Healthy Food Options

Hi everyone, I'm Christy Bergavaro, the Acting Associate Director for Policy and Communications in the Division of Nutrition, Physical Activity, and Obesity at CDC. I'd like to welcome everyone to today's seminar, Increasing Healthy Food Options in Hospitals and Healthcare Systems. This seminar highlights hospitals and healthcare organizations serving as models in expanding access to healthy food. This is an exciting time to be doing work, highlighted in today's webinar. We're seeing a real momentum across the country, including CMS's Healthy Hospital Food Pledge, which is a voluntary initiative that encourages hospitals to strengthen the nutritional quality of food offered to patients while supporting healthier food environments for visitors and staff. CDC recognizes the important role that hospitals and healthcare organizations play in promoting health, preventing chronic disease, and addressing the wellness needs of communities, and we are delighted to be sharing information about some of these ongoing efforts at the national, state, and local levels with you today. Next slide, please. Before we begin, I'd like to quickly cover our disclosure information. In line with continuing education requirements, all presenters have reported no relevant financial relationships. This presentation does not include off-label or investigational product discussion and no financial support was received. More information is also available on this slide. The DNPA seminar series is now accredited and we are excited to offer continuing education credits for today's seminar. Information will be available at the end of the seminar regarding how to obtain continuing education credits. In addition, registrants will receive an email with instructions to receive Credit for the session. And now, to move on to the reason you joined us today, I'm excited to introduce our lineup and tell you a little bit more about each presenter. First, we will have Diane Harris, a senior health scientist and team lead in the Obesity Prevention and Control Branch of CDC's Division of Nutrition, Physical Activity, and Obesity. Dr. Harris leads the Healthy Food Environments team, which focuses on research, technical assistance, and programmatic support for increasing access to healthy foods, including strategies like healthy food in hospitals and fruit and vegetable prescription programs. Diane will be giving an overview of CDC's healthcare-based public health nutrition strategies. Next will be Inka Deku, a Nutrition Integration Specialist and the Program Manager of the State Physical Activity and Nutrition Program at the Colorado Department of Public Health and Environment. She is a registered dietitian and serves as the subject matter expert for food policy, systems, and environmental change grantees. Inka will be discussing Colorado's efforts to improve food environments in hospitals. And Hannah Swartz is the program manager for the Intertribal Council of Michigan's Health Education and Chronic Disease Department. Hannah coordinates the CDC REACH and food pharmacy programs. Hannah will describe the Tribal Council of Michigan's approach to adapting produce prescription programs for tribal and rural communities with the food pharmacy program. At the end of the presentations, we will have some time for Qs and As. So without further ado, I will hand it off to Dr. Diane Harris to kick off the presentations. Thank you. Thank you, Kristi, next slide. So I'll provide an overview of hospital and healthcare-based public health nutrition strategies that DNPO supports in our programmatic work. I will focus on two priority nutrition strategies, food service guidelines and fruit and vegetable programs, including produce prescription programs, and then I'll provide you a brief summary of the DNPO programs, which will give us a lead-in to today's speakers. Next slide. So, I want to just spend a minute outlining the importance of hospitals and health care systems and healthy food initiatives. So, first of all, there are as many as 6,100 hospitals in the United States, according to the American Hospital Association. And these facilities are important work sites with about 5.8 million people employed in the hospital sector, according to the Bureau of Labor Statistics. Hospitals can be key anchor institutions in communities, as they can provide food access for not only inpatients, but also outpatients, staff, visitors, and really all community members. And sometimes this food service is available 24-7. So they encourage patient recovery with healthier nutrition, and we know how vital good nutrition is for recovery and wellness. And they serve as models for practices that promote health for communities, including healthy eating. Now, as institutional purchasers, hospitals and health care systems can have a large economic impact. One market research report indicated that the U.S. health care hospital food services market size was valued at over $22 billion in 2024. And health care systems can have powerful procurement leverage. That is, when purchasing favors healthier food and beverage options, these institutional buyers can drive change throughout the supply chain. Next slide. So, DNPO promotes a number of strategies for which hospitals and clinics can be key implementation partners. So, the first two strategies are food service guidelines and produce prescription programs, which I'll dive into a little bit further in a moment. But I also wanted to mention baby-friendly hospitals, which are programs which support maternity care practices and policies that support breastfeeding. Family healthy weight programs, or comprehensive family-based