Home Food Delivery to Address Food Insecurity Following Hospital Discharge

Abstract

Nearly 1 in 5 families with children in the U.S. are food insecure. Hospitalization of a child can exacerbate food insecurity, both during the hospitalization after discharge. While some hospitals provide free or subsidized meals during hospitalization, few address food insecurity in the immediate post-hospitalization period. To address this gap, we developed an innovative Inpatient Food Pharmacy program. This program offers families of hospitalized children experiencing food insecurity a choice of one week of prepared meals, six months of monthly produce delivery, or both, after discharge. Our goals were to assess program enrollment, underst family preferences, evaluate the program’s feasibility acceptability. Among 120 eligible families, 71 (59%) enrolled. Fifty-five families (77%) chose both prepared meals produce delivery, 13 (18%) chose prepared meals only, 3 (4%) chose produce delivery only. The program successfully delivered 6,972 prepared meals 348 boxes of produce over 10 months. Follow-up calls reached 41 (58%) of enrolled families, all of whom reported that the program met their acute food needs. Feedback from families resource navigators suggested the program was acceptable. We aim to advocate for sustainable funding for food delivery for children families experiencing food insecurity at three levels, (1) institutionally, through our hospital’s community benefit spending, (2) statewide, through a proposed Medicaid Section 1115 waiver providing grocery delivery to Medicaid-insured pregnant postpartum individuals their families, (3) federally, through the Special Supplemental Nutrition Program for Women, Infants, Children the Supplemental Nutrition Assistance Program.

Article Summary:

We describe lessons learned from implementing a post-discharge food delivery program for families of hospitalized children experiencing food insecurity.

Introduction

Nearly 1 in 5 families with children in the U.S. are food insecure, with limited or uncertain access to adequate food.¹ Food insecurity is associated with adverse child health outcomes increased health care expenditures.^2–7 Recent studies suggest food insecurity rates are higher among families of hospitalized children, with 25 to 46% of families reporting difficulty obtaining enough food while their children are hospitalized.^8–10 Having a child admitted to the hospital can exacerbate food insecurity due to limited availability of affordable food options, financial hardship due to lost wages additional expenses, difficulty accessing foods that align with a family’s dietary restrictions or preferences.⁸ Research suggests approximately one-third of children’s hospitals screen for food insecurity over 80% provide food to caregivers of hospitalized children.¹¹ However, financial hardship food insecurity persist for many families after discharge few programs address food insecurity specifically in the post-hospitalization period.¹²

In 2019, our children’s hospital implemented a social needs screening support program, screening families for food insecurity during their child’s admission.^13–15 We found that nearly 1 in 5 (19%) families reported food insecurity. Our hospital provides families with food vouchers, referrals to local resources like food banks, information about federal nutrition programs like the Special Supplemental Nutrition Program for Women, Infants, Children (WIC) the Supplemental Nutrition Assistance Program (SNAP). However, prior to this intervention, we did not directly support families in accessing food after hospital discharge, which is a critical period of healing for children, a time when families may experience financial hardship but may not yet have access long-term supports like WIC or SNAP.¹⁰ Post-hospitalization food resources may also be beneficial for families receiving WIC SNAP, as these programs may not fully meet families’ food nutrition needs.¹⁶

Prior research suggests families may prefer home food delivery over other forms of health system-based nutrition support.¹⁷ Food delivery may be more convenient less stigmatizing than receiving food in-person at a hospital or clinic.¹⁸ Prepared meal delivery may also support families by reducing time spent preparing meals, allowing them more time to care for their children immediately after discharge.

From a policy stpoint, there is increasing interest investment in health system-based nutrition assistance nationally. Many state Medicaid agencies are using Section 1115 demonstration waivers, which allow states to implement evaluate innovative projects designed to improve their Medicaid programs,¹⁹ to address health-related social needs, including funding nutrition benefits for food insecure families through grocery prepared meal delivery.^20–22 Some Accountable Care Organizations now provide nutrition assistance to families experiencing food insecurity in order to support their health well-being.²³ Despite increasing enthusiasm around health system-based food assistance, there is a dearth of evidence on strategies for providing food support after a child’s hospitalization.¹²

To fill this gap support families of hospitalized children experiencing food insecurity at our institution, we piloted an innovative Inpatient Food Pharmacy program. The program offered families the option to receive one week of prepared meals, six months of monthly produce delivery, or both, following their child’s hospitalization. Our specific objectives were to (1) examine the number of families who would opt into the program, (2) underst families’ preferences for prepared meals, produce delivery, or both, (3) examine program feasibility acceptability. Ultimately, our goal was to generate evidence to advocate for enhanced nutrition supports for families of hospitalized children experiencing food insecurity.

