New York State Food as Medicine (FAM) Program Survey

New York State Food as Medicine (FAM) Program Survey

Time to complete: approximately 5-10 minutes
Survey Instructions

The goal of this survey is to gather information about Food as Medicine Programs in NYS to better understand the landscape of FAM in NYS, assess program needs, and build a directory of NYS FAM programs.

This survey is intended to be filled out for the following programs:
- Clinically Appropriate Groceries
- Clinically Appropriate Meals
- Food Farmacy
- Medically Tailored Groceries
- Medically Tailored Meals
- Pantry Stocking (Healthy Pantry)
- Produce Prescriptions
Please complete one form per program at your organization.
Please confirm that your FAM program provides services in New York State*

Yes, the program provides services in NYS.
Organization Information

Basic Information about the Organization operating the FAM Program
Are you a member of the NYS Food as Medicine Coalition?*

YesNoNo, but would like to learn moreNot sure, and would like to learn more
Organization:*
Contact Name:*
Email:*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Address - County*
County Name Only - e.g. Albany
FAM Program Information

Information about your FAM Program. Please complete this form for each FAM Program your Organization operates.
Program Name: *
Type of FAM Program (Defunct as of May 2024)*

Medically Tailored GroceriesMedically Tailored MealsProduce PrescriptionsFood FarmacyPantry Stocking (Healthy Pantry)Other
Type of FAM Program (Defunct As Of 2025)*

Medically Tailored GroceriesMedically Tailored MealsProduce PrescriptionsFood FarmacyPantry Stocking (Healthy Pantry)Other
Type of FAM Program*

Clinically Appropriate GroceriesClinically Appropriate MealsFood FarmacyMedically Tailored GroceriesMedically Tailored MealsPantry Stocking (Healthy Pantry)Produce Prescriptions
*Program Types as listed in the NYS 1115 Medicaid Waiver Operations Manual. If your program does not fall into one of these categories, please contact us.
Please select the NYS Counties in which your program provides services (select all that apply):

AlbanyAlleganyBronxBroomeCattaraugusCayugaChautauquaChemungChenangoClintonColumbiaCortlandDelawareDutchessErieEssexFranklinFultonGeneseeGreeneHamiltonHerkimerJeffersonKingsLewisLivingstonMadisonMonroeMontgomeryNassauNew YorkNiagaraOneidaOnondagaOntarioOrangeOrleansOswegoOtsegoPutnamQueensRensselaerRichmondRocklandSaratogaSchenectadySchoharieSchuylerSenecaSt. LawrenceSteubenSuffolkSullivanTiogaTompkinsUlsterWarrenWashingtonWayneWestchesterWyomingYates
Does your program operate at more than 1 site?*

YesNo
If yes, please list the addresses for each program site:*
Service Area (city/county/target population): (Defunct April 2025)*
Hours of Operation (days of the week and hours):*
What is your primary method for accepting new referrals?*

Phone CallWebsiteEmailFax
Phone Number for Referrals:*
Please enter a valid phone number.Format: (000) 000-0000.
Website URL for Referrals:*
Email Address for Referrals:*
example@example.com
Fax Number for Referrals:*
Please enter a valid phone number.Format: (000) 000-0000.
How do you get your food to your participants? (Defunct April 2025)*
How do you get your food or vouchers to your participants?

Home DeliveryIn-Person Pick UpBoth
Do program participants pay a cost or fee for services?*

YesNo
If yes, what payment method(s) do you accept?

CashCreditEBT
Program website or social media platform (URL):*
Funding Source(s):*
Do you have barriers to using NY Produced Food? If so, what are the barriers?*
Do you receive Nourish NY through your food bank or do you have a direct contract?*
Do you have a health professional on staff (RDN, nurse, etc.): Please list how many and what kind.*
How do you get your food?*
What are your Clinical Care Elements/Outcome Measures?*
Other Program Measures/Metrics:*
Educational Resources used by organization staff:*
What would make your program better/more sustainable?*
What are your research needs for you to advance your Food as Medicine program? Select all that apply.