lifestyle change programs to help children with overweight or obesity make progress towards a healthier weight. And evidence-based physical activity and self-management programs for arthritis. So that includes many programs such as supervised exercise or self-management programs and education that can occur in healthcare settings. Next slide. So let's focus first on the Food Service Guidelines strategy. The food service guidelines for federal facilities are a set of voluntary best business practices that can be implemented at federal departments and agencies to increase healthy and safe food options for employees and visitors, while also improving facility efficiency and supporting the community through sourcing and procurement of local and regional foods. These food service guidelines offer standards in four domains, food and nutrition, facility Facility efficiency, environmental support, and community development. Food safety and behavioral design. Now, although they were originally developed for food service operators in federal facilities to operationalize the Dietary Guidelines for Americans, or DGAs, they can also be used in various worksite and community settings in addition to government facilities. The current version was released in 2017 and are aligned with the 2015-2020 DGAs, however we are currently reviewing the standards to align with the 2025-2030 DGAs that were released earlier this year. So I see you skipped ahead to the next slide where we can talk about the critical setting where food service guidelines are implemented, being hospitals and healthcare facilities, and the various food venues that can be found there, including cafeterias and the various retail outlets that serve outpatients, staff, and visitors, such as snack bars, vending, and franchised or leased outlets. The guidelines can also be adapted to food served to inpatients, although importantly, the individual dietary needs of patients undergoing treatment should be assessed and monitored by a registered dietitian in collaboration with other health care team members. Now, when considering hospital food service, there are multiple contextual factors that make each situation unique, but I'll list a few here. So one is the food service operations themselves. That is whether the food service is self-operated. And managed by the facility or if the food service operations are contracted with the management company, which has a number of implications, including how easily changes can be implemented within the terms of a contract, for example. Other factors include how food is sourced. One rising trend is farm to hospital, where direct purchasing agreements with producers can help create a more stable and predictable market for small and midsize scale regional farmers. Other considerations include various policy levers which can help sustain change. For example, implementation of food service guidelines can be a requirement of workplace wellness policies or incorporated into requests for bids or as contract stipulations and scope of work requirements. In addition, you'll hear today about recognition programs which support and honor hospitals as they make strides towards improving the quality of food environments. Next slide. So, DMPO has developed a number of online resources to support public health practitioners and food service operators implement food service guidelines across various settings. You can find links to these in the resource guide, which will be provided later. This implementation toolkit is a great place to start. It provides information on the various building blocks or stages of implementation of food Food Service Guidelines, from building a foundation through assessment. Strategizing, acting through working with partners and developing policies, monitor and evaluating progress and successes, and expanding initiatives to new types of facilities and new components of the food environment. Next slide. Today, we have an exciting announcement. In October, we are launching a brand new resource for those of you as a food service operator or public health practitioner or anyone else who is working through these stages of implementation and practice. The Healthy Hospital Foods Network will be a peer learning opportunity focused on practical field-tested support. We are planning quarterly networking calls, each focused on a particular topic such as building the organizational foundation or assessing the food environment. This is a great opportunity to work together to capitalize on this national focus of foods and beverages served in hospitals and healthcare settings. So if you are interested in participating, please use this QR code to sign up or see the link that's going to be provided in the resource guide. Next slide. So another priority strategy where healthcare is an important partner are produce prescription programs. Next slide. So, the basic model of a produce prescription program includes the following steps. A health care provider screens patients for risk for a diet-related chronic disease and or food insecurity, then refers the patient typically to a community-based partner program with a voucher as a prescription to be used to obtain free or reduced cost fruits and vegetables Nutrition and culinary education are integral parts of the program to ensure that patients have skills to know how to incorporate more fruits and vegetables into their diets. An evaluation of programs includes collecting patient data for quality improvement and documenting outcomes against program goals. You may see various names for these programs in the field, such as those listed here, and today we're going to hear about