Methods Process

Stakeholders

First, we convened key internal stakeholders. Our institution had a preexisting Food Pharmacy program that was developed with caregiver input based in two primary care clinics a multi-disciplinary Healthy Weight clinic. Through this program, families experiencing food insecurity could receive six months of monthly produce delivery. To discuss adaptation to the inpatient setting, we convened physician social work leads for our inpatient social needs screening program physician operational leads (S.K A.S.) of our existing Food Pharmacy program. We also incorporated caregiver feedback, obtained through two prior research studies,^13,17 into our plan for intervention adaptation.

Community Partners

Next, we convened hospital stakeholders community partners. To operationalize meal produce delivery, we worked with two community partners, Inflight Cuisine, a local community-based organization specializing in prepared medically tailored meal delivery, Common Market, a national community-based organization specializing in produce delivery. Preliminary meetings with these partners helped identify shared goals, create referral delivery workflows, calculate budgets. Our partnership with Inflight Cuisine was newly developed for this program. We chose to work with this organization in part because they were local to West Philadelphia had experience with meal delivery for adults with chronic conditions. Although they had not previously participated in a meal delivery program for families experiencing food insecurity, their leadership team was highly motivated to create adapted workflows menus that would allow them to serve this population. Our partnership with Common Market was originally developed for our outpatient Food Pharmacy program exped for this inpatient pilot.

Location Participants

The Inpatient Food Pharmacy was implemented on nine general pediatrics subspecialty inpatient units at the Children’s Hospital of Philadelphia, an academic quaternary care children’s hospital in West Philadelphia. These units were chosen because they had a preexisting social needs screening program, in which an opt-out tablet-based health-related social needs screener, which includes questions about inpatient outpatient food insecurity, is introduced to parents at the time of their child’s admission.^13–15 The household food insecurity question is adapted from the WE CARE questionnaire asks “Are you worried about not having enough food for your family?”. The inpatient food insecurity question was developed based on both WE CARE screening questions used by other children’s hospitals asks “Are you worried about having enough food for yourself your family while your child is in the hospital?”^24–27

Families were eligible to enroll in the program if they (1) had a child admitted to one of the included units, (2) endorsed food insecurity, (3) resided in eligible zip codes. Due to geographic limitations in the delivery radius for our community partners, only families residing in Philadelphia city zip codes could be enrolled. There was no cap on family size.

Inpatient Food Pharmacy Design

The Inpatient Food Pharmacy workflow is shown in Figure 1. We used data from our preexisting social needs screening program to identify families experiencing food insecurity. We created a process in which a resource navigator, typically a trained social worker or community health worker, approached eligible families during their hospitalization to explain the Inpatient Food Pharmacy program assess their interest in enrollment. Families were able to opt into receiving one week of prepared meals, six months of monthly produce delivery, or both. We recognized that families had many competing dems on their time during their child’s hospitalization. Resource navigators therefore aimed to approach families whenever they were available, sometimes attempting to connect with them at multiple different times during the day.

Figure 1.

Inpatient Food Pharmacy Workflow

We wanted families to receive meals that were aligned with their food preferences dietary restrictions. To do this, we developed a structured REDCap (Research Electronic Data Capture)²⁸ intake form that allowed families to express both firm dietary restrictions overall food preferences to add delivery instructions (e.g. ring buzzer, leave on porch). This information was transmitted to our community partners via secure email. A team member from our partner organization then reached out to families to confirm their food preferences, family size, delivery preferences. When each participating child was discharged from the hospital, partners coordinated the logistics of food deliveries with their family.

Funding

Our Inpatient Food Pharmacy pilot was funded via several mechanisms, including three private foundation grants institutional community benefit spending.

