Food Insecurity Screening and Intervention Strategies in Pediatric Primary Care Practices: A Mixed Methods Study.

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Published in final edited form as: Acad Pediatr. 2025 Dec 16;26(3):103200. doi: 10.1016/j.acap.2025.103200 Search in PMC Search in PubMed View in NLM Catalog Add to search Food Insecurity Screening and Intervention Strategies in Pediatric Primary Care Practices: A Mixed Methods Study Lilianna Suarez Lilianna Suarez , MD, MPH 1 Department of Pediatrics (L Suarez and R Cholera), Duke University School of Medicine, Durham, NC; Department of Medicine (L Suarez), Duke University School of Medicine, Durham, NC; Duke-Margolis Institute for Health Policy (G James and R Cholera), Duke University, Durham, NC; Department of Pediatrics (K Montez), Wake Forest University School of Medicine, Winston-Salem, NC; Department of Pediatrics (C Orr), Vanderbilt University Medical Center, Nashville, TN; Department of Pediatrics (C Orr), The University of North Carolina, Chapel Hill, NC; Duke University (V Nandagiri and A Huang), Durham, NC; Academic Pediatric Association (H Tyrrell), McLean, VA Find articles by Lilianna Suarez 1 , Greeshma James Greeshma James , MPH 1 Department of Pediatrics (L Suarez and R Cholera), Duke University School of Medicine, Durham, NC; Department of Medicine (L Suarez), Duke University School of Medicine, Durham, NC; Duke-Margolis Institute for Health Policy (G James and R Cholera), Duke University, Durham, NC; Department of Pediatrics (K Montez), Wake Forest University School of Medicine, Winston-Salem, NC; Department of Pediatrics (C Orr), Vanderbilt University Medical Center, Nashville, TN; Department of Pediatrics (C Orr), The University of North Carolina, Chapel Hill, NC; Duke University (V Nandagiri and A Huang), Durham, NC; Academic Pediatric Association (H Tyrrell), McLean, VA Find articles by Greeshma James 1 , Kimberly Montez Kimberly Montez , MD, MPH 1 Department of Pediatrics (L Suarez and R Cholera), Duke University School of Medicine, Durham, NC; Department of Medicine (L Suarez), Duke University School of Medicine, Durham, NC; Duke-Margolis Institute for Health Policy (G James and R Cholera), Duke University, Durham, NC; Department of Pediatrics (K Montez), Wake Forest University School of Medicine, Winston-Salem, NC; Department of Pediatrics (C Orr), Vanderbilt University Medical Center, Nashville, TN; Department of Pediatrics (C Orr), The University of North Carolina, Chapel Hill, NC; Duke University (V Nandagiri and A Huang), Durham, NC; Academic Pediatric Association (H Tyrrell), McLean, VA Find articles by Kimberly Montez 1 , Colin Orr Colin Orr , MD, MPH 1 Department of Pediatrics (L Suarez and R Cholera), Duke University School of Medicine, Durham, NC; Department of Medicine (L Suarez), Duke University School of Medicine, Durham, NC; Duke-Margolis Institute for Health Policy (G James and R Cholera), Duke University, Durham, NC; Department of Pediatrics (K Montez), Wake Forest University School of Medicine, Winston-Salem, NC; Department of Pediatrics (C Orr), Vanderbilt University Medical Center, Nashville, TN; Department of Pediatrics (C Orr), The University of North Carolina, Chapel Hill, NC; Duke University (V Nandagiri and A Huang), Durham, NC; Academic Pediatric Association (H Tyrrell), McLean, VA Find articles by Colin Orr 1 , Vibhav Nandagiri Vibhav Nandagiri , BS 1 Department of Pediatrics (L Suarez and R Cholera), Duke University School of Medicine, Durham, NC; Department of Medicine (L Suarez), Duke University School of Medicine, Durham, NC; Duke-Margolis Institute for Health Policy (G James and R Cholera), Duke University, Durham, NC; Department of Pediatrics (K Montez), Wake Forest University School of Medicine, Winston-Salem, NC; Department of Pediatrics (C Orr), Vanderbilt University Medical Center, Nashville, TN; Department of Pediatrics (C Orr), The University of North Carolina, Chapel Hill, NC; Duke University (V Nandagiri and A Huang), Durham, NC; Academic Pediatric Association (H Tyrrell), McLean, VA Find articles by Vibhav Nandagiri 1 , Amaris Huang Amaris Huang , BS 1 Department of Pediatrics (L Suarez and R Cholera), Duke University School of Medicine, Durham, NC; Department of Medicine (L Suarez), Duke University School of Medicine, Durham, NC; Duke-Margolis Institute for Health Policy (G James and R Cholera), Duke University, Durham, NC; Department of Pediatrics (K Montez), Wake Forest University School of Medicine, Winston-Salem, NC; Department of Pediatrics (C Orr), Vanderbilt University Medical Center, Nashville, TN; Department of Pediatrics (C Orr), The University of North Carolina, Chapel Hill, NC; Duke University (V Nandagiri and A Huang), Durham, NC; Academic Pediatric Association (H Tyrrell), McLean, VA Find articles by Amaris Huang 1 , Hollyce Tyrrell Hollyce Tyrrell , MSSW 1 Department of Pediatrics (L Suarez and R Cholera), Duke University School of Medicine, Durham, NC; Department of Medicine (L Suarez), Duke University School of Medicine, Durham, NC; Duke-Margolis Institute for Health Policy (G James and R Cholera), Duke University, Durham, NC; Department of Pediatrics (K Montez), Wake Forest University School of Medicine, Winston-Salem, NC; Department of Pediatrics (C Orr), Vanderbilt University Medical Center, Nashville, TN; Department of Pediatrics (C Orr), The University of North Carolina, Chapel Hill, NC; Duke University (V Nandagiri and A Huang), Durham, NC; Academic Pediatric Association (H Tyrrell), McLean, VA Find articles by Hollyce Tyrrell 1 , Rushina Cholera Rushina Cholera , MD, PhD 1 Department of Pediatrics (L Suarez