Chapter IV. Nutrition Services

conducted on site in conjunction with staff meetings, as often as monthly. For example, Grady
Hospital in Atlanta, GA, offers in-service training on at least a monthly basis for WIC and other
maternal and infant care staff. In addition to health-related in-service training, the sessions
include Occupational Safety and Health Administration (OSHA) regulations, self-esteem, stress
management, and computer training. There are also monthly staff meetings at which time
breastfeeding education updates are shared. In Montgomery County, MD, monthly in-service
education programs for staff are coordinated within the Family Health Services Division,
particularly for topics that are relevant to several programs. Examples of such topics include
universal precautions, AIDS, and child nutrition. Paraprofessionals must master specific topics
and also attend monthly in-service training. Wilkes-Barre WIC also holds monthly in-service
training sessions. Once per year they have an overnight session. In addition to standard topics,
Wilkes-Barre, PA, WIC surveys the staff regarding which topics they want to cover. In
Delaware, paraprofessionals participate in biannual nutrition education training sessions, and they
received special training on using new nutrition education materials when these were developed.

Statewide training programs address changes in WIC regulations, nutrition education, new
program issues, and coordination with other programs. In Delaware, there are presentations
describing each public health program to the care team, which consists of WIC, child health, and
prenatal providers. Colocation and integration naturally teach staff about the other programs
offered. Periodically, speakers from other service programs are invited to county-wide meetings.
A WIC coordination staff meeting is held biannually. Each meeting focuses on a different aspect
of coordination. For example, a recent meeting addressed adolescent pregnancy. In Cleveland,
OH, there are numerous interagency and interdepartmental meetings, and speakers from other
local agencies are brought to WIC to speak about their programs and share information. New
York State provided training on substance abuse; Ohio has an annual symposium with
workshops and speakers; and New Jersey holds quarterly meetings with WIC and public health
nutrition providers. These meetings include in-service training and updates on current issues in
nutrition and in the WIC Program. There is a Maryland WIC directors’ meeting monthly, which
is attended by about 30 people from 13 counties. At these meetings, county WIC directors
discuss caseload counts, changes needed, what people are doing in their programs, nutrition
education materials, and a general update on WIC activities. The State of California held
meetings to train staff in a number of programs on the use of the Wellness Guide, a document
with information on various services available in California.

Continuing education is geared to professional staff and is available outside of the WIC agency.
In Portage-Columbiana, OH, the local director requires all staff to complete one continuing
education course each year on topics such as client relations and computerization. Three to four
sessions a year are required for dietitians to fulfill minimum requirements for registration and
licensure (RD and LD) in the State. Some sites noted that funding for attendance at such outside
courses or workshops is limited. In Cleveland, OH, each staff member is paid up to 3 days per
ye: for continuing education. Palm Beach County, FL, WIC provides for all of the education
classes needed for continuing educauor, .:edit (for RDs, LDs, and nurses).

Nutrition Services
V-18



Chapter V. Integration and Coordination with Other Programs

Availability of on-site social services at the case study sites showed a similar pattern, with
integration and colocation occurring much less frequently than with health services (see
definitions of integration and coordination at the beginning of this chapter). Nine of the 22 case
study sites were integrated with one non-health service; none were integrated with more than one.
In the sites visited, colocation with non-health services was most commonly found with family
counseling and substance abuse treatment, with each at about one-third of the sites.

Exhibit V-7

Availability and Coordination/integration with Community
and Social Services at Case Study Sites (N=22)

No Service Not
Service Integrated Colocated | Referrals | Interaction Available
Locally
EFNEP 1 3 9 6 3
Food Bank 1 2 14 4
Family Counseling 8 14 1
Domestic Violence 4 17 1
Substance Abuse 7 17
Treatment
Drug Testing 1 5 W
AFDC 1 2 20
Food Stamps 1 1 21
Transportation 2 16 5
Adult Ed/Job Training 1 3 16 4 2
Head Start 1 1 18 2
Child Care 1 3 12 2 1
Homeless/Shelter 1 3 16 2 2
Programs
Housing Assistance 4 15 4

Source: 22 case studies, WIC Dynamics, 1993.
Note: Numbers do not total 22 because of more than one applicable answer.

