Food Pharmacy Development Guide

Food Pharmacy Development Guide 0 P a g e

Table of Contents BACKGROUND... 2 FOOD PHARMACY PLANNING... 3 Setting up the Pantry Space... 3 Nutrition Cards... 3 PATIENT REFERRAL PROCESS... 4 Working with Primary Care Practices... 4 Food Security Screening Questions... 4 Pre-packed Food Bags in Physician Practices... 5 FOOD PHARMACY DAILY OPERATION... 5 Patient Intake Process... 5 Providing Patients with Food... 7 Documenting Food Pharmacy Visits... 8 Nutrition Counseling with a Dietitian... 9 Open and Close Procedures... 9 FOOD INVENTORY... 10 Building Relationship with Local Food Bank... 10 Food Ordering Process... 10 Quick Notes on Inventory:... 10 Food Safety Practices... 10 STAFFING AND VOLUNTEERS... 12 RESPONSE FROM PROMEDICA PRACTICES AND PATIENTS... 13 DATA AND REPORTING... 13 FOOD PHARMACY SUSTAINABILITY... Error! Bookmark not defined. SUPPLEMENTAL MATERIALS... 14 ProMedica Food Pharmacy Layout... 14 Ideal Food Pharmacy Stock List... 15 Example Nutrition Card... 16 Physician Office Signage Example... 17 Food Pharmacy Intake Form... 18 Food Pharmacy Reminder Card... 20 1 P a g e

ProMedica Food Pharmacy Development Guide BACKGROUND Through our partnerships with many local, regional, and national organizations, and the community health needs assessment conducted for our member hospitals, ProMedica has come to better understand the link between hunger and obesity, and ultimately hunger and health. Our work has evolved into the nationally recognized Come to the Table initiative, which includes collaborating within our hospitals, throughout our communities, and across the nation to address hunger and other social determinants of health. ProMedica is helping to frame hunger as a health issue, rather than an issue based solely on poverty. ProMedica sees the health impacts of poor nutrition and hunger on our patients and families every day. The research on food insecurity and its effects are alarming: Adults living in food insecure homes face dietary shortfalls and irregular eating patterns, which can contribute to obesity, chronic diseases, and behavioral health conditions. Among seniors, poor nutrition increases disability, decreases resistance to infection, and extends hospital stays. Food insecure children suffer from more ear infections, colds, stomach aches, iron deficiency, and negative effects on cognitive and physical development. Food insecure pregnant women are more likely to deliver underweight babies. To continue improving the clinical applications of ProMedica s Come to the Table, Hunger as a Health Issue program, ProMedica has developed a Food Pharmacy modeled after the successful, decade-long program at Boston Medical Center s (BMC) Grow Clinic. In the fall of 2014, three members of ProMedica s Advocacy Department visited BMC to learn more about what makes their program successful. After several months of planning and preparation, the first ProMedica Food Pharmacy was opened in April 2015 in Toledo, Ohio. The idea of the Food Pharmacy is simple: food is medicine. As such, a healthcare professional writes a referral to the food pharmacy for patients that are identified as food insecure. These patients are then able to visit the pharmacy to pick up a supplemental supply of healthy food for their family. The food pharmacy takes patient diagnoses into account when fulfilling the order, ensuring that all items provided to the patient are in line with their medical needs. The pharmacy primarily offers healthy choices that promote healthy eating and balance at meals. Within each food group, patients are able to choose their food selection, such as the type of vegetables or the type of grains that they would prefer. Each time the patient comes to the food pharmacy, a note is placed in their electronic medical record. By connecting the food package with the patient record, we can better track and report on the progress of each patient and develop additional interventions as needed over time. 2 P a g e