and R Cholera), Duke University School of Medicine, Durham, NC; Department of Medicine (L Suarez), Duke University School of Medicine, Durham, NC; Duke-Margolis Institute for Health Policy (G James and R Cholera), Duke University, Durham, NC; Department of Pediatrics (K Montez), Wake Forest University School of Medicine, Winston-Salem, NC; Department of Pediatrics (C Orr), Vanderbilt University Medical Center, Nashville, TN; Department of Pediatrics (C Orr), The University of North Carolina, Chapel Hill, NC; Duke University (V Nandagiri and A Huang), Durham, NC; Academic Pediatric Association (H Tyrrell), McLean, VA Find articles by Rushina Cholera 1 Author information Article notes Copyright and License information 1 Department of Pediatrics (L Suarez and R Cholera), Duke University School of Medicine, Durham, NC; Department of Medicine (L Suarez), Duke University School of Medicine, Durham, NC; Duke-Margolis Institute for Health Policy (G James and R Cholera), Duke University, Durham, NC; Department of Pediatrics (K Montez), Wake Forest University School of Medicine, Winston-Salem, NC; Department of Pediatrics (C Orr), Vanderbilt University Medical Center, Nashville, TN; Department of Pediatrics (C Orr), The University of North Carolina, Chapel Hill, NC; Duke University (V Nandagiri and A Huang), Durham, NC; Academic Pediatric Association (H Tyrrell), McLean, VA ✉ Address correspondence to Lilianna Suarez, MD, MPH, Duke University School of Medicine, 3116 N. Duke St. Durham, NC 27707 ( lilianna.suarez@duke.edu ). Issue date 2026 Apr. PMC Copyright notice PMCID: PMC13078858  NIHMSID: NIHMS2156191  PMID: 41412565 The publisher's version of this article is available at Acad Pediatr Abstract Objective: Pediatric clinics identify and address food insecurity (FI), but processes vary nationwide. State and federal policies increasingly require FI screening in health care settings and as a quality metric in payment models. A better understanding of existing practices and opportunities for efficient and effective clinical integration is needed. Methods: A multiple-choice survey was first completed with 27 clinics nationwide. Semistructured interviews informed by the Consolidated Framework for Implementation Research were then conducted with clinics (n = 25) to explore current FI practices and understand how policies and payment models could support FI processes. Descriptive analysis was used for survey results. Rapid qualitative analysis was used to identify themes. Results: Pediatric practices were predominately in the South (44%) and in urban (70%) locations. Most used the Hunger Vital Sign to screen (89%); interventions included resource list distribution (89%), referral to federal nutrition programs (78%), and/or community-based organizations (78%). Few practices coded (37%) or billed (7%) for FI. Three overarching themes were identified as follows: 1) FI screening, intervention, and documentation processes varied across primary care clinics; 2) Multilevel barriers hindered efforts to address FI; and 3) Policy and payment reforms are needed to support the integration of FI screening and intervention in health systems and effectively assist families experiencing FI. Conclusions: While clinics have integrated FI screening and interventions, streamlined documentation and billing remain limited. As FI screening becomes increasingly incentivized, designing performance metrics that include health care provider input and address existing barriers should be a priority. Keywords: food insecurity, health policy, health-related social needs Health-related social needs (HRSN), including food insecurity (FI), are now screened for and addressed as part of clinical care in many pediatric settings nationwide. 1 FI, defined as the lack of access to enough food to live an active and healthy lifestyle, disproportionately impacts Black and Hispanic children and children living in a single-parent household. 2 Children are particularly vulnerable to the effects of FI, as it has been associated with poor health and worse well-being outcomes in childhood. 3 These include poor dietary quality and educational performance, development of cardiometabolic risk factors and mental health disorders, and increased pediatric hospitalizations. 3 While pediatric practices are increasingly screening for and addressing FI in line with American Academy of Pediatrics (AAP) and Food Research & Action Center recommendations, there is widespread variability in how these recommendations are implemented in clinical practices. 4 , 5 Prior studies have described FI screening and intervention in single health centers, hospital settings, or regions and explored HRSN screening and interventions more broadly. 6 – 8 In fact, the United States Preventative Services Task Force recently found there was insufficient evidence to assess the risks and benefits of FI screening in the primary care setting. 9 In the absence of robust evidence, differing clinical processes have emerged nationwide, ranging from entirely automated FI screening and referrals, including those that leverage electronic health record (EHR) capabilities, to those that rely on inperson care navigators to facilitate connection to clinic-based and community resources. 10 , 11 Furthermore, little is known about the factors that promote and hinder implementation of these various methods. The Consolidated Framework for Implementation Research (CFIR) is a determinants framework that provides a guide to understand facilitators and barriers critical for implementation. 