As with health care services, the location and the availability of services affect the integration
and coordination of WIC with social services. For example, the WIC Program in York, PA, is
sponsored by a community action agency and is located at a neighborhood center. The program

Tntegration and Coordination with Other Programs
V-11



Chapter V. Integration and Coordination with Other Programs

The following exhibit (V-5) summarizes the range of services and level of coordination at the
case study sites. The response columns are not mutually exclusive. For example, some local
agencies had several sites, some with health services colocated with WIC, and others with health
services available by referral. In some cases, services were integrated or colocated for a
particular target group, such as pregnant teens or high-risk pregnant women, but not for all WIC
participants. This is the case at the Grady Memorial Hospital WIC Program in Atlanta, GA,
which serves pregnant women, high-risk infants, and children. Infants who are not high risk are
certified by Grady WIC, but are then transferred to other WIC Programs in the city. Services
reported as "integrated" for the case study sites were routinely incorporated in the eligibility
determination, screening, appointment scheduling, or WIC service delivery process in some way.
For example, Montgomery County, MD, and Gainesville, GA, have integrated intake processes,
where a new client is screened and, if eligible, is enrolled in several public health programs,
Medicaid, and WIC at the same time. Exhibit V-5 shows that the service most often integrated
with WIC is related to breastfeeding promotion, found in over three-quarters of the sites. In
addition to breastfeeding promotion as part of nutrition education by WIC staff, WIC Programs
were integrated with peer counselor programs, support groups, breastfeeding hotlines, and
lactation consultants. These programs were sponsored by public health departments, private
organizations such as La Leche League, local hospitals, and Healthy Mothers/Healthy Babies
Coalitions.

Immunizations and health education were also frequently integrated with WIC. New York State
requires that all children participating in the WIC Program be screened for immunizations, and
WIC staff are responsible for checking that immunization records are current. Participants who
are not up to date on their immunizations must come in for voucher pick-up on a monthly basis.
Once they are up to date on their immunizations, they receive their vouchers on a bimonthly
basis. At the Medical and Health Research Association (MHRA) WIC Program in New York
City, where most WIC sites are located in Child Health Stations, it is not uncommon to see a
Nutritionist walking a participant to the immunization clinic. Delaware’s automated data
processing system enables the WIC nutritionist to check a participant’s immunization status and
generate referrals to the public health clinic for immunizations. In San Antonio, TX,
immunizations are available at 4 of 12 WIC clinics, and are provided on a walk-in basis to WIC
clients.

According to the Local Agency Survey data (Exhibit V-6), the most common health care services
available on site at principal' WIC clinics are breastfeeding support programs, family planning
services, and immunizations, followed by other health screening; Early Periodic Screening,
Diagnosis, and Treatment (EPSDT); and pediatric care. Those available on site in less than 40
percent of the clinics are: obstetrical/gynecological care, Medicaid screening, and dental care.
Health services most often colocated with WIC in the case study sites are well-baby/well-child
care and health education, each located at over two-thirds of the sites. Routine primary health

'"Principal” clinics are the largest clinics, up to 6, in the 1,777 local WIC agencies (see Chapter 3, p. HI-1, for
more detail on principal clinics in WIC Dynamics).

