Tackling Hunger

Hospitals, Food Insecurity and Chronic Disease

The term "patients" in the below form refers to individuals who have interfaced with the health care system through emergency room or acute inpatient care, regardless of health insurance coverage status, including former and discharged patients.

Contact Holly Calhoun at hcalhoun@phi.org with any questions or to submit additional materials.

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* 1. Program or policy name and location:

Name:

Affiliation:

City:

State

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* 2. Type of program or policy (check all that apply):

Identify food insecurity in patients

Address the needs of food insecure patients

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* 3. Contact information for program/policy:

Name

Organization

Email Address

Phone Number

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* 4. Contact information for nominator (if different than above):

Name

Company

Email Address

Phone Number

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* 5. Does the program or policy focus on patients with chronic disease?

Yes

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* 6. Does the program or policy target patients of a particular age?

Yes

If yes, what age?

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* 7. Does the program or policy focus on the internal hospital environment or the greater community that the hospital serves?

Internal

External

Both internal and external

Other (please explain)

Tackling Hunger

Hospitals, Food Insecurity and Chronic Disease

Question Title

* 1. Program or policy name and location:

Question Title

* 2. Type of program or policy (check all that apply):

Question Title

* 3. Contact information for program/policy:

Question Title

* 4. Contact information for nominator (if different than above):

Question Title

* 5. Does the program or policy focus on patients with chronic disease?

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* 6. Does the program or policy target patients of a particular age?

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* 7. Does the program or policy focus on the internal hospital environment or the greater community that the hospital serves?

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* 8. Please describe the intervention. What screening tool, policy, or program is being implemented?

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* 9. How long has the program or policy been in place?

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* 10. What is the planned duration of the intervention?

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* 11. What are the intended short- and long- term outcomes of this intervention?

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* 12. What data are collected related to this intervention?

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* 13. How are data collected or measured?

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* 14. What characteristics of this program make it a promising practice or an innovation?

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* 15. Is there anything else you want us to know about the program or policy?