12 Few have explored current FI processes in pediatric primary care settings using a framework such as CFIR, with even fewer exploring these factors among practices with innovative and novel FI processes. 13 Alongside pediatricians’ independent efforts to intervene on FI, policymakers and payers have increasingly incorporated HRSN screening and intervention into health care delivery and payment models. A health care effectiveness data and information set (HEDIS) measure for HRSN was adopted in 2023 for children and adults 14 and in 2024, the Centers for Medicare and Medicaid Services (CMS) began requiring that FI screening occur during adult inpatient hospitalizations. 15 By designing HRSN measures and necessitating health care organizations screen for HRSNs, CMS has begun to encourage the adoption of this practice as the standard of care. 16 In response, payers and health systems have leveraged value-based payment (VBP) models, which aim to support health care quality while reducing cost of care, to support HRSN screening and intervention. 16 , 17 However, pediatricians’ perspective on the design and role of these policies and payment models in addressing and sustaining FI screening and intervention in clinical practices, has not been examined. Therefore, we had 2 main objectives. First, summarize FI screening and intervention processes using the CFIR to identify barriers and facilitators among pediatric primary care clinics with known FI processes, based on publications and national reputation, from the perspective of pediatricians and frontline HRSN staff. Second, leverage the CFIR to explore how novel policies and payment models can best support FI efforts in pediatric primary care, given the recent emphasis on FI by policymakers and payers. Methods Study Design This sequential explanatory mixed-methods study, where an electronic survey was followed by interviews, was conducted from September 2022 to June 2023. This study was determined exempt by the Duke University Health System Institutional Review Board (Pro00110055). The Consolidated Criteria for Reporting Qualitative Research Checklist was used for reporting qualitative methods. 18 Study Population General outpatient pediatricians and social care staff (eg, community health worker, social worker, or nurse leader involved in FI screening and intervention within the clinical setting) were included. The study team first compiled a list of pediatric primary care physicians who led their clinic’s social needs or FI work, based on publications of their FI work in peer-reviewed literature and national reputation. Additional participants in general academic pediatrics were identified through the Academic Pediatric Association’s (APA) Continuity Research Network (CORNET) based on geographic locations that were underrepresented in the study. Subsequent interviewees were identified by snowball sampling from prior participants. As we aimed to describe current screening and intervention practices and opportunities for further policy support, practices not screening for FI at the time of the survey were excluded (n = 3; Fig. 1 ). If the practice was screening for FI, the participant was invited to complete a semistructured interview alongside any additional clinicians and/or social care staff involved in clinic-based FI initiatives. Each participant was given a $40 gift card as remuneration. Figure 1. Open in a new tab Flow diagram of quantitative and qualitative participant recruitment strategy. Data Collection and Study Measures Electronic Survey Participants completed an electronic, multiple-choice REDCap survey ( Supplement A ) that explored the practice’s current FI screening and intervention processes, including FI screening tool used, ages of children screened, visit type(s) at which screening occurred, strategies to address positive screens, FI coding and billing practices, and clinic demographic information. Qualitative Interviews An interview guide, grounded in the 2009 CFIR as an implementation framework, 12 was developed based on a literature review of current FI screening and intervention in clinical settings and in consultation with the expertise of the study team. Supplements B and C contain the interview guide and maps CFIR domains to interview topics. Participants’ survey responses were incorporated into the interview questions, and these were designed to expand on reasoning for survey responses, as well as barriers and facilitators. Interview questions were divided into 2 categories and asked at the clinic level as follows: current FI screening and intervention processes in the participant’s clinic and the role of policies and payment structures in supporting their clinic’s efforts within their larger health system. The interview guide was piloted with 2 participants. Interviews were conducted by 2 team members (G.J., L.S.) with training and experience in qualitative research. Interviewers did not have relationships with participants prior to the interview. Additional team members (L.S., V.N., A.H.) took notes during interviews. Interviews were conducted via Zoom, audio-recorded, and transcribed verbatim. All interview transcripts were verified for accuracy (V.N., A.H.). Interview length ranged from 38 minutes to 65 minutes, with a mean of 53 minutes. Data Analysis Survey results were analyzed using descriptive analyses. We classified geographic location based on 2020 US census regions. 19 All qualitative interviews were deidentified prior to analysis. Interviews were analyzed using rapid qualitative analysis, an intensive, team-based analysis method that has been previously validated. 