food pharmacy programs. Typically, these programs are offered for four to ten months, with many being six-month programs with a typical benefit in the range of $40 to $80 per person per month. Next slide. So the aims of produce prescription programs include encouraging health care providers to assess and provide for their patients' nutrition and cultural and religious food Food needs. And importantly, to reduce or eliminate the cost of fruits and vegetables to provide greater access to patients who need that. And to increase demands for fruits and vegetables at redemption sites, which can benefit the retailer. Also, increased purchasing of fruits and vegetables can increase revenue for the producers, for the fruit and vegetable farmers, including those that are regional or local producers if the product is sourced that way. Next slide. So, produce prescription programs are considered evidence-based interventions. In fact, the Community Preventive Services Task Force, or CPSTF, reviewed the evidence for fruit and vegetable incentive programs, which include produce prescription programs for households with lower incomes and recommends these programs based on strong evidence of effectiveness in reducing household food insecurity and increasing household fruit and vegetable consumption. And in those programs in which incentives were provided to participants who are at risk for or had diet-related health conditions, they improved blood glucose as measured using hemoglobin A1C levels. The CPSTF also found fruit and vegetable incentive programs to be cost-effective based on analysis of economic data. Next slide. So in DNPO, we help state, local, and tribal health departments, national and community organizations, land grant universities, and other partners implement evidence-based strategies like those described here that promote access to good nutrition as well as regular physical activity. This slide depicts our current cooperative agreements with organizations across the country. Three of DNPO's core programs are SPAN, HOP, and REACH. Today, you will hear one speaker from our State Physical Activity and Nutrition Program, or SPAN, which funds mainly state health departments to leverage state investments, partnerships, and resources to improve nutrition and physical activity. The other speaker is from the Racial and Ethnic Approaches to Community Health, or REACH, program. Which supports community-based organizations, universities, and health departments to utilize culturally tailored interventions in priority communities with higher risk of chronic disease to promote breastfeeding, healthy eating, and physical activity, and to increase access to family healthy weight programs. Importantly, all recipients across the 83 SPAN, REACH, and high obesity programs are working to promote use of food service guidelines and availability of produce prescription and nutrition incentive programs across the U.S. In addition, DNPO recently acquired two more programs, including State Arthritis Partner funding to support health and well-being of people with arthritis. And the Healthy Tribes Program, which is actually three programs that partner with American Indian and Alaska Native communities to advance culturally responsive, strength-based, and community-led strategies to support health and wellness. Next slide. So generally, the types of roles and activities that are supported through these funding programs are core public health activities, including relationship and partnership building, which fostering connections between state and local agencies, engaging with food policy councils and existing coalitions, and building new coalitions for resource sharing, collaborative learning, and actions across sectors. They also support assessment and planning, like community food needs assessments, identifying barriers and providing resources, and informing policies to sustain change, as well as supporting evaluation for collecting data and disseminating findings. So our speakers today will provide examples of what these public health roles look like firsthand in states and communities. So next slide. So let me turn the presentation over to our first speaker, Inka Deku, joining us from Colorado. Thank you. Great. Thanks so much. Can everyone hear me okay? I will take that as great. Fantastic. So Christy introduced me at the beginning of the presentation, so I don't think I have to reintroduce myself. So thank you. I have led Colorado's food service guidelines work since 2018, and I'm thrilled to have this opportunity to share how Colorado is supporting hospitals Adopting. and implementing healthy food policies and recognizing them for these efforts. So I was asked to share how Colorado is implementing food service guidelines with hospitals, the results of our long-term evaluation, and a recent case study published in Frontiers in Public Health on Colorado's results from the Colorado Healthy Hospital Compact. The Colorado Healthy Hospital Compact, it's a mouthful, so I'm going to refer to it as As the compact. is a statewide initiative for hospitals throughout Colorado to improve the nutrition environments by increasing the availability of healthier food and beverages and reducing or eliminating unhealthy items using the compact model. The results and data I will share today were funded under the CDC SPAN Grant Award 1807 and we evaluated the compact through SPAN long-term evaluation requirements. Through the support, the ultimate goal was to make sustainable improvements to healthy to hospital nutrition environments and help hospitals implement food service guidelines. Toward the end of my presentation, I will highlight