Data from: Design of Implementation Protocols for a Health System-Based Produce Prescription Program: A Process Evaluation

Use of Theory or Research: Improved provider-patient relationships, visit compliance and health outcomes are associated with primary care integration of produce prescription programs (PPR). These interventions may improve quality and costs of healthcare. The Theory of Healthcare Acceptability¹ recognizes provider and administrator buy-in is a key elements of successful healthcare integration.

Target Audience: Clinic providers and administrators, study staff, research and IT personnel

Program Description: Primary care patients are screened for enrollment in the Fresh to Flourish produce prescription program if they meet inclusion criteria: Adults with a chronic condition who are either 1) food insecure OR 2) Medicaid members OR 3) enrolled in SNAP. Participants receive $100 value of fresh produce vouchers redeemable at community food businesses offering local produce. Brief nutrition education is provided by a primary care provider at the enrollment visit and participants may attend optional live (in-person and virtual) or pre-recorded virtual nutrition education events offered by community-based SNAP-Ed providers. The intervention aims to track individual uptake of nutrition incentives and nutrition education for the evaluation of food security, dietary intake, biometric and health care utilization outcomes.

This process evaluation focuses on development two crucial program implementation components required for program delivery and data collection for this intervention: 1) Clinical workflow integration; and 2) Data collection and management systems.

Evaluation Methods: To evaluate learning and progress toward the objective after the one year start up period, key questions included 1) What was the experience of key internal stakeholders in project piloting and implementation? 2) What were the barriers and solutions identified in the implementation process? 3) How has participation in this project influenced working relationships, engagement and future project design?

Internal meeting (n=50) minute reviews were conducted to inform development of key informant interviews and included administrative meetings (n=5), project team meetings (n=22), evaluation meetings (n=17) and REDCap work sessions (n=6) completed between June 2022 and December 2023.

Key informant interviews (n=4) were conducted between February and June 2023 with internal stakeholders (n=7) in four interdepartmental categories: clinic operations, administration, research, data and technology, and patient access (scheduling). Interviews transcripts were coded and analyzed using reflexive and latent-level focused thematic analysis methods to identify themes and subthemes.

Interview questions were provided to participants in advance of the interview and the interviewer limited follow up questions to clarifying and open-ended questions such as, “Can you please tell me more about…” Internal meeting reviews added further context and accounting of Fresh to Flourish program staff implementation challenges to the latent approach.

Results: Interdepartmental key informant interview comments (n=40) were coded into three distinct themes: 1) Human capacity (time priorities and staffing), and project management (planning, communication and collaboration) 2) Infrastructure (IT systems, physical space and workflows), 3) Engagement (administrative support, staff buy-in, developmental involvement). These were further divided into two subthemes of barriers vs. solutions.

Results: Initial clinical workflow integration revealed barriers for patients (e.g., transportation, appointment reminders) and clinical staff (e.g., support staffing shortages, clinic admin staff limitations and physical space limitations). Development of data management and collection tools required technical skills and was incumbered by competing organizational priorities and staffing challenges.

Conclusions: Universal data collection and management systems will facilitate more efficient implementation and evaluation procedures for produce prescription interventions.