20 , 21 Each interview question was designated as a separate domain within a standardized summary template. Using both recordings and transcripts, summary templates were completed by summarizing participant responses for each domain. 20 Summary templates were verified by a second team member for completeness and accuracy. Discrepancies were reconciled through team discussions. Summary templates were then imported into a matrix, with domains along one axis and interview number along the other. 20 Study team members met monthly to identify and reach consensus on emerging themes based on review of the matrix. Interviews were conducted until saturation was reached, which was determined when no new themes emerged, and until all geographic regions had balanced representation in the sample. Results The study included a total of 27 clinical practices, with 25 of these clinics participating in an interview ( Fig. 1 ). The interview sample included 28 pediatric physicians and 16 social care staff. Survey Results Most pediatric practices were located in the South (n = 12, 44%), in urban regions (n = 19, 70%) ( Table 1 ), and were associated with academic practices (n = 24, 89%). Almost all (n = 24, 89%) used the Hunger Vital Sign (HVS) to screen for FI, either on its own or incorporated into existing screening tools. Half screened for FI at all well child visits (n = 14, 52%), while others screened at all clinic visits (n = 3, 13%) or at specific time intervals (ie, every 3 or 6 months; n = 6, 22%; Fig 2 ). Clinics largely screened all patients in their practice for FI (n = 24, 89%). After screening positive for FI, clinics most commonly distributed a list of local resources (n = 24, 89%), and/or referred to federal nutrition programs (n = 21, 78%) or to community-based organizations (CBOs; n = 21, 78%). Over half of clinics provided on-site food distribution (n = 16; 59%). Two-thirds of practices provided training on discussing FI with families (n = 18, 67%). Few practices coded (n = 10, 37%) or billed (n = 2, 7%) for FI. Table 1. Practice Characteristics for Pediatric Clinics Completing the Web-Based Survey Practice Characteristics N = 27 (%) Geographic location of practice South 12 (44.4) Northeast 4 (14.8) Midwest 4 (14.8) West 7 (25.9) Practice location Urban 19 (70.3) Suburban 6 (22.2) Rural 2 (7.4) Patients with Medicaid/CHIP 0%−20% 0 (0) 21%−40% 3 (11.1) 41%−60% 0 (0) 61%−80% 8 (29.6) 81%−100% 14 (51.9) Don’t know 2 (7.4) Patients that identify as racial/ethnic minorities 0%−20% 1 (3.7) 21%−40% 3 (11.1) 41%−60% 3 (11.1) 61%−80% 8 (29.6) 81%−100% 10 (37.0) Don’t know 2 (7.4) Number of visits completed yearly Less than 10,000 4 (14.8) 10,000–49,999 10 (37.0) 50,000–90,000 6 (22.2) More than 90,000 2 (7.4) Unknown 5 (18.5) Open in a new tab Figure 2. Open in a new tab Joint display demonstrating theme 1 findings, including how FI screening, intervention, and documentation processes varied across pediatric clinical settings. Qualitative Interview Results Three overarching qualitative themes were identified from the interviews: 1) FI screening, intervention, and documentation processes varied across primary care clinics; 2) Multilevel barriers hindered efforts to address FI; and 3) Policy and payment reforms are needed to support the integration of FI screening and intervention in health systems and effectively assist families experiencing FI. Theme 1: FI Screening, Intervention, and Documentation Processes Varied Across Pediatric Primary Care Clinics ( Figure 2 ) Subtheme 1: FI Screening Workflows and the Timing of RescreeninG Differed by Practice Participants screening at all clinic visits did so because their clinic served populations with multiple, dynamic social needs ( Fig. 2 ). While most clinics utilized a standard screening questionnaire, few clinics additionally evaluated the urgency of FI ( Fig. 2 ). Approximately a third of clinics offered resources to all patients irrespective of screening outcome. Pediatricians acknowledged positive screening results through a conversation with the family in almost all clinics, which allowed them to either tailor resource distribution or engage a social care staff member to provide referrals. A few clinics designed automatic referral processes to a care coordinator for positive FI screens. Some participants noted that families with negative screening results may disclose experiencing FI in discussions with providers or care coordinators. If FI was disclosed after a screening, patients were largely referred to resources as if they screened positive. For families with negative FI screens, clinics typically rescreened at the next visit. Subtheme 2: Clinics Tailored FI Interventions to Their Patient Population All participants reported diverse FI interventions ( Fig. 2 ). Most clinics did not directly assist patients with enrollment in federal nutrition programs due to limited staff capacity, but all referred to federal nutrition programs as a food resource from their clinical setting. Over half of clinics had on-site food distributions; most distributed prepackaged bags of food, while a few allowed for patients to select their preferred food items. Novel clinical interventions to address FI and other HRSNs included multicomponent food interventions, which simultaneously addressed food needs and nutrition and employment needs, and automated referrals to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) through the EHR. Subtheme 3: Pediatricians Increasingly Utilized Diagnostic Codes for FI, but the Unintended Consequences of Documenting HRSNs in the Medical Record Have not Been Well Described Less than half of participants reported using Z-codes, which document factors that influence health status, but are not billing codes themselves ( Fig. 2 ). 