FAM Return on InvestmentFAM Intervention Dose (Amount of Food)FAM Intervention Frequency of ServiceFAM Intervention Program DurationServing the Individual vs. Serving the Whole HouseholdNutrition Education Methods (e.g., MNT, Group Classes, etc.)Program Effectiveness Evaluation MethodsBiometric Outcomes: A1CBiometric Outcomes: Blood PressureBiometric Outcomes: LDLBiometric Outcomes: Weight/BMIBiometric Outcomes: OtherProgram Model: Medically Tailored MealsProgram Model: Medically Tailored GroceriesProgram Model: Medically Supportive Groceries (Pantry Stocking)Program Model: Produce Prescription ProgramsProgram Model: Nutritious Food ReferralsProgram Model: Food FarmacyProgram Model: Nutrition Incentive ProgramsProgram Model: OtherPopulation Category: Medicaid High UtilizerPopulation Category: Individuals in Health HomesPopulation Category: Pregnant or Postpartum PersonsPopulation Category: Post-Release Criminal Justice InvolvedPopulation Category: Juvenile justice involved, foster care youthPopulation Category: Children under the age of 18 with one or more chronic conditionPopulation Category: Children under the age of 6Population Category: Substance Use DisorderPopulation Category: Intellectual or Developmental DisabilityPopulation Category: Serious Mental IllnessPopulation Category: OtherDiagnosis: ObesityDiagnosis: Cardiovascular/Heart DiseaseDiagnosis: DiabetesDiagnosis: HypertensionDiagnosis: Kidney DiseaseDiagnosis: CancerDiagnosis: HIV/AIDSDiagnosis: Inflammatory Bowel DiseaseDiagnosis: Mental and Behavioral HealthDiagnosis: Rheumatoid ArthritisOther
If "Other" for any of the research categories above, please specify:
Would you like your program information to be added to a publicly accessible FAM Provider Map? (see details below)*

YesNoNeed more information
SAMPLE PROGRAM
- Organization Name
- Program Type
- Counties Served
- Program Site Address
- Hours of Operation
- Phone Number
- Delivery Options (Home Delivery/Pick Up/Both)
Section 2: Produce Prescription (PRx) Programs

Please fill out the following additional questions if you run a produce prescription (PRx) program. If you do not run a produce prescription program, you can skip this section and submit your responses.
How many people does your produce prescription program serve annually?

1-1011-5051-99100 or more
Which geographic areas does your produce prescription program serve? Please select all that apply.

UrbanSuburbanRuralOther
Which primary region(s) does your produce prescription program serve? Please select all that apply.

Western NYFinger LakesSouthern TierCentral NYMohawk ValleyCapital RegionMid-HudsonNorth CountryNew York CityLong IslandOther
What is the length of your PRx program?

SeasonalYear-RoundMulti-YearOther
What are the eligibility requirements for patients to enroll in your PRx program? Please select all that apply.

Low-income statusAt risk for and/or diagnosis of diet-related chronic diseases (e.g., diabetes, hypertension, cardiovascular disease)Medicaid/WIC/SNAP recipientPregnant or parentingOther
How is your PRx program funded? Please select all that apply.

Private Funding: Foundation, Trust, Enterprise or Large-scale Grant SupportFederal Nutrition Incentive Funding (GusNIP/FINI)State, Municipal, and other Governmental FundingPrivate Healthcare FundingCrowdfunding / DonationsSelf-Supported / Organizational BudgetOther
Who are your main program partners and what are their respective roles (healthcare provider(s), farmers/retailers/other produce sources, community outreach organizations, etc.)?
What is your program model? (How do patients enroll? What is the frequency and amount of the voucher/incentive? Do participants pick up produce at the healthcare site or other farmers market/retailer sites in the community?)
What are the gaps or barriers to operating/sustaining your PRx program (What is difficult to pay for? What is needed to make this program more sustainable?) Please be as specific as possible.
What policy initiatives could help improve or expand produce prescription programs across NYS? Please elaborate.
Should be Empty:

New York State Food as Medicine (FAM) Program Survey

Organization Information

FAM Program Information

Section 2: Produce Prescription (PRx) Programs