Challenges

We faced several challenges in operationalizing implementing this program. One early challenge was managing the amount of food delivered at once. For example, one family reported receiving too much food to store in their refrigerator having to store meals at a neighbor’s home. Based on this feedback, we began delivering prepared meals in 2 or 3 batches. Our partner also began asking if families wanted to receive their meals in individual containers or served “family sized” in larger pans, to avoid exceeding available storage space.

A second challenge was reaching families who speak languages other than English. To proactively address this challenge, we created a workflow for resource navigators community partners to use an interpreter to communicate with families. Having a bilingual Food Pharmacy program coordinator also helped us communicate with Spanish-speaking families.

Third, while we were able to cater to food allergies preferences with our prepared meals, we discovered that there were some medical dietary restrictions we could not accommodate. For example, one child was on a ketogenic diet one mother had Crohn’s disease with associated dietary restrictions. In these cases, we were still able to offer produce delivery.

Measuring Success

We tracked process measures including the number of families eligible for the program, the number enrolled, the number of meals produce boxes delivered during our pilot period. We also collected demographic characteristics of enrolled families including child race ethnicity, insurance status, primary language. While race ethnicity are social constructs, we included these variables given prior research showing that Black or African American Hispanic children are more likely to be food insecure than White children, likely due to disproportionate rates of poverty resulting from systemic racism discrimination.^29,30

We also tracked preliminary outcome measures including the proportion of families who reported that the Inpatient Food Pharmacy helped meet their needs. To obtain qualitative feedback regarding the program, we conducted follow-up calls with families at 2–4 weeks 6–8 weeks after enrollment. An interpreter was used for follow-up calls with families speaking languages other than English.

This quality improvement initiative was determined not to meet the criteria for human subjects research by the Children’s Hospital of Philadelphia Institutional Review Board.

Outcomes

Between July 2023 May 2024, we identified 120 families who were eligible for the Inpatient Food Pharmacy 71 (59%) opted into the program (Figure 1).

Demographic characteristics of all families served are summarized in Table 1. Most participants were non-Hispanic Black (69%) publicly-insured (94%). Six families (8%) spoke languages other than English, most commonly Spanish. Overall, 19 families (27%) reported inpatient food insecurity (defined as worry about not having enough food while their child was hospitalized), 9 families (13%) reported household food insecurity (defined as worry about not having enough food for their family in general), 43 families (60%) reported both.

Table 1.

Demographic Characteristics of Patients Served by the Inpatient Food Pharmacy

Characteristic	All Participants Served by Food Pharmacy N=71 n (%)	Participants Reached During Follow-Up N=41 n (%)
Child race a
Asian	3 (4%)	1 (2%)
Black or African American	49 (69%)	33 (81%)
Native Hawaiian or Other Pacific Islander	1 (1%)	0 (0%)
White	6 (8%)	4 (10%)
Other	12 (17%)	3 (7%)
Child ethnicity a
Hispanic or Latino	11 (15%)	2 (5%)
Non-Hispanic or Latino	61 (85%)	39 (95%)
Number of children in household
1	16 (23%)	9 (22%)
2	25 (35%)	15 (37%)
3	15 (21%)	12 (29%)
>4	15 (21%)	5 (12%)
Child insurance status a
Public insurance	67 (94%)	38 (93%)
Private insurance	4 (6%)	3 (7%)
Primary language
English	65 (92%)	41 (100%)
Spanish	5 (7%)	0 (0%)
Other	1 (1%)	0 (0%)
Food insecurity b
Inpatient food insecurity only	19 (27%)	14 (34%)
Household food insecurity only	9 (13%)	6 (15%)
Both inpatient and household food insecurity	43 (60%)	21 (51%)
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) enrollment
Yes	10 (14%)	10 (24%)
No	22 (31%)	22 (53%)
Not reported	39 (55%)	9 (22%)
Supplemental Nutrition Assistance Program (SNAP) enrollment
Yes	22 (31%)	22 (53%)
No	10 (14%)	10 (24%)
Not reported	39 (55%)	9 (22%)

^aChild race, child ethnicity, child insurance status, and language were extracted from the electronic health record.

^bFamilies with household food insecurity were those who reported that they were worried about not having enough food for their family in general. Families with inpatient food insecurity were those who reported that they were worried about not having enough food for themselves and their family while their child was hospitalized. Families who reported either household food insecurity or inpatient food insecurity were eligible for the Food Pharmacy program.