22 The majority of these clinics manually entered FI codes, with a couple of clinics developing an automated EHR documentation process. Those utilizing Z-codes felt that this was useful for tracking a patient’s needs and providing follow-up care, while those who did not use Z-codes were either not aware of this possibility or felt there may be unintended consequences for patients ( Fig. 2 ). These consequences included concerns that FI documentation could create bias during future health care encounters. About two-thirds of clinics could not bill for FI screening or addressing FI, with a small percent unsure if their clinic could bill. Clinics were unable to bill primarily due to state insurance regulations. In select cases, clinicians reported billing for increased visit complexity when the presence of HRSNs altered clinical decision-making. Theme 2: Multilevel Barriers Hindered Efforts to Address FI ( Table 2 ) Table 2. Theme 2 Subthemes and Illustrative Quotes Multilevel Barriers Hindered Efforts to Address Food Insecurity Subthemes Illustrative Quotes [Participant Role] Patient-level barriers: individual patient characteristics informed provider approaches to addressing FI “I think there’s some fear we’re going to report them to Child Protective Services, and that’s one of the things that our family advisory panel identified, is be super clear and granular about what you’re going to do with this information because it can be anxiety-provoking for them to disclose that to us… Because they’re somewhat concerned that we’re going to judge them, so I think that’s a real barrier for families.” [Participant 12, Pediatrician] “If they’re trying to get in contact with their case workers or representatives, it could take a while, and it’s even more hard if there’s a language barrier. One mom told me she was on the phone for an hour and got nowhere…I attempted it, and I was on the Spanish line for 45 minutes still going, then I use another phone for the English line, and I got connected to someone within fifteen minutes.” [Participant 6, Care Coordinator] Provider-level barriers: clinicians desired additional training around screening and addressing positive screens “Providers are not feeling comfortable having these conversations or [are] deferring them. The way this screening was rolled out was that the forms appeared one day, and so the providers weren’t expecting it…there isn’t a standardized way that residents are taught to have these conversations. There’s not really continuing education for me as a provider that talks through the latest evidence about how to do this in a thoughtful and trauma-informed way.” [Participant 31, Pediatrician] “I think that it would be really helpful to have people with lived experiences teaching our residents and medical students about what food insecurity feels like and what to do and what not to do. I also think that we, as health care providers, are not the right people that should be leading and advocating for that training. It should be really our community partners and people who are doing the work. So, I feel less inclined to teach my residents about how to navigate and deal with food insecurity, because I’ve never deal with food insecurity myself. I can advocate for the screening, but I think it would be really powerful to have our community partners to come in and really teach our residents and help them understand what food insecurity feels like, and how health care providers can be supportive to our community members.” [Participant 4, Pediatrician] System-level barriers: lack of cross-sector communication, limited staffing, and high patient volume prevented implementation of closed-loop referral systems “Getting in touch with families can be really difficult. A lot of families have difficulty accessing a stable phone…every time you call a patient; it might take a few times or more to actually get in touch with them. The patient navigators are so overworked that they don’t have the bandwidth to follow-up. Technology limitations or data sharing limitations, there is no data sharing between federal programs and partners.” [Participant 14, Pediatrician] “How do you really be effective in the use of their time. And honestly, how are you effectively using your patient exam room? Because if that means that the social worker comes and spends an hour helping that family sign up for WIC … that room has now been taken for a long period of time when other patients need to be seen.” [Participant 19, Pediatrician] Open in a new tab Subtheme 1: Patient-Level Barriers: Individual Patient Characteristics Informed Provider Approaches to Addressing FI Participants perceived multiple patient-specific barriers to disclosure of FI, including experiencing stigma when discussing FI in front of children, being labeled as food insecure in the EHR, and fear of being reported to Child Protective Services, or immigration authorities in cases of mixed documentation status ( Table 2 ). FI screening approaches were often adapted based on these concerns with some clinics opting to screen frequently to increase patient comfort with screening or intentionally discussing the purpose of FI screening with patients. Subtheme 2: Provider-Level Barriers: Clinicians Desired Additional Training Around Screening and Addressing Positive Screens About half of the participants noted a gap in training residents to discuss FI with families. Example educational sessions that were suggested included didactics on FI screening, presentations from community food resource organizations, and visiting a local WIC agency ( Table 2 ). Barriers reported to increasing FI