Thtegration and Coordination with Other Programs
V-7



Chapter V. Integration and Coordination with Other Programs

The case study findings indicate that coordination with private providers is considered critical by
WIC staff, not only for timely enrollment in WIC, but also for providing consistent nutrition
education messages to clients. Areas of greatest concern in this regard were attitudes toward
breastfeeding; understanding infant formula rebates and WIC’s limitations on formula brands; and
attitudes about infant feeding practices, such as use of iron-fortified formula and introduction of
solid foods. In some areas, such as Delaware WIC, physicians are prescribing birth control and
other medications that can impede breastfeeding without explaining these potential side effects
to mothers. Several sites, including Atlantic City and Montgomery County, noted that a
considerable amount of staff time was spent explaining the infant formula rebate program to
physicians, notifying them of changes in the WIC-approved brands, and explaining that a change
in brands for a patient on WIC required a physician’s written authorization. Staff at the Palm
Beach County WIC Program noted that private doctors’ standards for height and weight are often
different from WIC’s. Some WIC Programs, such as those in Delaware, Montgomery County,
and Salt Lake City, have found that participation on boards that include physicians, such as
breastfeeding advisory boards and community health planning coalitions, helps to explain WIC
to the medical community and establish ongoing communications.

Vill. Sharing of Staff and Resources

As discussed in Chapter III, sharing of certain types of staff and resources with other programs
is fairly common for WIC local agencies. Referring back to Exhibit III-8, only 23 percent of
agencies had space and utilities exclusively funded from their WIC budget. Space and utilities
were least likely to be exclusively funded by WIC, while educational materials, computer
equipment, and medical equipment were more likely to be funded exclusively by WIC. Case
study site visit data also support this finding. Exhibit V-8 summarizes site visit data on a number
of indicators of resource sharing. Shared facilities were common among case study sites, often
as part of colocation with other services. In most cases, WIC was not paying rent for the
facilities because they were provided by a government entity, such as the county or municipal
health department. Sharing of equipment occurred much less frequently. A typical example of
equipment sharing is the scales which are used by both WIC and public health staff.

Tntegration and Coordination with Other Programs
V-16



Chapter IV. Nutrition Services

Exhibit IV-9

Use of Nutrition Education Materials and Methods

Used in Used in Used in Used in
Materials Used in Individual Group Individual Group
Instruction Nutrition Nutrition Nutrition Nutrition
Education Education Education Education
Sessions Sessions Sessions Sessions
(% of (% of (# of case (# of case
agencies) agencies) study sites) study sites)
Verbal 100 77 21 14
Discussion/Counseling
Pamphlets 100 80 21 14
Food Models 84 67 7 4
Food Demonstrations 26 51 2
Tests 26 39 7 6
Audiotapes 24 23
Slides 14 35 14 19

Films/Videos 62 7

Flip Charts 58 61

Computer-Assisted 3° 2 0 0
Instruction

Other

Source: Based on estimates for 1,777 local agencies, Local Agency Survey, and 22 case studies, WIC Dynamics, 1993.

It is interesting to note that almost 80 percent of the case study site agencies reported using
audio-visual presentations on breastfeeding (not shown on table). This might reflect the
numerous educational videotapes that have been produced and marketed on this topic. Other
topics presented through audio-visual techniques by almost half of the agencies include
description of a good diet, importance of a good diet for fetal growth, and nutritious snacks.

One of the more interesting activities noted during the case study visits was the use of "nutrition
parties" in Portage-Columbiana, OH. This popular activity, which targets children, has attracted
up to 400 children at some parties. The nutrition parties involved the use of games and healthy
snacks as a way of teaching children (with some parental involvement) about good nutrition.
This agency also provides nutrition education to kindergarten and Head Start students. Using a
picnic basket, they teach children about the basic food groups.

Nutrition Services
W-12



Chapter VII. Current Operating Capacity and Perspectives on Accommodating
Future Growth

had a waiting list, many would-be participants who were not in that wait-listed category did not
apply for the program, thinking that they would not be able to get into it. A year after the
waiting list was no longer in use, potential participants were still under the impression that the
waiting list existed and were hesitant to apply for WIC benefits. This site and others expressed
concern over the nature of the growth process, hoping that problems could be avoided.

Planning Time: In order to properly and adequately address the practical concerns discussed
above, WIC agency staff felt that they would need advance planning time. This time would be
used not only to find adequate space or staff, if necessary, but also would be used to properly
reorganize their service delivery. Staff referred to the need to rethink the ways in which they
offer nutrition education (group or individual), voucher education (group or individual), the use
of audio-visual materials or handouts, the length of the time between voucher pickups, and the
ways in which they could be effective in their outreach efforts.

