Referrals and Interventions for Older Adults with Food Insecurity: 

Webinar Takeaways

Hosted Thursday, October 20, 2022

by the Office of Nutrition and Health Promotion Programs, Administration for Community Living

Speakers: Kathryn Tucker, ACL Consultant; Jennifer Raymond, JD, MBA, Chief Strategy 

Officer, AgeSpan

Go to the YouTube recording

What is Food Insecurity? 

• Food security per USDA: “access by all people at all times to enough food for an active life.”

• Low food security: poor nutrition quality and limited variety; little or no sign of reduced 

food intake.

• Very low food security: reports of skipping meals or not eating; reduced food availability.

Who Can Identify Food Insecurity?

• People in various roles may be able to identify needs during initial intake or at any time 

there is contact – such as Aging and Disability Resource Center staff, case managers, 

telephone reassurance callers, and others. 

• Encouraging communication within your organization can improve interactions and 

identification of participants’ needs. 

What is a Warm Handoff?

• A handoff that is conducted in person, whenever possible, between two agencies, in 

front of the participant and family if present.

Importance of a Warm Handoff

• Engages the participant and family as part of the team.

• Ensure participants receive accurate information.

• Prevents those in need from falling through the cracks.

• Builds relationships and communication between partners.

• Provides a safety check for participants.

Using Warm Handoffs in Your Organization

• Personally introduce participants to others in your organization.

• Utilize in-person meetings, telephone conferences, or a virtual setting.

• Organizations you have referred to can utilize a warm handoff to refer to your agency.

• Use with health care providers, food pantries, SNAP, dietitians, and other organizations.

Referrals and Interventions

• Demonstrate value of community-based organizations and services to stakeholders.

• Referrals within the Older Americans Act: Senior Nutrition Program, in-home services, 

health screenings, and more. 

• External referral opportunities: SNAP, SNAP-Ed programs, the Commodity 

Supplemental Food Program, and more.
Referrals and Interventions for Older Adults with Food Insecurity | October 2022 | ACL | Page 2 

Types of Referrals

• Referrals can be made by a health care provider or case manager.

• Internal registries set up between organizations can facilitate referrals.

• Self-referral: When a patient refers themself to a workshop.

Referral Workflow

• Clarify roles in outreach enrollment process.

• Identify who is responsible for scheduling workshops, contacting key staff, enrolling

participants, collecting and entering data, and following up with participants.

• Develop HIPAA compliance procedures.

Tracking Data

• Tracking data helps to identify areas that can be improved.

o Outreach efforts can be identified and documented.

o Reasons for refusals and common resources needed may be identified.

o Attendance records help staff follow up with participants as needed.

o Program completion data can help identify positive outcomes from interventions.

o Satisfaction surveys can help identify ways to improve services and activities.

• Outcomes can be communicated within the network and to community partners.

Resources

• Nutrition and Aging Resource Center (ACL)

o Assistance with Food vs. Meals Infographic

o Grocery Delivery Options by County Template

o Partnerships with Foodbanks and Other USDA Programs

o Using Groceries and Other Nutrition Services to Meet Senior Needs

• Community Food Security Assessment Toolkit (USDA)

• Definitions of Food Security (USDA)

• Design Guide for Implementing Warm Handoffs (AHRQ)

• Eldercare Locator

• Expenditure Reductions Associated with a Social Service Referral Program (National

Library of Medicine)

• Food Insecurity (Healthy People 2020)

• Free Online Course to Help Health Care Providers Address Senior Hunger (Food

Research & Action Center)

• How to Build Referral Systems for Community-Integrated Health Networks (National

Coalition on Aging)

• Implementation Quick Start Guide: Warm Handoff (AHRQ)

• National Aging and Disability Transportation Center

• Nutrition Security Webinar Series (USDA’s National Institute of Food and Agriculture)

• Older Adults Nutrition Program Referral Chart During COVID-19 (Food Research &

Action Center)

• Social Determinants of Health (Healthy People 2030)

• Social Work Case Management Software (Capterra)

• Warm Handoffs: A Guide for Staff (AHRQ)
Referrals and Interventions for Older Adults with Food Insecurity | October 2022 | ACL | Page 3 

• What Are We Assessing When We Measure Food Security? A Compendium and 

Review of Current Metrics (National Library of Medicine)