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More than 21 million low-income children rely on free or reduced-price meals during the school year. The US Department of Agriculture Summer Food Service Program (SFSP) provides meals to children during the summer months, but these programs are underused. The emergency department (ED) of urban medical centers is 1 of the few establishments that children access during the summer months, and as such, it may be a prime point of entry for such programs. This advocacy case study describes the implementation and evaluation of situating an SFSP in the pediatric ED and explores the impact on participant intention to connect with community resources after the ED visit. In this 7-week pilot, we partnered with a community agency to provide free lunch to all children ages 2 to 18 during their ED visit at an urban, freestanding children’s hospital. After patient rooming and clarification of nil per os status, boxed meals were delivered to patients and siblings along with information regarding the SFSP and how to access community program sites. Parents completed a survey about the experience with the meal program in the ED, previous knowledge of the SFSP, and intention to use community SFSP sites in the future. This case study demonstrates that situating the SFSP in the acute-care clinical setting is acceptable and has strong potential to improve the historically poor connection between families and critical community resources. Additionally, this project highlights the potential of community-clinical partnerships to improve family resources and enhance the reach of established programs.

More than 21 million low-income children depend on free or reduced-price meals during the school year, access to which is lost during the summer months.1  This causes inconsistent access to food for children, leading to poorer overall heath, increased hospitalizations, and increased rates of anxiety, aggression, anemia, asthma, and cognitive delay, among other issues.29  The US Department of Agriculture (USDA) Summer Food Service Program (SFSP) can close this gap, providing meals to children during the summer months, but these programs are severely underused; only 1.4 in 10 students in Pennsylvania receiving free or reduced-price meals during the school year accessed nutritious summer meals in 2016.10 

Ratified as part of the Healthy and Hunger-Free Kids Act, the Community Eligibility Provision, which has been available in Philadelphia since July 2014, allows regions with >40% school-lunch eligibility to serve summer meals at no cost to all children age 18 or younger without household applications or verification of income eligibility.11  This enables widespread programming for summer meals, eliminates stigma surrounding participation in the programs, and reduces the burden of paperwork on parents and administrators. Currently, food insecurity in Philadelphia County affects 21.7% of children, exceeding the national average of 16.5%.12,13  Although Philadelphia has >1000 SFSP locations and no individual-level eligibility requirements, there remains a substantial participation gap in the SFSP and a need to identify reasons for underuse.14 

The urban medical center is one of the few institutions that children access during the summer months, and as such, it may be a prime location as a point of entry into the SFSP. Furthermore, the emergency department (ED) often serves as a point of care entry for impoverished and high-risk families.15,16  This advocacy case study describes the implementation and evaluation of the SFSP in the Children’s Hospital of Philadelphia Emergency Department (CHOP ED). To evaluate the success of the SFSP at the Children’s Hospital of Philadelphia (CHOP), we assessed the acceptability of the program in the ED, measured the caregivers’ experience with the SFSP before and during their children’s visit to the ED, and the program’s ability to connect families with community resources. This advocacy case study describes one of the first hospital-based sites for the SFSP and, to our knowledge, the first effort to pilot and evaluate the SFSP in a pediatric ED setting and collect feedback from families.1720  We hope that the findings from this analysis will help inform the implementation of clinically based SFSP sites throughout the country and promote expansion of the program at CHOP.

We established a new site for the USDA’s SFSP in the CHOP ED in July 2017. The CHOP ED serves as both a quaternary-care referral center as well as the community pediatric ED in West Philadelphia. It contains 59 beds, including a 12-bed fast-track. All patients are eligible for participation in the SFSP via the Community Eligibility Provision. In 2017, this ED saw 66 952 unique patients over a total of 99 369 encounters; 55% were African American, 9% were Latino, and 3% were non–English speaking. Recent studies involving this patient population showed a food insecurity rate as high as 23.6%.21  At the time of program implementation, no generalized screening or referral for food insecurity was ongoing.

