record (EHR) system and begins screening all new patients and existing patients each year. The Quality Improvement team at the practice also establishes a new process whereby, during the visit when the screening occurs, the practice provides those identified as having risk of food insecurity or malnutrition with a) information and counseling about the national Supplemental Nutrition Assistance Program (SNAP) enrollment and b) an information sheet with referrals to food pantries and other community resources in the area. The Quality Improvement group also establishes protocols for calling patients who received counselling and information 3 weeks after their visit to follow-up. At the end of the year, the Quality Improvement group documents within their EHR an increase in SNAP enrollment among their patient population.


  • The following screening tools are tested and standardized, and include screening questions for food insecurity:
  • The following screening tools for nutrition/malnutrition are tested and recommended, though there are many other tools that would be appropriate to use:
    • Malnutrition Screening Tool (MST)
    • Subjective Global Assessment (SGA)
    • Mini Nutritional Assessment (MNA)
    • Malnutrition Universal Screening Tool (MUST)
  • Search for other tools using Kaiser Permanente’s screening tool database:
  • Agency for Healthcare Research and Quality’s resources on CDS:
  • Search for local Aging and Disability Resource Centers and Area Agencies of Aging to find out how they can help connect Medicare beneficiaries to funded home delivered meals, congregate meals and other nutrition services provided through the Older Americans Act as well as other state and local food programs (assistance applying for SNAP benefits, connection to local food pantries etc.).