System-Level, Decision-Making, and Program Operations During the Implementation of the Medicaid Direct Certificate...

Area of Science:

• Public Health Nutrition
• Health Policy Analysis
• Systems Science in Education

Background:

• The Maryland Department of Education piloted the USDA's Direct Certification with Medicaid (DC-M) program during the 2022-2023 school year.
• DC-M enables automatic qualification for Free or Reduced-Price Meals (FARM) for Medicaid-enrolled students and integrates Medicaid data into Community Eligibility Provision (CEP) calculations.
• CEP allows high-poverty schools to offer free meals to all students, aiming to improve food security and participation in school meal programs.

Purpose of the Study:

• To assess the impact of the Direct Certification with Medicaid (DC-M) program on Community Eligibility Provision (CEP) participation.
• To analyze these impacts from a systems perspective, identifying interconnected factors influencing program outcomes.
• To inform strategies for enhancing Free or Reduced-Price Meal (FARM) eligibility and supporting CEP initiatives in schools.

Main Methods:

• A qualitative research approach was employed, utilizing semi-structured, in-depth interviews with stakeholders in school district food and nutrition services.
• Inductive qualitative coding was performed on interview transcripts to identify key themes and relationships.
• Causal loop diagramming, facilitated by Kumu software, was used to visualize the systems dynamics and feedback loops identified.

Main Results:

• Twelve interviews yielded 36 interconnected factors, organized into five reinforcing and one balancing feedback loop.
• Three primary themes emerged: the influence of the school district landscape on student enrollment, the impact of federal and state policies on school meal funding, and the effect of school meal policies on meal operations.
• Findings suggest that schools can enhance meal participation through the implementation of DC-M.

Conclusions:

• The systems approach effectively identified barriers and facilitators related to DC-M implementation and its impact on school meal programs.
• The study provides a framework for understanding the complex interplay of factors affecting FARM eligibility and CEP participation.
• Results can inform policy development and practice to optimize school nutrition programs and improve student access to meals.