In addition to receiving healthy food, patients are offered the opportunity to meet with a registered dietitian free of charge to discuss their dietary needs. Patients are also provided with nutrition information, healthy recipes, and a community resource guide. The following sections of this guide detail the steps to developing the ProMedica Food Pharmacy and information about daily operation so that partners across the country can develop similar programs. FOOD PHARMACY PLANNING Prior to choosing the ideal location for the Food Pharmacy, food insecurity data was collected for three months from three primary care clinics in the Toledo area. This helped to determine the best location for the Food Pharmacy as well as to estimate the need within the community. The first ProMedica Food Pharmacy is located in a three-story medical office building that primarily serves the low-income community. The primary care practice that provides the most patient referrals to the Food Pharmacy is conveniently located across the hall in the same building, which allows many of our patients to fill their food referrals directly after seeing their doctor. Establishing the Food Pharmacy Location The food pharmacy space is only about 250 square feet. Although more space would be helpful, we are still able to stock food for approximately 100 families at a time. See the Food Pharmacy Layout in the Supplemental Materials section for the layout of our first Food Pharmacy. The main materials needed to establish the Food Pharmacy include heavy-duty metal shelving for food stock, a refrigerator and freezer to store perishable food items, a front window for communicating with patients, a front desk with a computer, as well as a filing cabinet for storing patient data and other resources. In addition, a small counseling space, including a round table and chairs, is separated from the rest of the room by a small wall partition. The second Food Pharmacy, which is planned to open in early 2016, will include a similar setup, but will also have a separate storage space to allow for stocking larger amounts of products for our patients. The Food Pharmacy is designed as a choice pantry, and foods are arranged by food group. A choice pantry offers patients an atmosphere similar to a grocery store where they are able to choose which foods their family would prefer. Food Pharmacy staff instructs patients as to how many choices they have from each food group, and the staff also guides patients to healthy choices based on their health conditions. This choice pantry setup also allows staff the opportunity to build a relationship with patients. An Ideal Food Pharmacy Stock List is included in the Supplemental Materials section for reference. Nutrition Cards Prior to opening the Food Pharmacy, a set of nutrition cards were developed by a ProMedica dietitian that provides general nutrition recommendations based on common disease states. The back side of each nutrition card also includes a table indicating how many choices each patient receives per food group based on their household size. An Example Nutrition Card is also included in the Supplemental Materials section. The number of choices provided by family size was determined based on MyPlate 3 P a g e

recommendations for an average person who needs 2,000 calories per day, and was adjusted to provide approximately 2-3 days worth of food for the entire household. The set of nutrition cards help Food Pharmacy volunteers and staff guide patients to appropriate foods based on any medical conditions or food preferences they may have. PATIENT REFERRAL PROCESS Working with Primary Care Practices Patients must be referred from their doctor s office in order to receive food from the Food Pharmacy. Patients are referred to the Food Pharmacy based on the food security screening process described below. At ProMedica, we have decided to keep the Food Pharmacy referral process within the primary care offices to prevent duplicate referrals. Since opening the first Food Pharmacy in April of 2015, we have been adding additional practices to the screening and referral process each month, with a goal of reaching all ProMedica primary care practices in the Toledo region. Each practice participates in a food security screening and Food Pharmacy training before providing referrals to the Food Pharmacy. Collaborating with the physician office manager, a ProMedica food insecurity physician champion joins the training meeting with staff from Advocacy to provide support for the initiative and to emphasize the importance of addressing hunger as a health issue. Designating a physician champion to help support the initiative is a key step for success. During the training, the process of how to ask the screening questions and how to provide food pharmacy referrals to patients is shared. Printed training materials are provided to all practices that detail how to screen and refer in the electronic medical record. The practice is also given Food Pharmacy signage to post in the office waiting room as well as in the patient rooms (see example provided in Supplemental Materials section). The detailed screening and referral process used at ProMedica is described below. Food Security Screening Questions Drs. Erin Hager and Anna Quigg and the Children s HealthWatch team validated the Hunger Vital Sign, a 2-question screening tool, suitable for clinical or community outreach use, that identifies families children as being at risk for food insecurity if they answer that either or both of the following two statements is often true or sometimes true (vs. never true ): We worried whether our food would run out before we got money to buy more. Was that often, sometimes, or never true in the last 12 months? The food that we bought just didn t last and we didn t have money to get more. Was that often, sometimes, or never true in the last 12 months? These questions are from the U.S. Household Food Security Survey Module, which is an 18-item survey created by the USDA. The 2-item screening tool has been added into the electronic medical record system that ProMedica uses so that the questions pop up for each patient visit. Primary care offices are encouraged to screen all patients as often as once per month. Below is a summary of the full Patient Referral process: 4 P a g e