training in current residency programs were limited curricular time for intensive resident training and frequent resident turnover at clinics. Subtheme 3: System-Level Barriers: Lack of Cross-Sector Communication, Limited Staffing, and High Patient Volume Prevented Implementation of Closed-Loop Referral Systems Closed-loop FI referral systems, which would allow providers to know if patients have accessed food resource referrals, were strongly desired. The majority of participants could not follow up on referral outcomes. If follow-up occurred, this was largely completed through care coordinators calling patients individually, requiring a significant time commitment ( Table 2 ). Additional barriers included limited staff, high patient volume, and difficulty reaching families by phone ( Table 2 ). Other clinics assessed referral outcome at subsequent visits. Finally, a few clinics utilized automated platforms to follow up on referrals. However, automated platforms were felt to limit patient privacy, as data collected in the health care system was shared with external partners, and were thought to be burdensome for CBOs, as they were required to opt in and document referral outcomes. One clinic was working to financially support CBO participation in their integrated online platform. Moreover, some believed the health system may not be the most well-suited to address FI, with the social service or school sector better suited for this work. Among the clinics that had a process for follow-up in place, none tracked metrics such as the rate of completed follow-ups. Theme 3: Policy and Payment Reforms Are Needed to Support the Integration of FI Screening and Intervention in Health Systems and Effectively Assist Families Experiencing FI ( Table 3 ) Table 3. Theme 3 Subthemes and Illustrative Quotes Policy and Payment Reforms are Needed to Support the Integration of FI Screening and Intervention in Health Systems and Effectively Assist Families Experiencing FI Subthemes Illustrative Quotes [Participant Role] Novel clinical practice and payment structures did not support FI efforts “It would be helpful to see this incentivized as a key component of care alongside shots and screenings and keeping kids healthy…that probably would come more from payers than just the hospital…understanding the time it takes to do this, it would help to have more than just one community resource navigator or feel like there were more in-depth connections with some of the CBOs that might be able to pick up the reins when a family leaves the clinic.” [Participant 11, Pediatrician] “People don’t go into pediatrics because of money. It’s a lot of preventative health, and taking care of families, and most pediatricians want to address these things, and there’s no time. There’s no space, there’s no reimbursement for it, and so it’s a lot of just trying to do it on your own time and not get burnt out in the process. And so, I think, having a value-based model surrounding these important foundational things would be reinvigorating for pediatrics…would feel like we’re doing good work. We’re not just checking a box…if these things that generally fill our cups can then be tied within our work in a better and more meaningful way, I think that would be fantastic.” [Participant 40, Pediatrician.] Participants advocated for addressing upstream causes of food insecurity and supporting family health through federal and state policy changes “Food insecurity is a symptom of a bigger problem…Sometimes it can be a life-altering event that happened. But a lot of times for families, it’s not something that’s happening just one week, and then it’s not going to come back again. So how can we help assist the root cause? Is it the parent needs help getting sustainable employment? Is it that childcare costs have taken up the vast majority of the budget or housing costs have taken up the vast majority of the budget that they haven’t been able to also get food as well? So, I think it’s hard, for all of these social determinants of health to focus on one area without addressing them all, because the problems will just continue to grow.” [Participant 1, Pediatrician] “Policies that might help families get out of poverty include recently having the increase in the child tax credit… Having the federal programs like WIC and SNAP be widely available and easy to apply to would also help. They are great programs. I think some families struggle to apply for them, or don’t know if they qualify.” [Participant 2, Pediatrician] Open in a new tab Subtheme 1: Novel Clinical Practice and Payment Structures Did not Consistently Support FI Screening and Intervention Efforts Nearly half of participants were not sure if their clinic was part of a network to improve care and reduce cost, such as a clinically integrated network (CIN) or accountable care organization (ACO). Among clinics participating in such organizations, about a quarter received support from their network for their FI processes, which primarily supported the development of EHR templates for FI screening, care coordinator funding, or the facilitation of data sharing and best practice dissemination across the network. The majority of networks did not track FI screening metrics. Approximately 40% of clinics were known to participate in at least 1 pediatric VBP model, but only half of these models required HRSN or FI screening. Participants were open to utilizing quality or performance metrics to support FI processes. However, they preferred incentivization of FI interventions, as this would be more valuable than metrics focused primarily on screening. Approximately a quarter raised