Second, we examined families’ preferences for prepared meals produce delivery. Of the 71 families who opted into the program, 55 (77%) chose to receive both prepared meals produce delivery, 13 (18%) chose prepared meals alone, 3 (4%) chose produce delivery alone. Two families opted out of the meal delivery program after initially expressing interest, because of clinical dietary restrictions which did not allow them to participate.

Third, we examined the feasibility of our Inpatient Food Pharmacy program. We determined the program was feasible. Over the 10-month pilot, we delivered 6,972 prepared meals to 147 adults 185 children in 68 families, 348 boxes of produce to 58 families. We conducted follow-up calls with families after enrollment reached 41 (58%) of 71 families who participated (Table 1). Of families reached, 100% reported that the Inpatient Food Pharmacy helped meet their acute food needs. In January 2024, we began asking families about participation in government nutrition benefit programs. Of 32 families reached by phone since January 2024, 22 (69%) reported receiving SNAP, 10 (31%) reported receiving WIC.

Finally, qualitative feedback was obtained from follow-up calls with families interviews with two resource navigators who connected families to the program. Feedback from these interviews suggested the program was highly acceptable to families. Representative quotations are presented in Table 2. Families praised the convenience of the Inpatient Food Pharmacy program the high quality of the meals provided, which they described as family-friendly easy to prepare eat. Resource navigators appreciated being able to offer families concrete food resources, in addition to information about community-based food banks food pantries.

Table 2.

Qualitative Feedback Regarding the Inpatient Food Pharmacy

Participant	Representatives Quotations
Food Pharmacy Recipients	“The program has been very convenient for us, since I recently went back to work after being out sick and stopped receiving food stamps. The meals are convenient and my kids have been eating them every day before and after school.” – Participant 16 “I love the food I’ve been getting so far. It’s great that I don’t have to worry about cooking and can just focus on my child. This is a big step in helping the community out.” – Participant 26 “My family loves the Food Pharmacy program. I am so happy [the hospital] was able to provide us with these delicious meals. I even made a video about the meals, so that hopefully other people will see it and want to donate money for the program, and people who need help will know to fill out the form for the program while they are at [the hospital]!” – Participant 28 “The Food Pharmacy has been amazing! The food tastes great...I’m happy [the hospital] is able to help with these things.” – Participant 32 “I was very happy with the Food Pharmacy Program. I was surprised that [the hospital] was able to provide help so quickly. I think it’s great that there’s an option for families like mine who aren’t eligible for food stamps but still have trouble affording food at the supermarket. The meals were easy to heat up, and our whole family enjoyed them.” – Participant 38 “I really appreciate the Food Pharmacy Program. We got the meals for a week [after discharge] and then we just got our first box of fresh food. The meals actually tasted good – I was shocked. Even my kids liked them, and they are all really picky eaters. This program has saved me a lot of money and has been a big help.” – Participant 47
Resource Navigators	“The Food Pharmacy program has been very big for families...Families appreciate it a little bit more because it’s not just a piece of paper with a phone number, it’s something that’s there. It’s something they can physically touch, food they can eat, you know what I mean? It’s actually there, and they actually can see that we’re actually doing our best to help them now.” – Resource Navigator 1 “It’s helpful to have [the Food Pharmacy] as a resource because a lot of the families aren’t eligible for other resources. They’re right above the cut off of being eligible, income wise. So having something where you didn’t necessarily have to meet the income requirements...it’s good, so at least they remember us or they have a positive experience with us. It’s unfortunate because I know these outside resources, they try to do as much as they can, but they often don’t have enough resources. So it’s limited. And since it’s limited, they have those [income] requirements.” – Resource Navigator 2

Limitations

Our findings should be interpreted in the context of the pilot’s limitations. First, we describe our experience implementing a food delivery program within a single hospital, the reported challenges lessons learned may not be generalizable to other practice environments. Second, importantly, implementation of this program required substantial resource investment in terms of paid unpaid time provided by team members contracting with our community partners. The total value of these investments return on investment in terms of patients’ health health care utilization were not quantified in this study. More work is needed to determine the cost-effectiveness of food delivery programs, as well as their effectiveness in improving children’s health well-being. Third, we were only able to reach a subset of families via follow-up calls focused only on program participants. In the future, we could use multimodal forms of outreach, including text email, to reach a greater number of families could also conduct focused outreach to underst non-participants’ reasons for opting out of the program. Finally, as this program was part of a quality improvement advocacy effort, we did not conduct a systematic qualitative analysis of feedback from our resource navigators enrolled families. Instead, we used this feedback to iteratively improve the program for families.