our current work under 2312. Next slide. So I really don't know, I don't need to go into detail on this slide. Diane did an excellent job. But again, we're working with hospitals because they're optimal venues to really implement and adopt food service guidelines. Next slide. Evaluator Amy Meyring designed and conducted an evaluation of the Compact to assess how effective this model of collaboration between a state public health department and hospitals could be for improving nutrition environments. Colorado supported hospitals through regular meetings, technical assistance, education, and tools aligned with food service guideline standards. The Compact is a voluntary collaboration among hospitals with a recognition program as the incentive. For this presentation, I will focus on healthy food, healthy beverage, and marketing programs that hospitals implemented in alignment with food service guidelines. Next slide. For time, I can't go into the program details of the compact, but I want to share that our work was recently published in Frontiers in Public Health. My presentation will briefly highlight findings from our long-term evaluation presented in the article. This was a collaborative opportunity with significant support from CDC staff. And I've linked it here in the chat if you want to come along with our compact dashboard as well as the link to the article. Next slide. All right. I'm going to talk about our evaluation methods. We initiated this evaluation as part of the CDC's long-term evaluation component, focusing on one core question. To what extent have efforts to implement food service guidelines in hospitals led to improved food environments? Our methodology was mixed method approach, combining qualitative and quantitative data over a two-year time period. Our quantitative data was collected using an assessment tool at two time points, 2021 and 2023. And then our qualitative data was gathered through key informant interviews with hospital leads in 2023. We had a total of 14 hospitals participate in the compact, 10 completed assessments at both time points, and eight participated in the interviews Next slide. So how do we collect this data for our quantitative data? It was collected via an Excel-based spreadsheet, Excel based. assessment tool and online survey, which can be found on the Compact website. This tool tracks detailed nutritional information for meals, entrees, sides, children's meals, snacks, and beverages to evaluate the adherence to food service guidelines standards. Some key features and benefits of this tool, it auto-calculates standard compliance and awards points based on the nutritional data, giving hospitals clear visibility into the healthfulness of their offerings and highlighting areas for improvement. Next slide. So some key findings from our assessment related to healthy food. We had 10 hospitals that completed the assessment tool in 2021 and 2023, really allowing us to track progress over time. In 2021, 60% of hospitals met the benchmark of offering over 50% of healthy foods across venues, and that increased to 90%, reflecting significant effort across institutions to expand healthy food options. Next slide. We saw something not as a big of a jump with food, but we saw an improvement with healthy beverages. And by 2023, an average of 77% of all beverages offered in hospitals met food service guidelines criteria. Next slide. Related to all the different categories within food service guidelines, we saw an increase in all areas from 2021 to 2023. As you can see, there wasn't a major increase, but hospitals were successful at maintaining a higher percentage of healthy foods, over 55%. Next slide. And then related to the marketing strategies, which is called behavioral design and food service guidelines, one of the things that we noted was more than 40% of hospitals implemented pricing incentives in 2023 compared to 2021. Strategies included offering price discounts on healthy items and adjusting prices on less healthy choices. Next slide. So as part of our qualitative data, we did key informant interviews with eight out of the 14 participating hospitals. That's a 57% response rate. And this provided us with some valuable feedback during a challenging post-COVID recovery period. Some of the key interview topic areas explored implementation of facilitators and barriers, employee and community feedback, program sustainability, experiences of the project implementation leads, and experiences of those leading the efforts. Next slide. Some key takeaways from hospital leadership interviews, there are some consistent themes regarding the feasibility and the value of the compact model. So some facilitators included that people really liked having healthy options added to the menu and having a dietetic intern to support the evaluation, completing the assessment or the reassessment was found really valuable. Some barriers I think we're all familiar with is, you know, receiving pushback from clients, participants, as well as fear of change. And then overall, there was a positive feedback on. The health and food beverage changes next slide and sustainability really through contracts and policies were really key in the success of maintaining compact criteria and then generally overall leadership support and buy in was proved to be very positive. If they had leadership buy-in, they're more likely to have a higher ranking in the Healthy Hospital Compact. Next slide. So evaluation conclusion, the compact model proved effective for driving measurable improvements in hospital food environments. There were increased availability of healthy food and beverages, there was sustained