Increase in Regulations: WIC staff expressed concerns about whether increased funding for WIC
would be accompanied by increased regulation and regimentation of the program. Many sites
indicated that current regulations and reporting requirements (e.g., regarding waiting times,
voucher issuance, staffing, and nutrition education contacts) were burdensome because of the
amount of documentation required. WIC staff noted that each new program aspect results in new
reporting requirements, such as obtaining documentation of formula substitutions from physicians
since the implementation of infant formula rebates. Directors who have worked in the program
for 10 years or more have seen regulations grow with funding and caseload.

This concern related to service quality as well as program capacity. Staff expressed concern over
the abundant documentation, referrals, and other counseling requirements that WIC staff must
incorporate into their limited time with participants. If program growth includes an increase in
program requirements, there is concern that the quality of WIC services will suffer.

Increase in Program's Scope: WIC staff have seen the scope of WIC broaden in response to
new program requirements, as well in response to changing (and often more complex) needs of
WIC participants. At the local level, WIC staff are aware that, as they expand to serve harder-to-
reach populations, the client needs they must address may be broader in scope and intensity.
WIC is already seen as a "gateway" to other services, and this role may increase with program
growth. For example, WIC staff in Salt Lake City noted that the community’s expectations of
WIC are high. Future roles for WIC that were mentioned included "preventive health triage" and
“WIC could be the agency that keeps people from falling through the cracks." While WIC staff
agree that WIC has become an important community public health resource, they voiced belief
that expansion of the program’s scope goes beyond growth in participation and should be
carefully planned and appropriately funded.

In summary, the findings of the State Agency Survey, the Local Agency Survey, and case study
site visits provide valuable new information on WIC Program operations, coordination of WIC
services with other community providers, and implications for future growth. During the study
period (since 1988), the WIC Program has grown and significant changes have occurred in the

Turrent Operating Capacity and Perspectives on Accommodating Future Growth
Vil-8



Chapter VI. Synthesis of Reported Changes on State and Local Agency
Operations and Factors Affecting Quality of WIC Services

Agency Size. Currently, a majority of local agencies (58%) have between 100 and 1,999
participants. Nearly all (89%) have caseloads between 100 and 9,999. Larger agencies tend to
have more clinics and service sites, as Exhibit VI-1 shows.

Children, ages 1 through 5, comprise the largest proportion of the WIC caseload. Overall
participant mix has not changed notably in the past 5 years. The percentage of women in WIC’s
caseload has decreased slightly in comparison to children.

Ethnic Populations. Information on ethnic populations served by WIC does not show any clear
trends. According to FCS data, minorities, especially black and Hispanic populations, tend to
be served by larger agencies. There are local agencies that serve primarily a single ethnic
population—e.g., black, white, Hispanic, or Native American—but none that serve a primarily
Asian population. Less than 1 percent of agencies serve a population made up of more than 25
percent Asians, a different pattern from other ethnic groups. There was no apparent relationship
between growth and ethnic groups served."

Growth. The WIC Program has grown over the past 5 years, both in terms of funding (an
increase of $800 million from 1988 to 1992) and of participation. While caseload fluctuations
occurred during this period, very few agencies experienced a decrease in their caseload over a
5-year period, and the actual growth was quite varied. Exhibit VI-2 illustrates that significant
proportions of local agencies fell into a variety of growth levels. It also shows that agencies that
grew by 50 percent or more serve 45 percent of the WIC participant population.

The growth rate of State agencies roughly parallels that reported by local agencies, with 77
percent of State agencies experiencing growth between 15 and 100 percent.

While the number of participants has significantly increased during the study period, the program
does not serve all who are eligible. State agencies were asked how many eligible individuals
were unserved at the time of the survey. The most common answer was "Don’t Know" (38%
of agencies). Of those State agencies that did have an estimate of number of eligibles unserved,
42 percent reported between 25,000 and 100,000 people were currently unserved within their
service area. Only one agency reported that no eligibles were unserved.