1 Clinician asks food security screening questions in the clinic. This may be the physician, nurse, or medical assistant asking the questions. 2 3 4 Patient flagged as food insecure if answer sometimes or often true to either question. Clinician provides food insecure patients with brief introduction to the food pharmacy and offers a referral. Patient can accept or decline referral. If patient accepts, clinician fills out referral in electronic medical record and provides a printed referral form to the patient. (*On days that the food pharmacy is closed, physicians will have a few pre-packed food bags in their office to distribute to patients in immediate need.) 5 Patient takes printed referral form with them to the food pharmacy. Pre-packed Food Bags in Physician Practices A few emergency food bags are placed in each of the physician offices. The bags are filled with shelfstable items that are generally low sodium, low sugar, and low fat. These are re-stocked as necessary. These bags are intended for patients who are in immediate need of food on days that the food pharmacy is not open. Clinicians have the option of providing food insecure patients with these bags, which also include the ProMedica Food Resource Guide. The Resource Guide has information about other food pantries that can provide the patient with food. An intake form is also attached to the bag for the patient to fill out before taking the bag. Intake forms are collected in the office and picked up by food pharmacy staff whenever new bags are dropped off. FOOD PHARMACY DAILY OPERATION Patient Intake Process 1. Patient arrives at the front window. Greet the patient. a. When a patient first visits the pharmacy, they may be anxious about receiving help; therefore, it is very important that staff greets and assists every patient in a polite and friendly manner. b. First ask if they have their printed referral form. All patients must have a referral from their physician on their first visit. c. Example greeting: Hi, welcome to the food pharmacy. My name is Do you have a referral form from your physician? d. If a patient does not have a referral form, ask if they have been referred to the Food Pharmacy from their doctor or if they have received food from us before. 5 P a g e

i. If they are coming back to refill their original referral, proceed to step #4 ii. If they have been referred but do not have a printed referral paper, ask for the patient s name and date of birth, and look up their referral in Electronic Medical Chart (located in the Orders section). iii. If they have not been referred by their doctor, inform them that the Food Pharmacy is a program to help provide access to healthy foods for families in need. They must first talk with their doctor and receive a referral before visiting the pharmacy. 1. Ask the patient if they see a doctor at any one of the clinics that is associated with the Food Pharmacy. a. If yes, let the patient know that they can talk with their doctor and ask for a referral for the Food Pharmacy. b. If no, let the patient know that the Food Pharmacy is currently only taking referred patients. Ask the patient if they are currently in need of food for themselves and/or their family, and if so, let the patient know that you will provide them with a one-time bag of food. Continue with the regular intake process 2. Verify patient s name and date of birth (DOB) 3. Introduce new patients to Food Pharmacy. a. Patients will receive approximately 2-3 days worth of supplemental food for themselves and their family. b. Patients are able to return to the Food Pharmacy once per month to refill their food referral for a total of 6 months. After 6 months, the patient must visit their physician for a new food pharmacy referral if they are still in need. c. Hours of Operation: i. Let the patient know the set days and hours of Food Pharmacy. ii. Patient can call the Food Pharmacy to make an appointment for food or counseling with the Dietitian. 4. Provide patient with the Patient Intake Form. a. For new patients, provide with a new form for them to fill out. i. If the patient cannot read and/or write, please help the patient to fill out the form. b. For patients who have been to the pharmacy before, find their form in the records (sorted alphabetically). i. Ask for patient s date of birth to confirm that you have the correct patient. ii. Check the original referral to make sure that the patient is still eligible to come to the food pharmacy (at least one month from their last visit and no more than 6 months from their last referral). 1. If the referral is over 6 months old, continue to provide patient with food for this visit as usual, and ask the patient to please see their physician for a new referral before coming back again. 2. Mark in the patient s note that their referral is outdated. 6 P a g e

3. If the same individual tries to come back a second time without getting a new referral from their physician, ask the patient to please see their physician for a new referral. (no food is provided at this time) 5. Complete patient order in Electronic Medical Chart. 6. The intake form is returned to the front window/desk and reviewed. a. Once the client has filled out the form (or you retrieve it from the records), go through the answers so that you can verify that they are filled out correctly. i. It is important that we obtain the # of people in their household, so that we can provide them with the appropriate amount of food (based on the food cards). We also must report this data to the food banks we work with. ii. If the patient does not have a cooking stove, oven, refrigerator, or freezer, try to guide them to nutritionally balanced foods that do not require cooking or refrigeration. iii. If the patient has food allergies or follows a special diet, this information will help guide them to options that will work best for their health needs. iv. If the patient is not enrolled in SNAP, WIC, or the school meal services, and they may be eligible, provide them with information as necessary. Background information is available in the Food Pharmacy binder under Food Resources. b. Make sure to also note any diet recommendations given by the patient s physician. 7. Patient is asked to schedule a nutrition counseling appointment a. Ask the patient about their further interests. Even if they did not check any of the boxes on the intake form, ask if they would be interested in talking with a dietitian and/or receiving more information about any health conditions or general healthy eating and cooking. i. If they would like to meet with a dietitian, schedule them an appointment on the designated schedule. Include name, DOB, and phone number. 8. Continue to provide patient with a food bag, as described below. Providing Patients with Food 1. Review health status and food preferences. a. Describe the patient s diet recommendations, as checked on both their referral form and indicated on the patient intake form. i. Choose the appropriate Nutrition Card(s) related to special diet needs. These cards will guide you in helping the patient make healthy and appropriate food choices. 1. The following cards are available: a. Diabetes or Low-Sugar Diet b. Hypertension, Low-Sodium Diet, Low Salt Diet c. Atherosclerosis/hyperlipidemia, Low-fat or Heart-Healthy Diet d. Kidney Disease e. Pregnancy or Lactation (breastfeeding) f. Underweight, High-Calorie and High-Fat Diet 7 P a g e