implementation of food service guidelines standards over time, and it expanded marketing and pricing strategies for healthy options. There was positive overall experience for hospital staff, patients, and community members, and the public health impact is that broad systems and policy change which fosters healthy behaviors and support chronic disease prevention across community. This case study demonstrates a successful pathway for expanding healthy food environment initiatives across additional institutions and workplaces. Next slide. So what is Colorado doing today? This is a snapshot of where we've been and where we're going, Thank and I want to share the work that we're doing with HealthLinks to expand food service guidelines to other institutions besides hospitals. Next slide. So HealthLinks operates out of the Center for Health, Work, and Environment, a NIOSH Center of Excellence for Total Worker Health with over 14 years of experience guiding you. and educating businesses. NIOSH and Total Worker Health is out of the National Institute for Occupational Safety and Health and drives research and practical strategies to prevent work-related injury and illness and workplace hazards. Their Total Worker Health approach brings together safety, health protection, and overall well-being promotion as a unified strategy. And what was missing was a food-at-work module. Next slide. And so under our current SPAN award in Colorado, we expanded the compact model into a broader food at work initiative, which is being led by HealthLinks in partnership with the state health department to recruit all types of employers to complete the food at work survey. It's a cloud-based assessment based on food service guidelines, and we're continuing to maintain the compact recognition for hospitals. And so to continue the technical assistance and education opportunities, HealthLinks is also convening the Colorado Food at Work Collaborative to connect employers, public health partners, and food service experts across Colorado to share best practices, test tools, and improve workplace food environments. Next slide. And I just love pictures. And I wanted to show some images that were sent to us through the assessment process, a few photos from our recognition event. And so I didn't, I didn't have time to go into the detail of the compact and the recognition. But we do, we do provide recognition for our hospitals through an in person event. And so here are some of those photos, and each hospital gets a banner that they can have in their cafeteria to highlight and show that they're participating in a statewide initiative. And then of course just it's so inviting to go to into a hospital that has cases full of just healthy food options right there when staff only have a few minutes. That's an example of a behavioral design is make the grab and go all healthy options. And then next slide. And so I really encourage you, if you're interested in HealthLinks, they've made it a really easy way for employers to participate via this cloud-based assessment. It aligns 100% with food service guidelines in all four domains that Diane mentioned earlier. And so this is their website, and I encourage you to reach out to them. And also feel free to reach out to me directly if you're interested in learning more about the details of the compact as well as... Thank you. I think I'm just jumping in. Hi, everyone. My name is Hannah Swartz. And yes, thank you, Inka, for putting in your contact information. I just see you did that. But I just want to say thank you to everyone for the opportunity to show some of the work that's being done through the Intertribal Council of Michigan. Today, I'm going to share how we've partnered with tribal communities in Michigan to implement our food pharmacy program, which is a culturally adapted produce prescription program. And I'll talk about some of the lessons that informed our food pharmacy implementation guide. So next slide. A little bit about the Intertribal Council of Michigan. We are a nonprofit organization located in Sault Ste. Marie, Michigan, and we act as a forum for the 12 federally recognized tribes. And we advocate for the development of programs and policies which improve the economy, education, quality of life for Michigan's Native Americans. Next slide. The goals of our food pharmacy program are a little bit different than what you might see in traditional produce prescription programs. Of course, we want to increase fruit and vegetable consumption and nutrition knowledge. But we're also thinking about cultural relevance, incorporating traditional foods, strengthening local and tribal food systems, and ultimately helping each community build a program that works for them and that can be sustained over time. When we first started implementing this program, we were working with three tribal communities and our starting point was the Washtenaw County Health Department. Prescription for Health Implementation Guide. That is quite the mouthful, but their guide outlines key aspects of the program to consider. However, Washtenaw County is in a primarily urban or suburban setting with multiple farmers markets. They have lots of public transportation and other resources, and the implementation strategies that they offer very much fit that setting. The tribal communities that we work with are primarily rural and have varying geographies. They have different climates throughout the year, different food systems and resources, as well as cultural priorities. So we knew we couldn't simply take the existing model from Washtenaw County and implement it just as they have it laid out. Instead, we needed to determine