‘Analysis of this topic was preliminary and limited to cross-tabulations; more sophisticated analyses may detect
trends.

—Synthesis of Fleported Changes on State and Local Agency Operations
and Factors Affecting Quality of WIC Services
Vi-2





Chapter VI. Synthesis of Reported Changes on State and Local Agency
Operations and Factors Affecting Quality of WIC Services

extent to which local agencies have incorporated initiatives vary considerably. Immunization and
breastfeeding promotion have been highly integrated into the operations of many of the other
agencies visited as well, and many unique and thoughtful promotions have been devised. Drug
abuse education and homeless services have not been as widely adopted into the core of WIC
operations as breastfeeding and immunization. While these requirements were mentioned less
frequently, some examples were observed during site visits. The New York City, NY, site
provides WIC- services at transitional shelters for the homeless. Delaware issues vouchers for
UHT milk and juice to those participants that do not have access to refrigerators. A number of
sites visited indicated that lack of drug education and treatment resources (especially for women)
in their respective communities limited the opportunities for drug education initiatives in WIC.

Other Initiatives. In addition to the specific initiatives mentioned in the previous sections, other
factors have also impacted local WIC agencies. Sixty-six percent of State agencies and 77
percent of local agencies, serving 83 percent of participants, reported an impact from Medicaid
expansions. As discussed in the previous chapter, the Medicaid expansion also resulted in more
private physicians providing medical care for WIC participants.

Computerization and automation have also significantly impacted agencies. Eighty-one percent
of State agencies serving 92 percent of participants cited this factor, while 68 percent of local
agencies reported it. The majority of States noted that more PC and minicomputer equipment
has been used since 1988, and the case study findings confirmed this use. Many of the agencies
visited are using computers or are in the process of implementing a system. There is a wide
range of levels of automation, however. For example, while Delaware’s system is completely
automated and includes other providers, New York had no automation at the time the case study
visits occurred (April 1993); however, plans were underway to phase in automation.

Ill. Facilitators and Barriers to Providing High-Quality WIC Services

In the mail surveys, local and State agencies were asked to detail the five factors that contributed
most to their ability to provide high-quality WIC services and the five factors that hindered them.
After all responses were coded and entered into a database, responses composed of at least 5
percent of the local agencies were considered as relevant categories. Each survey was then re-
evaluated to ensure that responses of "other" truly did not fit into any categories. In addition,
those categories mentioned by less than 5 percent of respondents were then included in the
“other" category. Exhibits VI-4 and VI-5 list the factors and percentage of agencies that
mentioned that particular category.

Factors that Promote High Quality. Issues related to staffing were the two most frequently
cited factors by local agency respondents. Sixty-nine percent of local agencies cited caring or
concerned staff, and 53 percent cited qualified, well-trained staff, as factors that promote
quality. State agencies cited these two factors at 57 percent, most frequent, and 42 percent,
fourth most frequent, respectively. State Agency respondents cited support/cooperation within

Synthesis of Feported Changes on State and Local Agency Operations
and Factors Affecting Quality of WIC Services
VI-6







Chapter IV. Nutrition Services

————————————————————————————_—————————————

record reviews, and analysis of management reports provided by State agencies or via the local
agency’s WIC automated data processing system.

In addition to evaluation by the WIC State agency, many of the case study agencies are subject
to periodic evaluations by their sponsoring organizations. County health departments, municipal
governments, and non-profit organizations undertake financial audits of local WIC Programs.
In Hudson, NY, health department financial audits include a review of the participants’ files. In
New Haven, ‘CT, the WIC Program participates in chart reviews and other quality control
activities with staff of the hospital’s Primary Care Center.

Finally, several case study sites reported participation in special evaluation studies. Most of these
studies were short term (1 year or less), and addressed a wide range of issues related to WIC
operations. In Tangipahoa Parish, LA, the Health Unit, which includes WIC, has served as the
test site for a number of State initiatives (such as automation), which have evaluation
components. Over the past 5 years, local agencies in Delaware have conducted studies of
breastfeeding practices and patient flow.