g. Food-Medication Interactions (Warfarin/Coumadin, MAOIs) h. Vitamin/Mineral Deficiencies (Vit B12, Vit D, Iron) i. Food Allergies and Intolerances (Peanut/tree nut, Egg, Wheat, Milk, Fish/Shellfish, Soy, Celiac or Gluten Intolerance, Lactose Intolerance) j. Vegetarian Diet 2. If the patient has a condition not included on any of the cards, ask the diet tech or dietitian for help providing appropriate food 2. Provide patients with food. a. The number of items provided is based on household size. The back of each Nutrition Card includes the amount of choices allowed by household size. b. Allow patient to enter the Food Pharmacy beside the cart. Walk through each section of the pantry asking the patient what items they would like in their bag while reading off their options. a. Allow the patient to select the products they want; however, you should be available to help provide suggestions and assistance, making sure they have selected from each of the food groups and encouraging patients to follow diet recommendations. b. Including an element of choice in the Food Pharmacy upholds the dignity of patients. c. Remember to keep in mind the following while helping the patient make choices: i. Family Size ii. Special diets or allergies listed on both referral form and intake form iii. Cooking resources (stove, microwave, oven, can opener, etc ) iv. Patient preferences 3. Refer the patient to other Recipes and Educational Resources a. There will be healthy recipes and other helpful resources available to the clients to take. Even if the client does not think they will use any, remind them it is FREE. b. Look back at the patient intake form to make sure you provide everything that they were interested in receiving. c. Provide patient with a food insecurity resource guide for the area they live in (for first time pharmacy users or those who would like another copy). d. Provide patient with a Reminder Card and ask patients to bring back reusable bags at next visit. e. If the patient is shopping for multiple people in the household or has mobility issues (e.g. senior citizens and handicap), please help the client with their boxes/bags, as canned goods can be heavy. Documenting Food Pharmacy Visits 1. Document patient visit to the food pharmacy a. On the back of patient intake form, note the date of visit as well as the services provided i. Once you have confirmed with the patient that the information on their form is up to date, place a check mark in the Verified patient info column. 8 P a g e

ii. Include the type of food provided (if on a special diet) as well as any handouts, recipes, and nutrition counseling provided iii. Initial and date the column where visit is noted iv. Enter information about visit into Excel sheet Visit Log (this can be done at a later time when there are no current patients to help) v. The information that is tracked on Excel is last name, the clinic, date of visit, total household size (seniors 60+,adukts 18-59, children 0-17), recipes given, handouts given, counseling schedule and completed, new patient, pre-packed bags, and time in and out. b. Provide note of visit in patient s medical record (this will only be completed by certain staff members) i. If not done previously, complete patient order in Electronic Medical Chart ii. Provide any tasks or notes for the physician if necessary Nutrition Counseling with a Dietitian 1. All patients are asked if they would like to schedule a nutrition counseling appointment a. If they would like to meet with a dietitian/diet tech, schedule them an appointment on the designated schedule. Include name, DOB, and phone number. b. Reminder calls will be made for patients 1 2 days before their appointment, or the week before if scheduled on a Tuesday. c. All nutrition counseling appointments will be logged in the patient s Food Pharmacy record as well as the patient s electronic medical record. Open and Close Procedures What to do when opening the Food Pharmacy: Log the temperature for the refrigerator and freezer. Make sure shelves are adequately stocked and MyPlate signs are in place. Make any Nutrition Appointment reminder calls, as necessary Unlock the front window What to do when closing the Food Pharmacy: Make sure all EHR orders have been completed. Enter all patient data from the day into Food Pharmacy Excel sheet. File away all entered patient intake forms alphabetically. Lock the front window. Weekly: Check in with clinics to re-stock pre-packed bags and pick up intake forms Monthly: 9 P a g e