how. How to maintain the important components of an evidence-based program while giving tribal communities the flexibility to make it work locally. And we ended up documenting that all of those changes in an implementation guide for native communities, which I'll have the link available after this, but the guide holds our lessons learned throughout different phases of the program with sample materials included. So next slide. In the guide, we start out by identifying what we call the program's key ingredients. And these include health care partners, food source partners, program staff, as well as evaluation. And rather than saying, here's exactly how you need to run a program like this, we can say, here are the core pieces that you'll want to maintain. Now, what does each of those pieces need to look like in your community? And that allowed our partners to identify the staff needed to implement a program like this, which is really important when working not only with tribal health systems, but rural health systems who are usually running with limited resources and staff. So key ingredients are nice to have laid out at the beginning. Next slide. There's also a program map key. So we have The different icons and different colors kind of outlined here and the map allows people who are accessing the guide to see where each partner's responsibilities lie. And in the next slide we actually have the program map with the different icons included. So this map shows actually the participant experience and how they flow through the program, but then it is overlaid with the partners and where they come in. So when our tribal communities that we work with started implementing or planning this program, I should say, they all started with the same template and we had identified places where we expected adaptations to be made. And overall, the map helped partners answer practical questions like who's going to do the screening that's a health partner and how will we enroll folks, where are they going to use their vouchers and who is responsible for each step. So next slide. Throughout the guide, we have implement or we have adaptations at different phases of the program. So on this slide you can see how intake and referral might look different across the three different tribes that we worked with. Referrals could happen in a more traditional way, coming from the health care provider where they're writing a script for the participant or maybe they're learning about the program at a community event, but the communities that we worked with really valued using chart reviews. And recruiting through other programs where staff time was limited or providers maybe didn't have enough time in an appointment. So that was really a key piece. And I think it's important to note in tribal communities, they do have a unique advantage to some of this because most community health departments who are putting on programs like food pharmacy. are housed in the same building as their clinic or referring partners, and oftentimes those community health teams have access to even the EHR system where they can identify eligible participants and really save a lot of time. So on the next slide, it does say intake and referral, but in this slide, we're actually talking about the program adaptations that were made for patient engagement. We saw a lot of adaptation around this piece or phase of the program. You can see that all three of the communities that we worked with wanted to expand the program benefits to include traditional foods. This was really important because traditional foods are more than just nutrition. It's connection to culture. It's connection to community and tradition. So expanding the benefits. Each tribe to incorporate foods that were not only meaningful, but also available in their community. And that makes the program that much more culturally relevant to the folks that are participating. So the important takeaway isn't that one approach works better than the other. It's that communities need to be able to adapt the program around their own resources and barriers and cultural priorities. While maintaining the core purpose of the program, culturally responsive implementation doesn't mean creating one tribal version of the program, it means creating enough flexibility for each tribal community to determine what works best locally. And the next slide. Also in our implementation guide, we include evaluation resources including baseline and follow-up surveys with questions that were developed with our tribal partners, so we actually sat down and hammered out some questions so that we could understand both participant outcomes and how the program is being implemented so that it can be, you know, improved over time. We have sections assessing health and wellness with questions about connection to mind, body, and spirit, connection to community, We have questions about attitudes and beliefs, knowledge on food storage and preparation to better inform our nutrition education efforts that are available. There's also questions about health eating behaviors as well as health impacts and program feedback. Next slide please. And then since working with our tribal partners we've seen positive participant feedback and behavior change Along with decreases in food insecurity, which is, you know, what we're trying to do with this program. And recently, we've been able to start tracking changes in health outcomes. So we're getting a little bit more into the clinic side. So we don't quite have those results yet, but we're working on them. We've also seen important system level changes where stronger relationships between health care or