A network of federal, community, and hospital partners joined together to plan and implement the SFSP in the CHOP ED (Table 1). Oversight for the program was led by the USDA, the Pennsylvania Department of Education, and the Pennsylvania Department of Health. The Nutritional Development Services (NDS) of the Archdiocese of Philadelphia, approved by the state to operate as a sponsor, provided staff training and ensured proper implementation of the program in the CHOP ED. NDS arranged meal preparation to meet federal requirements, managed meal delivery and communication with state and federal agencies for reimbursement, and ensured compliance with regulatory standards. A team of hospital-wide partners collaborated to identify resources to implement the SFSP in the CHOP ED. This multidisciplinary team included those in public relations, facilities management, environmental services, and security; social workers; legal associates; and the food supplier for the hospital. ED clinical champions, including physicians, nurses, nurse practitioners, and child life specialists, managed the operation of the SFSP. The CHOP Career Path Program, a federally funded and hospital-run job-training program for young adults with medical complexity, provided operational staffing of the program.22  We considered employing volunteers, interns, and/or cooperative students as options for program staffing in the event that Career Path was unavailable.

TABLE 1

Roadmap of Program Design and Stakeholders

PlanningStepsPartner (Role)BarriersResolution
Decision to develop SFSP site in clinical areas at CHOP Determine opportunity for clinical location Office of Community Relations and Government Affairs (convener) Establishing partner in clinical setting Clinical champions of the program identified in the ED 
 Partner with regulatory bodies Pennsylvania Department of Education (oversight) and USDA (funding agency) Determining opportunity for a closed program site (available only for patients and/or siblings) and establishing a plan for food source and communication with regulatory bodies Closed site established and decision made to partner with community agency with experience administering SFSP 
 Reconcile any conflicts of interest with hospital food services Hospital food services Potential concern regarding profit margin Partnership in an effort to address food insecurity among patient population 
Organization of clinical site Establish clinical site buy-in ED leadership, clinical champions (members from nursing, nurse practitioner group, physician group, and child life specialists), and environmental services (trash collection) Concerns regarding allergies, choking hazards, waste management, and length of stay Establishment of age limits in program, clearly marking ingredients, and verbal disclaimer to caregivers; partnership with environmental services to ensure frequent trash collection during program operation; and time-limited pilot period during low-volume hours 
 Determine food purveyor NDS (community partner, food provision, communication with state and/or federal regulatory bodies, staff training) — — 
 Train staff NDS and clinical champions Biases in meal ticket distribution Education that all children (ages 2–18) are eligible if not NPO, Career Path interns provided nursing staff with daily reminders of program operation and patient eligibility, screensavers on patient-facing computers encouraging caregivers to ask about the program; and multiple clinical champions present during hours of program operation 
 Determine staffing Career Path (staffing) — — 
 Determine food storage Facilities (provision of dedicated refrigerator) Concerns regarding infection prevention and food theft Dedicated program refrigerator in locked room 
 Establish flow diagram of program operation ED leadership, clinical champions (members from nursing, nurse practitioner group, physician group, and child life specialists), hospital security (food delivery), and Career Path (staffing) Concerns regarding flow of operations and ensuring hallways are clear and families stay in the room for the duration of patient care Delivery of food by interns to individual patient rooms (Table 2
 Establish plan for extra food and/or returned components of meals Fostering Health Program (recipient of surplus food) and clinical champions Ensure expired food is discarded before donation Clinical champions discard expired and/or perishable food before donation 
PlanningStepsPartner (Role)BarriersResolution
Decision to develop SFSP site in clinical areas at CHOP Determine opportunity for clinical location Office of Community Relations and Government Affairs (convener) Establishing partner in clinical setting Clinical champions of the program identified in the ED 
 Partner with regulatory bodies Pennsylvania Department of Education (oversight) and USDA (funding agency) Determining opportunity for a closed program site (available only for patients and/or siblings) and establishing a plan for food source and communication with regulatory bodies Closed site established and decision made to partner with community agency with experience administering SFSP 
 Reconcile any conflicts of interest with hospital food services Hospital food services Potential concern regarding profit margin Partnership in an effort to address food insecurity among patient population 
Organization of clinical site Establish clinical site buy-in ED leadership, clinical champions (members from nursing, nurse practitioner group, physician group, and child life specialists), and environmental services (trash collection) Concerns regarding allergies, choking hazards, waste management, and length of stay Establishment of age limits in program, clearly marking ingredients, and verbal disclaimer to caregivers; partnership with environmental services to ensure frequent trash collection during program operation; and time-limited pilot period during low-volume hours 
 Determine food purveyor NDS (community partner, food provision, communication with state and/or federal regulatory bodies, staff training) — — 
 Train staff NDS and clinical champions Biases in meal ticket distribution Education that all children (ages 2–18) are eligible if not NPO, Career Path interns provided nursing staff with daily reminders of program operation and patient eligibility, screensavers on patient-facing computers encouraging caregivers to ask about the program; and multiple clinical champions present during hours of program operation 
 Determine staffing Career Path (staffing) — — 
 Determine food storage Facilities (provision of dedicated refrigerator) Concerns regarding infection prevention and food theft Dedicated program refrigerator in locked room 
 Establish flow diagram of program operation ED leadership, clinical champions (members from nursing, nurse practitioner group, physician group, and child life specialists), hospital security (food delivery), and Career Path (staffing) Concerns regarding flow of operations and ensuring hallways are clear and families stay in the room for the duration of patient care Delivery of food by interns to individual patient rooms (Table 2
 Establish plan for extra food and/or returned components of meals Fostering Health Program (recipient of surplus food) and clinical champions Ensure expired food is discarded before donation Clinical champions discard expired and/or perishable food before donation 

