PROJECT SUMMARY/ABSTRACT Social Determinants of Health (SDoH), or the environment and conditions in which one lives, can greatly impact one’s health and quality of life. In the White House conference on Hunger, Nutrition and Health, the president stressed the importance of good nutrition and healthy eating on child academic and health outcomes.1 The Council outlined a national strategy that included the need to improve food access and affordability, integrate nutrition programs and education in healthcare, provide support for these activities through Medicaid and Medicare, and increase nutrition and food security research.2 Thus, there is an urgent need to develop and test effective and acceptable workflows that connect families experiencing food insecurity with healthy nutrition support programs. In this proposal, we will conduct a pilot type 2 hybrid effectiveness- implementation trial of the I-FRESH (Implementing Food Referrals for Equity and Sustained Health) program using a Roll-Out Implementation Optimization (ROIO) design among families with children with nutrition-related illnesses who receive Medicaid or Supplemental Nutrition Assistance Program (SNAP) benefits. I-FRESH, our food security nutrition support program that was developed with several community stakeholders, involves 4 main components: screening and identification of families experiencing food insecurity (FI); social worker/care navigator-led discussions with families to determine need and readiness to receive support; referrals and assistance to engage with these programs; and follow-up assessments to determine fit, track utilization, and determine need for additional referrals. This program will be tested at Rady Children’s Hospital San Diego in the Type 1 and Type 2 Diabetes, Metabolic Dysfunction-Associated Steatotic Liver Disease, and general gastroenterology clinics as these conditions are heavily affected by nutritional intake. These settings are conducive to testing the initial implementation and effectiveness of the program because they already have dietitian and social work support and built the FI screener in the electronic health record. To aid in this work, we have obtained funding from USDA/NIFA to provide nutrition incentives or a fruit and vegetable prescription (FVRx) program to families receiving SNAP benefits. We will apply the PRISM4, 5 implementation determinant framework and RE-AIM6, 7 implementation outcome framework to guide implementation processes and evaluation, and engage stakeholders. The specific aims of this proposal are: 1) To engage our Community, Clinical, Administrative, and Research Advisory Board (CARAB) to refine and optimize the program before and after each roll-out in 4 clinics; 2) To assess implementation outcomes; and 3) To examine preliminary impact and effectiveness outcomes on family-level food insecurity and pediatric nutrition-related health outcomes. This information will be important as health system leaders, insurance provider...