Overall, eight food banks and two charitable food system experts were contacted to participate in the interviews. A total of six interviews were completed. Four of the food banks contacted did not respond to the participation request. Each food bank participant directly worked within the food bank/healthcare partnership (n=4). Charitable food system experts included individuals with extensive knowledge of food bank networks (n=1) and management of charitable food organizations (n=1). See the Table 1 for the program scope and experience of participants.
Table 1
Descriptive characteristics of food banks and charitable food system experts interviewed (n=6)
Size | Program Scope/Experience |
Food Bank/Healthcare Partnership Leader |
Large, urban | Food prescriptions, onsite food pantry, mobile food markets, screening, and referral network (Current) |
Small, rural | Screening and referral (Current) |
Large, urban | Mobile food/produce delivery, therapeutic food clinics, and electronic referral system (Current) |
Large, urban | Onsite food pantry, mobile food delivery, and tailored food boxes (Discontinued) |
Charitable Food System Expert |
State-wide network | Leadership in state-wide organization that supports all food banks in Texas (Current) |
Regional, academic expert | Academic expert in community nutrition (Current), Leadership in local meal support program (Previous) |
Responses were organized into implementation challenges at the partnership level, program level, or structure/system level and implementation facilitators for creating sustainable food bank/healthcare partnerships. Each is discussed in below using context from interviews.
Partnership Level Challenges. Participants made it clear that discussions about expected program scale within a food bank/healthcare partnership should be at the center of partnership planning and negotiation. For example, participants indicated that food banks work the best “at-scale,” meaning they function efficiently when they can deliver large quantities of food to communities. Ultimately, they suggest that larger the program scale the better, when it comes to working most efficiently with food banks. Participants went on to suggest that if a food bank is considering partnering with a clinic that serves a small population, it could be challenging or not seen as a priority for the food bank, as outcomes such as pounds of food delivered are the primary outcomes for a food bank.
Another implementation barrier reported by participants centers around data: data collection, data sharing, and program evaluation. All participants suggested that food banks often do not have the capacity or expertise to collect data or enter large amounts of data, nor are food bank staff commonly experienced or trained in data collection, yet they understand that without data to support the program, there is little chance of the program surviving because of funding pressures to produce measurable outcomes. Problematic data sharing was also a common theme within interviews. Specifically, participants noted that even with data agreements between the food bank and the healthcare providers, healthcare partners often did not collect complete data or did not provide timely data reports back to the food bank as outlined in agreements. All participants also mentioned that some clinics may not want to share or have the capacity to share individual level data because of patient privacy concerns. These difficulties with data sharing are seen as a problem for food banks because it is difficult to show program success to current and future funders with incomplete or missing data. Data discussions during interviews almost always ended with a focus on evaluation. To facilitate effective program evaluation, participants emphasized that food banks should think ahead to what metrics and outcomes are essential to allow for tailored data collection across programs and prevent excessive data collection on measures that are not useful.
Program-Level Implementation Challenges. When entering a partnership between charitable food partners and healthcare providers, multiple participants emphasized the need of clear communication and discussion about food expectations. For example, food banks operate with significant amounts of donated foods, so certain foods cannot be guaranteed. This variability often creates frustration because clinics can have expectations that are unachievable by food banks. Given the known variability in food, food banks should be clear on what it can deliver early in the formation of the partnership to ensure a positive relationship between food bank and healthcare partner.
Another common implementation challenge discussed among participants was an inability of the food bank to receive a variety of produce, a commonly requested item from healthcare partners. Reliable and varied produce is not something that most food banks are able to provide year-round. For example, within a 30-pound box of produce, clients may only get 2-3 types of produce, as it depends on what is in season and available in bulk. Issues of culturally appropriate foods were also discussed, as not all food banks will have access to bulk produce that is culturally appropriate or familiar/easy to cook with for recipients. To help with food and produce consistency, results suggested food banks should consider working with local farms to produce consistent produce.