—, not applicable.

We named the CHOP ED SFSP “Complete Eats” to embody the nutritional meal that children received during their visit. Complete Eats operated as closed meal site; only CHOP ED patients and their siblings 2 to 18 years of age were eligible to receive a meal. Although the SFSP does not have a lower limit of serving age, the ED SFSP designated age 2 to ensure age-appropriate food safety practices and avoidance of choking hazards. Complete Eats was initiated as a pilot program, operating for a portion of the summer in 2017: July 10, 2017, to August 25, 2017, with an extended lunch period Monday through Friday from 10 am to 2 pm (Table 2). These tend to be lower-volume hours in the ED and were selected to ensure adequate capacity for troubleshooting difficulties that could arise with the flow of patient care, security, or garbage accumulation.

TABLE 2

Daily Program Operation

TimeDescription
8 am Food delivery at ED entrance, security calls dedicated intern phone 
 Intern accepts food, counts and tracks meal numbers, measures milk temperature, stocks dedicated refrigerator 
10 am Start of dedicated meal hours 
 Intern reminds nursing staff of program operation 
 Nursing staff determines eligibility of patients to eat (NPO status), distributes meal tickets, calls dedicated intern phone with room number 
 Interns deliver meals to rooms, track meal distribution, review with caregivers potential allergens and choking hazards, provide written information about how to access SFSP meal sites in the community 
 Interns walk around ED at any slow times and remind nursing staff of program availability 
2 pm End of dedicated meal time 
 Intern contacts clinical champion with number of meals distributed, clinical champion contacts NDS with number of meals requested for following day 
 Returned and/or unconsumed components of meals or excess food picked up by representative from Fostering Health Clinic 
TimeDescription
8 am Food delivery at ED entrance, security calls dedicated intern phone 
 Intern accepts food, counts and tracks meal numbers, measures milk temperature, stocks dedicated refrigerator 
10 am Start of dedicated meal hours 
 Intern reminds nursing staff of program operation 
 Nursing staff determines eligibility of patients to eat (NPO status), distributes meal tickets, calls dedicated intern phone with room number 
 Interns deliver meals to rooms, track meal distribution, review with caregivers potential allergens and choking hazards, provide written information about how to access SFSP meal sites in the community 
 Interns walk around ED at any slow times and remind nursing staff of program availability 
2 pm End of dedicated meal time 
 Intern contacts clinical champion with number of meals distributed, clinical champion contacts NDS with number of meals requested for following day 
 Returned and/or unconsumed components of meals or excess food picked up by representative from Fostering Health Clinic 

The Complete Eats site received preboxed lunches daily from the sponsor and properly stored the items in a designated refrigerator in the ED. On rooming patients in the ED during program hours, the bedside nurse confirmed if the patient was medically allowed to eat and, if so, distributed a meal ticket to the patient and all children present between ages 2 and 18. Caregivers were included in the program if they were 18 years of age or younger. All children in a given room were excluded from participation if the registered patient was not allowed to eat for medical reasons (nil per os [NPO]) or if the patient was <2 years of age. The meal ticket contained information regarding the Complete Eats program and instructions to access the USDA’s national Text 4 Food service. Through this service, individuals can text the word “food” to 877-877 to find additional SFSP sites in their community. At a medically appropriate time, the bedside nurse notified the Career Path intern of the number of meals to be delivered to a given patient’s room. Career Path interns reviewed potential allergens and choking hazard information with the caregivers to ensure that each of the food items was suitable for their children. After review, meals were distributed in the ED patient-care room in exchange for the meal ticket. We provided all caregivers with a half-page information sheet that included details on the SFSP and how to access other sites in the community. Any leftover meals were donated to the Fostering Health Program at CHOP, a specialized clinic caring for children in the foster care system.