clinics. And community health programs are happening. So there's new or strengthened referral pathways. And then we've seen new partnerships with farmers and food vendors, as well as, you know, program dollars being invested back into the local food systems. In the next slide, when we first started this work back in 2021, like I mentioned, we were working with three tribal communities. And since having the REACH grant, we've been able to expand and work with four additional tribal communities in Michigan, and we are building on the adaptations that we identified and have in the guide and are continuing to document new changes and lessons in hopes to have a 2.0 kind of version of our guide. And in the next slide. We've also continued refining the program mapping process so the Kind of flow that I was talking about previously, we now document in MuralBoard, which is an online platform where we can outline many different entry points and more components of the program so that they can be laid out. And for organizations considering, you know, starting a program like this, it's one of the most practical tools that we can recommend. And the next slide. We have all of our resources. So we have implementation guide as well as updated program materials available for folks who are wanting to start a program like this. So we have a link and a QR code and I'm sure there'd be more links later on. In the next slide we also have some resources on our Intertribal Council of Michigan website. We have a A, um, cookbook with traditional recipes that have videos and recipe cards. Those are all available. And And, um, I think that kind of closes us up in the next slide. I just want to say Chi Miigwetch, which means thank you to our tribal partners who have worked on this project with us, our funders and our evaluation team who have made this work possible. So we'll hand it back over to our hosts. Great. Thank you so much. Thank you to all of our presenters for those very informative presentations. We will now have time for some questions and answers. So I just want to bring everyone's attention. There is a question and answer button that you can put questions if you have, that you can add your questions to if you have them. And I will go ahead and kick it off with starting by asking. about your partnership. So each of you mentioned the importance of partners in implementing your work. What did each of you see as being the most important partnerships to advancing this work? And so for Diane and Inka, I'm asking this related to hospitals and Hannah for Produce Prescriptions. Thank you. Inka, do you want to start it out? I think what was key with our partnerships was having a time and place for hospitals to come and have a regular meeting that they could participate in. So we had the Colorado Healthy Hospital steering committee meetings every month in the very beginning. So it was a time that I would facilitate those calls and really bring those hospitals together to talk to each other. They would talk to each other about the challenges, the successes, what worked well, what didn't work well. I would bring in speakers, talk about national and state happenings around nutrition policies. So I think those partnerships was really critical in supporting each other. Also having the dashboard. as a way to show new hospitals what this work actually looks like. And so one of the things that we didn't do with our data was we never shared that data back with the hospitals or with partners. And so by building the dashboard, we could show like, this is how this hospital did this in a rural setting. This is how this hospital did this in a more urban setting or a food service management company or not having a food service management company. So I think if Having visuals was also really key in attracting new partners to this work. Yeah. And let me direct you back to the toolkit that I mentioned in my presentation. And there is a section about building your team. So if you're working with a hospital healthcare facility and you're trying to identify the champions or those that can be really instrumental in your coalition to affect change, you might look at leadership, right? You certainly would We would like to have buy-in from leadership. Our public health partners are always out there willing to help support those efforts. And then you need the folks that are overseeing the food service operations, and that's not just the operators, but it's the facilities managers and the purchasing directors and so forth. And then the other key component in some of these worksite settings are the worksite wellness staff and the professionals. Many times there's registered dietitians also that can be your champions in the pool. So really trying to do that assessment of who within the facility can really help you come together and help really get the implementation underway. Hannah? Yeah. So a little bit different in the produce prescription world, right? Some of the most important partners are going to be your referral or your referring partners who are going to be able to identify who's eligible for a program like produce prescription as well as your food vendors. So where participants are going to be able to use the vouchers that you're providing them in the program. And I think understanding from the community first Where the like the food vendor partnerships should come from is really important because you may think that, oh, we have this co-op that, you know, they provide really good food. But if the patient population that you're working with doesn't feel comfortable going to a co-op like that or doesn't understand how it works, maybe that's not