Run Food Pharmacy Statistics (# of patient screened for food insecurity, # of patients referred to the food pharmacy, # of patient visits, patient demographics)and report to Food Banks as well as Physician Offices FOOD INVENTORY Building Relationship with Local Food Banks The Food Pharmacy works with a non-profit food bank serving 8 counties throughout Northwest Ohio. The Food Pharmacy sources a majority of its food from the Food Bank. The food bank offers a variety of foods at no cost to member agencies. The Food Pharmacy also purchases some additional food from other food banks in the area for a small fee. A few additional items are also purchased as needed to stock the Food Pharmacy shelves with healthy items. Food Ordering Process 1. Complete inventory of food pharmacy on Thursday after closing 2. Determine food ordering needs based on Thursday s inventory 3. Call food bank the prior week before delivery. 4. Send order to food banks that items are paid for (for any extra purchases) Friday morning 5. The food bank delivers food to food pharmacy on Tuesday morning, where staff is there to help unload 6. The food banks provide food pharmacy with an invoice for food delivered 7. Food pharmacy staff confirms food order is correct upon delivery and unpacks food onto shelving 8. All new food is marked with an expiration date 9. Food costs and amount of food received is logged into inventory records Quick Notes on Inventory: The Food Pharmacy operates under the FIFO method (First-In, First-Out). FIFO is an inventory management control system, designed to distribute the oldest food first, to minimize waste. FIFO allows food to be moved in a continuous, orderly manner while also serving as a food safety measure. Food is to be stored with the earliest expiration date in front, which gets used first. As foods are unpacked after deliver, mark the top of the item with: o EXP (for expiration date) and the date on the package o If there is no exp. date on the product, mark RE (for received date) and the date A physical inventory of all items in the food pharmacy is taken on a weekly basis. This helps to determine the food ordering needs for the following week. Food Safety Practices Proper Pantry Storage Keep all non-food items separate from food. 10 P a g e

Maintain thermometers in all freezer units, refrigeration units, and dry storage areas, with temperature logs for each area. Allow 18-inch clearance from the ceiling for all items in the pantry. No personal food should be stored with food pharmacy food. All corrugated boxes must be removed from the food pharmacy as soon as possible o Place in cardboard recycle bin, or if this is full, in the outside dumpster Dry food products must be stored: At 50-70 degrees F With ideal humidity levels between 50% and 60% Away from direct sunlight A minimum of 6 off the floor Away from walls In a clean and secure storage area that is inspected regularly Liquid items on the lowest shelves, lighter items on the top shelves Refrigerated food products must be: Refrigerated at temperatures of 35-40 degrees F Stored to allow for proper air circulation In a refrigerator that is clean and inspected on a regular basis All fruits/vegetables stored above fish or meat items Frozen food products must be: Stored in a freezer at a temperature of 0 degrees F or below Stored to allow for proper air circulation Stored in a freezer unit that is clean, secure and regularly inspected Storage Area Maintenance Spoilage Maintain a good pest control system o Pest controls such as traps and tape/glue boards are recommended. Place along walls and near doorways, moving the traps monthly. o Have a qualified person on staff or a contract with a licensed firm to handle pest control management. Establish a cleaning schedule o Floors, shelving units, and refrigerator/freezer are cleaned regularly o The Food Pharmacy room is cleaned on a weekly basis by CHS cleaning staff To assure the quality and freshness of USDA food products, the inventory practice of first in first out (FIFO) must be followed. Food must be stored so cases with the oldest pack dates are used first. If the product has visible mold, off odors, the can is bulging, the packaging is contaminated or leaking, this spoilage could be a sign that dangerous microorganisms may also be present, so with such products, use the If in doubt, throw it out rule. ProMedica s Food Pharmacy does not accept opened or damaged food and beverage products. The product date can help determine product quality and estimate product safety: 11 P a g e