We recruited caregivers of meal recipients to participate in a brief, voluntary, anonymous survey. Caregivers were excluded if they reported previous participation in the Complete Eats program in the CHOP ED. All surveys were conducted on a designated study tablet (iPad) with information recorded directly into Research Electronic Data Capture.23  All study procedures were deemed exempt from review by the hospital’s Committee for the Protection of Human Subjects.

Tracking the proportion of ED visitors who received meals was not a goal of the program in its pilot phase. However, we did assess patterns of meal distribution that could inform full implementation of the program. Accordingly, we tracked the daily number of meals distributed to patients and other age-eligible children present during program hours. We collected self-reported information regarding the caregiver’s relationship to the patient, caregiver age, and the number of children present in the ED.

Four questions assessed the caregiver experience with the Complete Eats program at the CHOP ED: perceived need for the program, comfort with the program in the ED, perception of the hospital as an SFSP location, and ease of the meal receipt process. We collected responses using a Likert scale with the options “strongly disagree,” “disagree,” “neutral,” “agree,” and “strongly agree.”

We assessed caregivers’ previous knowledge of the SFSP before their children’s visit to the CHOP ED, their previous use of the SFSP, reasons for nonparticipation in the past, future plans to use the SFSP sites in their community, and confidence in their ability to access SFSP sites in their community.

We report frequencies and descriptive statistics (mean ± SD) for the age and number of children with the family during the ED visit, the number of children who received a meal, caregivers’ experiences with the SFSP before and during their children’s visit to the ED, and intention to use other SFSP locations. Likert responses were coded in a binary format (“agree” or “strongly agree” versus any other response) to indicate program acceptability. All analyses were conducted by using IBM SPSS Statistics version 24 (IBM SPSS Statistics, IBM Corporation).

Eighty-six caregivers agreed to complete the survey. An overall response rate was not calculated because the estimated number of caregivers eligible to participate in the survey was not available. Seventy-four percent of the survey respondents reported being the mother of the child who received the meal (Table 3). Ninety-three percent of respondents reported being a family member. The mean age of the caregivers was 32.5 years (SD 12.7), and the mean number of children present in the ED per respondent was 1.7 (SD 1.0; range 1–7).

TABLE 3

Demographic Characteristics of Survey Respondents (N = 86)

Characteristicn%
Age, y   
 <19 11 
 20–29 26 30 
 30–39 31 36 
 40–49 
 >50 11 
 No response 
Caregiver type   
 Mother 64 75 
 Father 11 
 Parent and/or guardian 
 Grandparent 
 Other 
 No response 
No. children present   
 1 44 51 
 2 25 29 
 3 11 
 4 
 5 
 6 
 7 
 No response 
Characteristicn%
Age, y   
 <19 11 
 20–29 26 30 
 30–39 31 36 
 40–49 
 >50 11 
 No response 
Caregiver type   
 Mother 64 75 
 Father 11 
 Parent and/or guardian 
 Grandparent 
 Other 
 No response 
No. children present   
 1 44 51 
 2 25 29 
 3 11 
 4 
 5 
 6 
 7 
 No response 

During the pilot time period, an average of 57 patients were seen daily in the ED, with a median length of stay of 163 minutes. There was no significant difference in the mean number of patients presenting or median length of stay during this time period when compared with the same time the year before (60 patients and 172 minutes, respectively).

Over the 7-week pilot period, 367 meals were distributed to children between 2 and 18 years of age. An average of 12 meals were distributed per day with an average of 57 patients seen daily in the ED during the hours of program operation. When general feedback was solicited from ED staff, the process of distributing meals to the children had no reported interference with clinical care during their visit to the CHOP ED, and there were no reported security or trash-related concerns. In addition, no choking or food allergy incidents were reported.

Ninety-one percent of caregivers agreed that there was a need for programs like the SFSP, and 86% of respondents expressed that the hospital was a good location to provide children meals. Caregivers indicated that the process of their children receiving the summer meal was easy, and they felt comfortable with the SFSP in the ED (91% and 92%, respectively).

