Almost 20% of children in Texas lack reliable access to nutritious food. In Houston and Harris County, where many of Texas Children’s Pediatrics’ 65 clinics and more than 300 physicians and nonphysician providers are located, that rate climbs as high as 25%.
That proximity to families from a wide range of socioeconomic backgrounds makes the Texas Children’s Pediatrics well positioned, both practically and philosophically, to address food insecurity at scale.
“It’s hard to have a conversation with a family about healthy eating when they’re not even sure where dinner is going to come from,” said Alyssa Kuban, MD, an associate medical director for Texas Children’s Pediatrics and a pediatrician at Texas Children’s Pediatrics Cypress. Texas Children's Pediatrics is part of the AMA Health System Member Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
That sparked the adoption of annual food insecurity screening using the Hunger Vital Sign tool across all practices.
Parents are asked whether two statements were often, sometimes or never true in the past 12 months:
- “We worried whether our food would run out before we had money to buy more.”
- “The food we bought just didn’t last and we didn’t have enough money to get more.”
A response of “often true” or “sometimes true” to either question is considered a positive screen.
The scale of the challenge became evident quickly.
“Our original plan was that if a family screened positive, we would refer them to one of our social workers,” Dr. Kuban said. “But within a couple of months they were overwhelmed. The need was too great for that model to be sustainable.”
Even the modest 2–3% positivity rate translated into thousands of families who needed help, forcing the team to rethink their approach. The model evolved by reframing food insecurity as a medical referral problem.
“We know that when a family has food insecurity there is often housing insecurity, transportation issues and other needs as well,” Dr. Kuban added. “We also know that active referrals to community resources are more effective.”
Instead of simply handing families a list of food banks, Texas Children’s Pediatrics built a direct referral infrastructure much like that used for clinical subspecialty care.
“If a patient has a broken arm, I make a referral to orthopaedics using a known workflow,” Dr. Kuban explained. “We asked ourselves, ‘If a patient screens positive to food insecurity, can we refer them to a community partner that can actually help?’”
A streamlined workflow that closes the loop
The flow from identifying need to connection with resources is simple by design. A positive screening prompts physicians and care teams to check a box in the EHR or insert a prebuilt smart text. The family consents, and then the front desk completes the referral. The screening is part of a routine workflow, so the additional administrative task was minimal.
“We have so many things we need to cover in these visits,” she said. “Therefore, it needed to be efficient to make the process sustainable.”
Within two weeks, community health workers at partnering food banks contact families directly and often begin by helping them complete the complex 19-page Supplemental Nutrition Assistance Program (SNAP) application.
“We know that patients who receive SNAP have improved health outcomes, a lower risk of childhood obesity, increased life expectancy and lower risk of low birth weight for women who are pregnant,” Dr. Kuban said. “We also knew that up to 15% of patients walking through our doors were eligible for SNAP but not receiving benefits.”
Families who do not qualify for SNAP or who need additional support can be referred to the Houston Food Bank Food Rx program available at nine clinics. Families receive a “prescription” for food and an ID to a Food for Change market where every month they can receive up to 60 pounds of fresh fruits and vegetables, along with nutrition education.
The program reflects a broader commitment to food as medicine. Many pediatric patients have elevated cholesterol or early signs of metabolic associated fatty liver disease which respond to improved nutrition.
“This is where access to those foods is really critical for their health,” Dr. Kuban said. “Children don’t live in silos. They live in the context of their own family and if we’re trying to drive behavioral change, we’re not going to be effective unless the whole family makes those changes together.”
Scaling successfully and sustainably
Since the project launched in 2024 Texas Children’s Pediatrics has implemented referral processes at 34 clinics and connected more than 800 families to food security resources. Meanwhile, a $67,000 Physicians Foundation grant will help the program expand further.
“Our goal is to have some sort of referral process or intervention at every single one of our 65 clinics,” Dr. Kuban said. Much of the grant funding will support the capacity of community partners and scale infrastructure.
“Some of our partners can take five or six new clinics easily, but when we talk about adding 20 clinics, I need to make sure they have the capacity,” she said.
The expansion will be phased over two years with continued training for physicians and staff at each site. As the program grows the team is also exploring additional interventions.
Some community partners offer meal delivery programs and data from the Food Rx initiative continues to strengthen the evidence base for nutrition prescriptions.
A top priority remains at closing “the SNAP gap by creating a strong foundation that will give us the capacity to expand,” Dr. Kuban said, noting that addressing food insecurity within an even broader context strengthens the impact of clinical care.
A model built for replication
Dr. Kuban believes the program’s greatest strength is its simplicity and its replicability.
“Our Texas Children’s Pediatrics clinics are not academic clinics,” she said. “That’s what makes this something others could replicate where they are.”
Additionally, any practice can initiate a relationship with a local food bank.
“If a physician’s office has a referral process, perhaps, that office can contact their local food bank and say, ‘Do you offer SNAP application assistance, and if you do, how would I refer a patient to you?’” said Dr. Kuban.
She emphasized that partnerships have been essential because “the community organizations are responsive, they’re eager, and they truly want to help these families.” Her advice for other health care organizations considering similar efforts is straightforward: start small, start local and build from there.
“Different communities have different needs,” Dr. Kuban noted. “Starting with something small will be more achievable and more likely to be successful.”
Most importantly, approach food insecurity the same way as clinical conditions.
“Think about it like you would any other medical problem,” she said. “Ask, ‘How do I connect them to the resources who are best able to help them and their families?’”