concerns about the potential for providers to be held accountable for reducing FI prevalence in their patient population due to the many upstream drivers of FI that cannot be addressed in a health care setting. Funding from VBP models or health systems was felt to be a potential pathway for sustaining FI interventions, as existing FI interventions were largely funded through short-term grants, and many were uncertain about the future of these funding sources. A few participants wanted funding for staff to assist with FI referrals, such as community health workers. Finally, participants desired reimbursement for time spent addressing FI and stable financial and/or operational support to augment their clinics’ FI efforts ( Table 3 ). Subtheme 2: Participants Advocated for Addressing Upstream Causes of FI and Supporting Family Health Through Federal and State Policy Changes Nearly all participants advocated for increased federal funding for the Supplemental Nutrition Assistance Program (SNAP), WIC, and school meals ( Table 3 ). Additionally, participants felt the Child Tax Credit was a beneficial program for low-income families. About a quarter of interviews mentioned wanting to direct funds to CBOs that received referrals from clinics to help address FI in the long term, rather than to clinic-level interventions. Discussion In this mixed-methods study among pediatric clinics, we identified a wide range of FI screening and intervention practices and opportunities for payment and policy reforms to support integration into clinical settings. While nearly all clinics used standardized FI screening tools and addressed FI through provision of a resource list, the implementation of screening, on-site food distribution, direct FI referrals, and EHR documentation varied due to funding limitations, staff constraints, and clinician opinion. Despite increasing participation in CINs/ACOs and VBP models, we found that these networks and payment structures did not consistently support clinics’ efforts to screen for and address FI currently. As addressing FI rapidly becomes the standard of care in clinical practice, these collective findings allow for those processes that are commonly implemented nationwide (ie, screening by HVS or food resource list distribution) to be shared broadly for implementation consideration with tailoring to unique practice and patient needs. Additionally, these results contribute to the emerging evidence base for health care delivery and payment reforms that support efforts to create sustainable FI screening and intervention processes. While we found FI screening was largely standardized, FI interventions varied widely depending on clinic context and resources. In line with the AAP FI guideline and building upon prior studies, the majority of clinics used the evidence-based HVS to screen for FI. 1 , 5 A facilitator of frequent FI screening was provider’s perception that their patients’ had a high and persistent level of need. Once FI was identified, providers viewed connecting patients to SNAP and/or WIC as the best long-term solution to addressing FI, as previously shown. 4 Despite this perspective, we found that providers most commonly distributed a resource list to families due to clinic limitations with cross-sector communication and staff bandwidth, acknowledging this was not sufficient to ensure resource connection or to reduce FI experienced by families. 1 These findings align with prior research that has demonstrated there is no consensus on what is considered an intervention for HRSN. 16 With even more limited evidence comparing the impact of these different interventions, there continues to be significant variation in clinical practices depending on clinic setting (ie, inpatient vs outpatient) and available funding. 6 , 8 , 23 Future research will be needed regarding the comparative effectiveness of interventions to address FI, in addition to evaluating best practices for the implementation of FI screening and interventions. Many barriers hinder practices’ FI efforts, but the inability to form closed-loop, cross-sector partnerships is a key barrier. In clinics’ current process, follow-up after resource referral predominantly occurs via phone. Few leveraged online referral platforms to both refer to CBOs and complete follow-up, which are seen in the literature as a promising innovation. 10 , 11 However, as raised by participants, the implementation of these partnerships can be complex, resulting in low uptake 24 and evidence on their effectiveness in facilitating resource connection and follow-up is mixed. 25 Directing more funding to CBOs to support infrastructure development and incentivize engagement, as one practice did in this study, may be a strategy to facilitate collaboration with health systems and improve the capacity of partner organizations. Importantly, as the social services sector has been addressing FI and other HRSNs for much longer than the health care sector, the health care sector may not be best positioned to lead FI efforts. 26 In fact, there can be consequences to health systems engaging in and leading efforts to address HRSNs, including diverting funds from community programs, and detracting from ensuring equitable delivery of health care services. 