Sell by or pull date Tells a store the last date a product should be sold. This date allows for a reasonable length of time to use at home in an unfrozen state. o *can be good for up to 1 week after date Best if used by/before date Often used on canned foods, frozen foods, cereals, and snack foods, this coding indicates the approx. date after which the product will no longer be at the highest quality level. o *usually still safe to eat after date Expiration OR Use by date last day an item should be used before it is likely to lose flavor or quality. Frequently appears on refrigerated dough products, yeast and eggs. o *can be good for up to 1 week after date o As long as you purchase eggs before the expiration date and keep them refrigerated, they should be good to use for 3 to 5 weeks after purchase Once a perishable product is frozen, it doesn't matter if the date expires because foods kept frozen continuously are safe indefinitely. (Source: Food safety information was adapted from the Ohio Department of Job and Family Services, Office of Family Assistance, Food Programs Manual for the Commodity Supplemental Food Program and The Emergency Food Assistance Program, revised February 2012) STAFFING AND VOLUNTEERS ProMedica s first food pharmacy is currently open three days a week from 11am-4pm. A part-time Diet Tech manages the daily operation of the Food Pharmacy during open hours. A dietitian is on site to provide nutrition counseling as scheduled and also assist with the daily operation. In addition, ProMedica s Associate Vice President of Advocacy manages the overall operation of the Food Pharmacy. In order to successfully fulfill our mission, we need caring volunteers to help carry out the food pharmacy operations. Volunteers are actively involved in the functioning of the food pharmacy, which includes, but is not limited to: Assist in maintaining organization of food pharmacy for optimal work flow and efficiency, including tracking inventory, stocking shelves, and general clean-up. Maintain temperature logs on cooler, freezer and other equipment in the food pharmacy and ensure safe food handling procedures are in place and followed at all times. Assist the pharmacy staff with the patient intake process Help put together patient food packages based on patient health and food preferences. Actively engage with food pharmacy patients, including suggesting healthy meals, referring the client to helpful nutrition education materials, boxing & bagging food, and signing up patients for nutrition counseling appointments Document patient visits per food pharmacy protocol Maintain patient confidentiality at all times Treat all patients in a positive and professional manner Perform all other duties as assigned. 12 P a g e

Volunteers are currently recruited through the ProMedica Toledo Hospital Volunteer Services office. In addition, ProMedica has formed partnerships with two local dietetic programs, and the Food Pharmacy operates as a rotation site for local dietetic students to learn about food insecurity and health. RESPONSE FROM PROMEDICA PRACTICES AND PATIENTS The overall response from the ProMedica practices has been overwhelmingly positive. They have given many referrals out to the patients and feel that the Food Pharmacy services have helped their patients. The patients are grateful for the food pharmacy referral and appreciate everything the Food Pharmacy has done for them. Some patients have stated they never heard of a program like this and that it makes them feel good to know that their physician cares enough to send some where to get food. The success of the current program has led to the development of a second metro-toledo location slated to open in January 2016. Further interventions are being developed for other parts of ProMedica s 27-county service area. DATA AND REPORTING Currently, ProMedica has developed reports that record the number of patients both new and returning as well as the services provided to each. Additionally, ProMedica is tracking the percentage of patients who are asked the screening questions in their provider office so that additional follow up and training of physician office staff can be scheduled, if needed. Further research on the efficacy and health outcomes of patients participating in the program are under development. 13 P a g e

SUPPLEMENTAL MATERIALS ProMedica Food Pharmacy Layout Freezer Fridge Counseling Area Shelf Shelf Cart Shelf Shelf Filing Cabinet Shelf Front Window with Desk 14 P a g e

Ideal Food Pharmacy Stock List Plan to offer 2+ items to choose from each group daily Fruits Canned fruits or shelf-stable fruit cups (canned in juice or light syrup) Dried fruit (no added sugar) Fresh fruit Frozen fruit Dairy Boxed shelf-stable milk (1% or skim) Dry milk powder Lactose-free milk (soy milk) Low-fat cheese Low-fat yogurt Refrigerated milk Vegetables Grains Canned vegetables ( low sodium or no salt added ) Diced tomatoes, tomato sauce, spaghetti sauce (low-sodium) Fresh vegetables Frozen vegetables Low-sugar, high-fiber cereal Oatmeal/oats Brown rice Whole grain pasta White pasta, rice (for low-fiber diets) Combination/Other Foods Soups (low-sodium) Canned chilis and stews (low-sodium) Broths (low-sodium) Whole grain snack crackers Herbs and Spices Low sodium condiments Non-stick cooking spray Oil (canola, olive, or vegetable) **Pull-tab cans preferred if possible Protein Canned beans ( low sodium preferred) Dried beans and peas Canned chicken, tuna, salmon (canned in water instead of oil) Peanut butter or nuts Eggs Lean frozen or refrigerated meat (lean ground beef, chicken breasts) 15 P a g e

Example Nutrition Card (front) (back) 16 P a g e

Physician Office Signage Example 17 P a g e

Food Pharmacy Intake Form 18 P a g e

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Food Pharmacy Reminder Card 20 P a g e