Lessons Learned

This Advocacy Case Study describes an innovative Inpatient Food Pharmacy pilot program for families of hospitalized children experiencing food insecurity. We share five key lessons that may inform efforts by health systems insurers to mitigate food insecurity through healthcare-based food delivery programs.

First, we found that a hospital-based food delivery program was feasible helped meet acute post-hospitalization food needs for families experiencing food insecurity. In particular, families appreciated both prepared meal delivery immediately after discharge longer-term produce delivery. Nearly two-thirds (59%) of eligible families opted into the program, with more than three-quarters (77%) choosing both prepared meals produce delivery. Health systems insurers developing similar programs should consider the types of assistance that are appropriate for their patient population. For example, prepared meals may be especially beneficial for families coping with the stress of bringing a recovering child home from the hospital.

Second, our pilot highlights the importance of customization to meet families’ allergies, preferences, dietary restrictions. In total, 17% of families reported allergies (e.g., tree nuts, peanuts, shellfish), 19% reported dietary restrictions (e.g., no pork, halal meat), 29% reported specific preferences (e.g., no seafood, beef, mushrooms). Our community partner was enthusiastic about accommodating families’ preferences customized all delivered meals to meet these needs. However, we were not able to cater to a few specific medical diets (e.g., a ketogenic diet for epilepsy). Therefore, health systems insurers providing prepared meals should consider whether how they are able to meet not only dietary preferences, but also medically indicated diets, to be inclusive of all families.

Third, our pilot underscores the need to receive adapt to family feedback throughout implementation. For instance, one family reported receiving too much food to store in their refrigerator. We adapted to this feedback by delivering meals in smaller batches. Health systems insurers should gather regular feedback from families be willing to dynamically alter their approach to meet families’ needs.

Fourth, although we only collected data on government benefit program enrollment for a subset of Inpatient Food Pharmacy patients, we found that 69% reported receiving SNAP 31% reported receiving WIC. Qualitative interviews revealed that SNAP benefits were often insufficient to cover food costs, some families who did not qualify for SNAP still struggled to afford food. This aligns with prior research indicating that many food-insecure families eligible for SNAP WIC are not enrolled ¹⁰, while others earn too much to qualify but still struggle to afford food. Health system insurer-based nutrition assistance programs could augment SNAP WIC offerings, help identify eligible but non-enrolled families provide them with application assistance, support families with food insecurity who do not qualify for federal programs.

Finally, partnering with a local community-based organization for meal delivery ensured that funds were reinvested into the surrounding community, supporting employment business development. Nonprofit hospitals’ community benefit spending does not always align with local needs preferences.³¹ This partnership was a way to ensure direct investment in the community that surrounds, employs, seeks care from our health system. ³¹

Conclusions

This Advocacy Case Study details the successful pilot of an Inpatient Food Pharmacy program for families of hospitalized children experiencing food insecurity. As the program continues, we will collect data on changes in food insecurity healthcare utilization among participants, recognizing the need for more studies on the impact of health system-based nutrition assistance on health healthcare utilization outcomes. Additionally, we plan to develop a workflow to connect families in our program to our hospital’s Medical Financial Partnership ^32,33, which helps with enrollment in government benefit programs including WIC SNAP. ¹⁰ Given our initial success, we are seeking continued grant funding to sustain exp our work. The costs of our pilot suggest substantial investments are needed to scale this work. We aim to use our findings to advocate for sustainable funding for food delivery programs at various levels: institutionally, through our hospital’s community benefit spending, statewide, through a pending Medicaid Section 1115 waiver that includes grocery delivery for Medicaid-insured pregnant postpartum individuals their families, federally, through SNAP’s online purchasing program WIC’s online purchasing pilots.

Abbreviations:

WIC

Special Supplemental Nutrition Program for Women, Infants, Children

SNAP

Supplemental Nutrition Assistance Program