11 Sep
The problem we’re still not solving
Every week in New York, thousands of families walk into clinics quietly struggling with an empty fridge. They might not say it out loud. But the signs are there: missed meals, rising blood sugar, trouble affording both insulin and groceries.
Food insecurity now affects more than 2 million New Yorkers. That’s roughly one in ten people. And while many hospitals and clinics are doing the right thing, which is screening for food insecurity during intake, the follow-through often stops there.
A question we rarely ask out loud:
Did that patient actually get the help? Did it make a difference?
If we can’t answer that, we’re not closing the loop; we’re just checking a box!!
This is where FHIR analytics can change the story.
Why Food Insecurity demands a Data-Driven Response
In 2025, New York’s Medicaid waiver introduced a powerful shift:
Social care referrals must now be tracked, measured, and shared using FHIR.
This isn’t just policy. It’s a challenge to all of us in health and social care:
“If we say food matters, we need to prove it. If we screen for it, we need to follow through.”
That means using a common data language (FHIR) to ensure the patient journey doesn’t vanish once the referral is made. It means food banks and clinics sharing data. It means measuring impact, not just effort.
And most importantly, it means treating food support as part of care, not charity.
What this looks like for a Real Person
Meet Jon. He’s a Medicaid member living in Rochester. He shows up at a community health center for a routine check-up.
He’s screened for food insecurity. It’s positive.
Here’s what happens when the system is built right:
- His provider logs the result using a FHIR QuestionnaireResponse.
- A secure referral is sent via FHIR ServiceRequest to a local food pantry.
- That pantry accepts the referral, delivers a grocery kit, and logs it as a FHIR Procedure.
- All of this flows back into Jon’s health record.
- His care team sees that the support was delivered and can begin tracking how it affects his A1C, ER visits, and overall stability.
That’s not just coordination. That’s care with dignity, accountability, and data to back it up.
Analytics in action
Screening and referrals are important first steps, but without analytics, it’s impossible to know if the system is making a difference. This is where FHIR analytics become a game changer.
FHIR gives us the ability to structure and track each touchpoint – from the initial screening to the referral and service delivery. But analytics is what truly brings those data points to life. By standardizing information across systems, FHIR enables providers, payers, and community organizations to measure the real impact of food support on both health outcomes and costs.
With FHIR analytics, healthcare teams can finally ask and answer critical questions in real time:
- Are food programs reaching the people who need them most?
- Are patients with diabetes or hypertension improving after nutrition support?
- Is the referral network closing the loop or leaving people behind?
- What savings in hospitalizations and ER visits result from these interventions?
What this looks like in practice:
- Dashboards like a “Nutrition Support Impact Tracker” aggregate data from EHRs, food banks, and Medicaid claims into a single FHIR-enabled view.
- Care teams can monitor referral completion rates, clinical improvements, and utilization trends.
- Policy leaders can identify which programs are delivering the best outcomes and replicate them across regions.
The difference is powerful: analytics transform food insecurity interventions from good intentions into measurable results. And behind every data point is a real person – a parent, a grandparent, a teenager – whose life is changed when support is not just offered but tracked and delivered with accountability.
Scaling this for the future
Food insecurity is just the beginning.
The same FHIR workflows and analytics can be applied to:
- Housing instability
- Transportation access
- Utility assistance
- Crisis care
New York’s 1115 waiver has laid the foundation. But building a compassionate, data-informed system will require more than compliance. It will take collaboration, infrastructure, and empathy built into the data itself.
Aigilx Health: Turning Interventions into Outcomes
At Aigilx Health, we believe data should help people, not just systems.
That’s why we build tools that don’t stop at referrals. We build for closure, clarity, and impact.
- We implement FHIR-based referral workflows that actually talk to food programs.
- We build analytics dashboards that show the whole picture; not just the process, but the outcomes.
- We help health systems and SCNs turn screenings into something real – interventions that matter.
Because food is healthcare. And tracking it with care and precision is the least we can do.
Let’s not miss ‘the moment’
We’ve never had more visibility into need. Or better tools to act.
FHIR lets us do more than identify food insecurity; it lets us track who’s helping, who’s being helped, and what changes because of it.
Let’s not let that go to waste.
Let’s build systems that see the whole person, follow through, and measure what matters.
Aigilx Health is ready to help you get there.
Visit Aigilx Health to know more about us.
Aigilx health specializes in developing Interoperability solutions to create a healthcare ecosystem and aids in the delivery of efficient, patient-centric and population-focused healthcare.