Of the 86 survey respondents, only 32 (37%) reported knowing about the SFSP before their children’s visit to the CHOP ED. Of those with previous knowledge of the program, 84% reported that their children partook in the SFSP before visiting the ED that day. Of the 54 (63%) who had no previous knowledge about the SFSP, 79% planned to use an SFSP site in their community, and 73% reported feeling confident in their ability to find a site in their community.

This advocacy case study describes one of the first efforts to pilot and evaluate the SFSP in a pediatric ED setting. Findings demonstrate that providing summer meals to children in a clinical setting is feasible and acceptable to families. Over a 7-week period during low-volume hours, the ED nurses and Career Path interns successfully distributed 367 meals to children without any observable interference with clinical care. Caregivers agreed that the hospital was a good location for the SFSP, felt comfortable with the program in the ED, and thought the process of their children receiving the meals was easy.

Our evaluation data demonstrate that families presenting to the CHOP ED benefit from, and have a high level of interest in, programs like the SFSP but may lack the knowledge of how to access these services in their community. These findings are consistent with a previous study that found that a lack of knowledge about the summer meals program was a major impediment to participation.24  Providing information regarding SFSP sites in the community along with meals in the clinical setting resulted in a high level of intended participation in the SFSP and high levels of confidence in caregiver ability to locate community sites of the program. Although we did not measure subsequent participation in the community-based SFSP, the Complete Eats model shows potential to increase awareness and use of community programs.

This advocacy case study also demonstrates the importance of community-clinical partnerships in successfully increasing the reach of the SFSP. To implement the SFSP, a sponsor site must apply to the program, attend trainings, identify the source and process for meal distribution, train site staff, and work with partners to ensure that the families know where their children can get summer meals.10  Each of these steps can serve as a barrier to an institution beginning to distribute summer meals in that community. The established network of hospital, community, and federal partners played a significant role in the successful implementation of the SFSP in the CHOP ED. This highlights the importance of continuing the program in a clinical setting to improve the connection between families and community resources. The only direct cost to the hospital for this pilot program was $10 for printing of meal tickets and resource information. Costs to be considered in replication of this program could include the purchase of dedicated program refrigerators, program staffing if a program like Career Path is not available, and salary support for a program coordinator.

Although the Complete Eats model serves as an example of how a clinical setting can serve the needs of the community through effective partnerships, our study has several limitations. First, although hospital staff did not report any effect on patient care or workflow and overall patient length of stay did not vary significantly from the year before program initiation, we did not measure these aspects directly. Second, because we did not obtain individual-level information from the caregivers, we were not able to follow up with caregivers to assess subsequent program use. Third, because surveys were voluntary and collected immediately on meal distribution, our evaluation results may be biased by nonresponse, and because we did not track the number of caregivers approached for the survey, we cannot accurately report the survey response rate.

The Complete Eats program was a feasible and well-received pilot of the SFSP in the CHOP ED, providing food to patients and families and connecting these families to community resources. Since the initial pilot, Complete Eats has been expanded to multiple clinical settings through the hospital, with nearly 7500 meals being distributed during the summer of 2018. Future evaluations will include a more in-depth evaluation of the feasibility and acceptability of the program, evaluation of program implementation in a variety of clinical settings, and assessment of participant engagement with community-based SFSP sites after participation in the medical setting. We are exploring opportunities through the USDA and local food resources to provide meals after school as well as during school holidays. Programmatically, we plan to integrate more partnerships with community agencies to further connect families with other food and social resources.

Drs Cullen and Fein and Ms Mirth conceptualized and designed this advocacy study and participated in all stages of program implementation and evaluation, manuscript drafting, and review; Ms Blauch designed the data collection tool, supervised data collection, conducted the initial analyses, and drafted the initial manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Dr Cullen was funded by a National Institutes of Health training grant during conduct of this research: Ruth L. Kirschstein National Research Service Award (NRSA)-T32-HP10026. Funded by the US Department of Agriculture Summer Food Service Program. Funded by the National Institues of Health (NIH).

     
  • CHOP

    Children’s Hospital of Philadelphia

  •  
  • CHOP ED

    Children’s Hospital of Philadelphia Emergency Department

  •  
  • ED

    emergency department

  •  
  • NDS

    Nutritional Development Services

  •  
  • NPO

    nil per os

  •  
  • SFSP

    Summer Food Service Program

  •  
  • USDA

    United States Department of Agriculture

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.