Implementation and Evaluation of a Quality Improvement Project to Standardize Food Insecurity Screening in a Pediatric Nephrology Clinic

Background: Food insecurity is common among children with kidney disease and may worsen health outcomes. Although screening is recommended, implementation in pediatric subspecialty clinics has not been well described. Methods: Universal in-person screening was developed, implemented, and evaluated at one of the two primary pediatric nephrology clinics at UCSF Benioff Children’s Hospitals and compared with a control clinic over a 16-month study period. At the intervention clinic, medical assistants and licensed vocational nurses screened all in-person visits using a validated two-question tool. The second clinic served as the control and continued usual care, in which selected patients were screened during multidisciplinary visits by a renal nurse, dietitian, or social worker. An interrupted time series analysis assessed changes in screening rates over time, and a difference-in-differences analysis compared trends between the intervention and control clinics. Implementation outcomes were evaluated using the RE-AIM framework. Results: After implementation, screening rates in Clinic A (intervention clinic) increased immediately by 33%, followed by a modest but sustained upward trend of 1.0 percentage point per month. Screening completion was maintained, indicating successful integration into the clinic workflow. Staff initially reported discomfort performing screening due to uncertainty about how to respond to positive results; this improved after workflow refinements, including the introduction of a standardized script and the assignment of a nephrology-specific licensed vocational nurse to support follow-up. Caregivers reported high comfort with the screening process. Conclusions: Food insecurity screening was feasible and acceptable in a pediatric nephrology clinic, with clear workflows and defined roles supporting sustainability.