the best partner or maybe it's an opportunity to do some education. And, um, And some work there, but yeah, I would say the, um, food vendors and the referrals are really how you make a program like, um, produce prescription programs work. So great. Thank you. The next question is for Inka. You mentioned that some hospitals reported challenges, including pushback and sort of fear of change when implementing these interventions. How did participating hospitals successfully address these challenges when implementing new food service guidelines? I heard several things from our hospital partners, and that included feedback cards where allowing I'm starting Patrons at the cafeteria to provide a feedback on new entrees that were added to the menu, meal satisfaction surveys and some surveys that would be sent out to employees. to Food service director staff would speak do cost analysis on items sold as well. And so if there was a new entree, they would compare it to sort of other entrees on the menu. now. And then I mentioned this also, but creating a healthy hospital compact work group. within the hospital showed that those hospitals had higher level recognition because there would be representatives from all different areas within the hospital. Wellness, human resources, lactation, and especially leadership support as well were some examples that hospitals highlighted of how to deal with some pushback or fear of change. Great, thank you. The next question is for Hannah. What advice would you give to another community that is interested in starting a produce prescription program? Yeah, I think starting at the planning phase first before like getting ahead of yourself is key. So identifying like why do you need a program like this in your community? What is it going to solve? It's also on our program apps, those questions and supporting questions. So identifying like all of your. You know, assets that you have in your community, identifying the partners. I think that's the best way to start instead of being like, oh, we have one really strong component or, you know, we know how we're going to find these people, but where are they going to spend their vouchers? Thank So I think laying it out and planning it all ahead of time because you're going to run into roadblocks. And, um, There's a lot of great implementation tools, including the one for tribal communities that we have and others out there. So that's where I would start. you. Thanks. And then one last question for Inka is, what key lessons learned from the hospital compact are most valuable as you expand the Food at Work initiative to other industries across Colorado? We made it easier. So one of the things with the Healthy Hospital Compact Assessment, we asked a lot of our hospitals for that nutritional data. We wanted two weeks worth of data for entrees, sides, snacks, beverages. And that is not realistic to ask of workplaces that may have a coffee cart or vending machines. And so what we did is we changed The Food at Work online module to a range for each standard And so they could just click, you know, zero to 10 percent, 11 percent to 25 percent and sort of like kind of see where they fell in those ranges and so just a radio button that they could click. They didn't have to upload any data or nutritional information. They could use the assessment tool if they wanted as a resource but that was one step that we really made it easier We also included skip logic within the food at work module where they would click what venues do you have in your work site and so if they don't have a cafeteria it's not necessary for them to complete all the data for A cafeteria that but if they have a vending machine and a coffee cart, then they would click those venues and they would ask those the same thing for each of the standards If they don't have prepared entrees and they just have vending, we're just going to ask questions around packaged snacks and beverages. So the online cloud based tool is a lot more robust. So it's been an Excel spreadsheet that we were sort of limited to in our previous award And I think also the cloud-based, having it in a portal that anyone could access where hospitals complained about having an Excel spreadsheet that they had to make sure they had to save and then share it with someone else. This is all cloud-based. It's automatic. I'm It repopulates every single year, starting and so when worksites have to update their assessments, they have to look through it They don't have to redo an assessment. So a lot of more computer, more of the technology is easier for worksites to complete the assessment. to speak Great. That's very helpful. Thank you So, I do not think we have any more questions and answers, now. or questions to answer So, with that, we'll just, as promised, we'll move on to the next slide, which shows the steps for obtaining continuing education credits If you're watching this live, please make sure to visit CDC Train and follow these instructions before October 17th. And then the presentation will be available online after that. And I think someone dropped the link to past seminars in the chat earlier. And this one will be there in a few weeks. Also, someone will drop this PDF into the chat that provides a list of resources that you can go to to find more information about any of these products. And additionally, if you have any questions about this seminar, you can email the DNPAO policy team. You should have the contact information from the registration. We would be happy to connect with you. So thank you all for your time and for your participation. The patient. And we will see you on the next seminar. Thank you.