27 Nonetheless, CBOs remain interested in cross-sector collaborations to increase their legitimacy and funding for their work. 28 Designing cross-sector, collaborative systems that address all the factors contributing to child health, including HRSNs, remains essential. We found that almost all clinical FI interventions were supported by grants, and few clinics received financial support from emerging practice and payment structures, such as CINs, ACOs, or VBP models. While providers desired reimbursement for their work, few could bill for FI under current policies. As CMS and other regulatory agencies increasingly require social needs screening and reimbursement becomes tied to performance, the development of documentation and billing processes will be needed. 15 Nonetheless, participants felt FI intervention was a more meaningful metric than screening and that quality metrics for more downstream outcomes, such as reducing FI or improving health outcomes, would be challenging to achieve. This finding is reflected in the Social Interventions Research & Evaluation Network (SIREN) social care logic model, which suggests several nuanced mechanisms by which HRSN intervention may improve health and decrease unnecessary health care utilization. 29 As prior research has demonstrated variable health care utilization and cost outcomes among patients receiving HRSN assistance within national and local studies, 30 – 32 it will be important an outcome like health care utilization is not solely used to measure effectiveness. While these health care delivery structures and payment models provide a source of stable funding, insurance billing alone may not be sufficient to fund the multidisciplinary workforce needed for FI screening and intervention. Health policies, such as Medicaid state plan amendments allowing for reimbursement of community health workers addressing social needs, may be important as well. 33 Therefore, it is critical that providers’ perspectives are incorporated to effectively support FI and HRSNs’ efforts. Study Limitations About half of clinics did not respond to our requests for survey completion. While this response rate is similar to other survey studies, 1 it may limit the generalizability of findings, as clinics who responded may have been systematically different than those that did not respond. Additionally, in order to meet the study goal of synthesizing current practices and identifying innovation, we utilized a convenience sample, selected based on national reputation or publications in peer-reviewed journals, which may have biased the findings. The study sample included mostly academic practices and clinicians who had specific expertise around FI and potentially more resources to address FI compared to other practice settings. Therefore, these findings and recommendations may not be fully applicable to practices with less access to community resources. Further, demographic information from providers and social care staff was not collected, so we are not able to present more granular data about the individuals in the study. We did not stratify qualitative outcomes by physician and social care staff independently, and we cannot differentiate how varying providers may have had differing recommendations based on their role in the health system. Our study did not include the patient perspective, although several prior studies have focused on this topic. 34 , 35 Finally, these practices served predominately Medicaid-insured patients, limiting application of findings to patients who are uninsured or those with private insurance. Conclusion We synthesized FI screening and intervention practices in pediatric clinics and explored potential policy and payment innovations that could promote sustainability. Our results demonstrate the widely streamlined use of FI screening tools with interventions modified to clinics’ capacity and patient population. Yet, most clinics relied on low-touch interventions, such as distribution of resource lists, that are practical to implement due to limited capacity, rather than implementing more robust food interventions. Participants suggested opportunities to support FI screening and intervention that would make this work more feasible and sustainable. These findings may be drawn upon in the development of HRSN policies and reimbursement practices within novel health care delivery structures and payment models. Future research will be needed to explore the impact of these interventions and policies, so that providers can implement tailored and effective practices that ultimately reduce child FI and improve health. Supplementary Material Supplemental File NIHMS2156191-supplement-Supplemental_File.docx (56KB, docx) Supplementary data associated with this article can be found in the online version at doi: 10.1016/j.acap.2025.103200 . What’s New. Pediatric providers nationwide utilized similar food insecurity screening and intervention processes, but tailored implementation to specific patient needs. Payment and care delivery reforms that prioritize systems which support pediatric providers in addressing food insecurity and its root causes are needed. Acknowledgments The authors wish to acknowledge the support and contributions of the Academic Pediatric Association’s Continuity Research Network. Funding This work was funded by NICHD K12HD105253. Footnotes Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. References 1. Montez K, Bennett-Tejes D, Ashbrook A. Addressing food insecurity among children—pediatrician beliefs, practices, and resource needs. Acad Pediatr. 2021:1–11. 〈 https://frac.org/wp-content/uploads/AAP-Survey-2021.pdf 〉. [ Google Scholar ] 2. Rabbitt MP, Reed-Jones M, Hales LJ, Burke MP. Household Food Security in the United States in 2023. 2024. doi: 10.32747/2024.8583175.ers. [ DOI ] [ Google Scholar ] 3. Hartline-Grafton H, Hassink SG. Food insecurity and health: practices and policies to address food insecurity among children. 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