DENVER — The integration of a food outreach specialist into a community pediatric clinical practice helped families connect to community resources and sign up for the state’s food stamps program when they encountered difficulties, according to research presented at the annual meeting of the American Academy of Pediatrics (AAP) 2025 National Conference.

“Food insecurity in children is associated with higher rates of chronic health conditions like asthma, skin allergies, and depression, along with increased emergency department visits and school absences,” reported Constance Gundacker, MD, MPH, an associate professor of pediatrics and section chief of General and Community Pediatrics at Medical College of Wisconsin and physician lead at Children’s Midtown Clinic, Milwaukee. “Initial results [of the program] suggest that embedding a FoodShare outreach specialist within the clinic is both feasible and beneficial to families and staff.” FoodShare is Wisconsin’s Supplemental Nutrition Assistance Program (SNAP).

Nationally, more than 1 in 6 families — an estimated 17.9% of US families — experienced food insecurity in 2023, which included an estimated 39% of families served by Gundacker’s practice that year. Her clinic had already been meeting regularly with a regional food and healthcare coalition, but then they took the additional step of partnering with the coalition and Feeding America to improve access to resources for the clinic’s families.

The program started in September 2023 with an embedded food outreach specialist from Feeding America who provided weekly in-person assistance at the clinic.

“Their job is to help families navigate food-related resources, [including] signing up for FoodShare SNAP and being able to identify other resources,” Gundacker said during a press briefing.

“So many clinics are now screening for health-related social needs because half of health outcomes are due to social or structural determinants of health,” Gundacker told Medscape Medical News. “It takes the burden off the pediatrician to have somebody that specializes in food access as part of the clinic. It’s really nice to be able to say, ‘I’m not an expert on this, but I know somebody who is, and I can connect you.’” The benefit has been having that food specialist help navigate a complex system that has often already failed families, she said.

Gundacker recalled one family whose mother had tried twice to sign up for the state SNAP program but was denied. The food outreach specialist helped her successfully enroll, “which just shows the power of being able to help navigate that system,” she said. Clinics can typically give families paper-based resources based on their zip code, such as food pantries they can use, “but this person really can help navigate each individual family’s specific needs,” she told Medscape Medical News.

Four months later, the specialist had become fully integrated into the clinic’s operations, including “standardized tracking to document the number of families engaged, FoodShare enrollments facilitated, and connections to additional resources,” Gundacker reported. Today, the food specialist is in the clinic lobby every Thursday to answer questions and provide help accessing local, state, and federal resources.

Another community partnership provides free meals once a week to families, and the clinic has paired the two services so that families can get the free meal and speak with the specialist at the same time.

In the partnership’s first year, the specialist served 664 families, providing 708 resources, and helping 24 families enroll in the state’s SNAP program, with an estimated economic impact of $115,512 from 19,176 annual meals. The specialist helped with submitting medical expenses, Medicaid renewal, work requirements, pantry information, Wisconsin ACCESS, Summer EBT, and Milwaukee Market Match, among other programs.

The program began with a grant from Children’s Wisconsin, but after the grant ended, the food bank continued to support the specialist’s role at the clinic as part of their community outreach.

“That’s huge from a sustainability standpoint” because funding is often the challenge with programs like these, Gundacker said.

The clinic held monthly team meetings to assess and refine engagement strategies, and two staff trainings helped increase awareness of the specialist’s role and the resources available to families. The researchers assessed the program through patient and staff satisfaction surveys.

Among the 16 staff members who responded to the survey, 81% reported finding the program somewhat or very useful, while 19% had neutral responses. In addition, all except one staff member said the program either decreased their workload or did not affect it.

For pediatricians interested in starting a similar program, Gundacker suggests using the AAP’s professional tools and resources on food insecurity to get started. That way pediatricians have resources on hand for families when they begin screening for food insecurity. She also suggested visiting local food banks and initiating partnerships with them.

Jaime Friedman, MD, a pediatrician at Children’s Primary Care Medical Group in San Diego, agreed that pediatricians play an important role in identifying food-insecure homes and helping connect families with resources.

“Depending on the size of the practice, pediatricians can either provide written handouts with resources for food-insecure families or bring in team members who are able to provide these resources in person,” Friedman told Medscape Medical News. “I’m lucky to work for a large group that has care coordinators who are able to reach out to families who may need support.”

That support may become even more important in coming years.

“I’m very concerned about how families will get the support they need with changes occurring at the federal level,” Friedman said. “This includes access to healthcare, access to food, and other safety net programs. Pediatricians will need to be ready to fill in the gaps wherever they can, but this means families will need to have the medical coverage to be seen. We will also need access to resources to provide to them in the absence of SNAP availability.”

Gundacker also worries that food insecurity will become worse in the coming years and said that pediatricians need to be prepared for that possibility.

To identify other ways to expand how they can help families, the research project hosted three qualitative “Data Chats” — focus group-like conversations with 35 community members and service providers about their views on food access data.

The researchers’ next steps will be “incorporating community feedback from the Data Chats, expanding to other clinics, and strengthening resource referrals across community-based organizations to maximize impact,” such as looking at the feasibility of creating a universal intake form to streamline enrollment in different programs.

The research was funded by Children’s Wisconsin and the Advancing a Healthier Wisconsin Endowment; the partnership also received support from Feeding America Eastern Wisconsin. Gundacker and Friedman reported having no disclosures.

Tara Haelle is a science/health journalist based in Dallas.