Structural Challenges. All participants discussed the structural implementation barrier of food safety requirements. Participants reiterated that few healthcare partners have adequate refrigeration to safely store produce or perishable foods. This lack of safe food storage can often result in a limited variety of foods available within food boxes distributed at clinic sites. Expired food presents another structural challenge for food bank/healthcare partnerships as a significant amount of food available in food banks has been donated. When relying on donated food, as all food banks and pantries do, participants suggest the food bank and healthcare partner need to have clear guidelines around how to handle expired food that enters the charitable food system.
Participants also highlighted that many food bank programs are funded through federal and state programs with that carry government regulations that specify on how funding is used. While participants reiterated that food banks have a strong purchasing power for commodity and government foods, food banks are also required to use that purchased food for specific populations. For example, participants noted that food items purchased through government funded programs commonly required recipients to acknowledge income eligibility requirements, which can make distributing food to children particularly complicated because children are unable to legally complete the income verification forms. One exception to the income verification required discussed among participants was when the food was highly perishable (i.e., produce). These highly perishable foods can be distributed to any clinic visitor, regardless of income, to ensure that the produce was distributed quickly.
Given the nature of any healthcare partnership, issues of patient privacy were discussed by participants as a barrier that must be overcome or addressed before entering a partnership. Participants indicated that food bank/healthcare partnerships would likely involve data sharing of sensitive medica data, and therefore, food bank staff should receive training on patient privacy and the Health Insurance Portability and Accountability Act (HIPAA), something that is currently uncommon in food bank staff trainings. Participants also discussed that healthcare partners need to have a similar understanding of protected patient data. Specifically, results highlighted that some healthcare systems see sharing food insecurity screening results with the food banks as a violation of HIPAA, yet other healthcare partners willingly share this information with the food bank. This discrepancy should be addressed in early discussions of data sharing between the food bank and healthcare system.
Implementation Facilitators. Across interviews with food banks and charitable food system experts, four facilitators needed for developing and sustaining food bank/healthcare partnerships were 1.) leadership support for addressing social determinants of health, 2.) mission compatibility/organizational readiness, 3.) food insecurity training, and 4.) identification of program/partnership champions.
All participants emphasized that need for leadership and staff at both the food bank and healthcare partner to have a strong desire to support all social determinants of health. Specifically, food bank leadership should have an interest in addressing other social determinants of health in addition to food access, and clinical partners should understand the interconnectedness of food insecurity with other social determinants of health. To address a variety of social determinants of health among food bank clients, participants suggested that food banks should participate in local health coalitions to collaborate with partner agencies and facilitate development of referral strategies.
The importance of mission compatibility and organizational readiness across both food banks and healthcare partners was also highlighted across all participants. Food banks must ensure that a food bank/healthcare partnership would further the food bank’s mission priorities, as it is possible that this kind of partnership may not be of interest or within scope for all food banks. Participants also reiterated that healthcare partners must have the willingness to treat food insecurity as an essential part of health and be willing to devote time and resources toward the partnership.
Food insecurity training was also discussed as a critical facilitators of food bank/healthcare partnerships. Participants felt it was essential for healthcare partners to receive training on the significance of food insecurity and how to successfully identify food insecure patients using the Hunger Vital Signs, a validated two-item food insecurity screening questionnaire based on the U.S. Household Food Security Survey Module to identify households at risk of food insecurity [20]. To support the partnership, participants also suggested that healthcare partners should universally screen all patients to ensure equitable access to program resources.
Program champions on both sides of a partnership was also discussed as a program facilitator. Within the food bank, there should be a partnership/program leader, as this person will be the point person for healthcare partnerships, decision making, and partnership outreach. Similarly, there is a necessity for a healthcare champion with dedicated time for the partnership that also holds leadership responsibility within the clinic, as this person will help facilitate partnership programs and ensure that the clinic upholds its responsibility.