Quality of Nutrition Education. The overall perception of WIC local agency staff is that the
current quality of nutrition education in comparison to 1988 has improved—21 percent believe
that quality is substantially higher, 43 percent report it is somewhat higher, 23 percent report it
is about the same, and 13 percent report it is lower (Exhibit IV-14). Responses to other survey
questions indicate that WIC local agency staff do perceive some problems related to delivering
nutrition services. Fifty-seven percent have too little staff time per participant, 44 percent have
an inadequate number of professional staff, and 9 percent have less than sufficient skills among
their staff for providing nutrition education.

Exhibit IV-14

Degree of Change in the Quality of Nutrition Education Since 1988

Agencies’ Perceptions of Change Agency Participant
in Quality of Nutrition Education (%) (%)
Since 1988
Substantially Lower 3 3
Somewhat Lower 10 15
About the Same 23 17
Somewhat Higher 43 47
Substantially Higher 21 18
[ee 100 100

Source: Based on estimates for 1,777 local agencies, Local Agency Survey, WIC Dynamics, 1993.

Nutrition Services
IV-22



Chapter V. Integration and Coordination with Other Programs

ee ——————_——EEE

is not colocated with any maternal and child health services, but its services are colocated and
coordinated with the sponsor’s case management program. About half of the WIC clients at this
site also see social workers in the case management program, which provides housing assistance,
budget counseling, and referrals to other agencies (e.g., drug treatment facilities, domestic abuse
prevention services, shelters, etc.). Clients are often escorted from WIC to a social worker at the
case management program.

Although colocation with social services is not routine, coordination does occur, and most
services are available on a referral basis. In Salt Lake City, UT, the Expanded Food and
Nutrition Education Program (EFNEP) coordinates its teaching activities with and conducts
nutrition education activities for WIC. The Palm Beach County WIC Program has access to
drug-screening information on participants who receive their care from the health department, and
it refers active drug users to treatment programs. In the case study sample, the services with
which WIC Programs were least likely to interact were: EFNEP, transportation, food banks, and
adult education/job training programs. For some sites, these services were not available in the
local area. This was reported to be the case most often for EFNEP, adult education/job training,
homeless or emergency shelter programs, and child care programs. The Local Agency Survey
indicated that obtaining non-health care services is a problem in 32 percent of the local WIC
agencies.

V. Outreach

Outreach activities are directed toward community health and social service providers as well as
toward potential participants, and they include information dissemination and the use of itinerant
and mobile services.

Information Dissemination. Most case study sites provide information about WIC to public
health providers (20 sites), social service providers (16 sites), private physicians (19 sites), and
local hospitals (18 sites). Outreach to providers includes keeping providers informed of WIC
Program eligibility requirements; changes in regulations, location, or service hours of clinics;
addressing provider groups at meetings; and meeting individually with providers to establish good
working relationships and an understanding of the WIC Program. A number of communities
visited have task forces and advisory councils that facilitate coordination. Respondents in Portage-
Columbiana, OH, noted that the WIC representative at community advisory council meetings
exchanges information with other members of the health and social services community and uses
this group as a resource for speakers at group education classes and staff in-service training.

The frequency and intensity of outreach to potential participants varies depending upon the local
agency’s assessment of its ability to accommodate additional participants. Since the most
common source of referral to WIC is “word of mouth," more formal participant outreach
activities are undertaken on an as-needed basis. Over three-fourths of the case study sites used
publicity, such as posters in libraries, supermarkets, and other public places, as well as newspaper
articles about the WIC Program. Nearly two-thirds of the case study sites reported participation
in coordinated outreach activities. For example, WIC Programs in Portage-Columbiana, OH, and

Thtegration and Coordination with Other Programs
V-12



Chapter Vil. Current Operating Capacity and Perspectives on Accommodating
Future Growth

Martinsville agency, where the WIC Program is colocated but not integrated into health
department services. A great strain reportedly exists between WIC and the health department
services due to the perception that WIC is a self-contained program that must be kept separate.
WIC may be perceived as being in competition with other health department programs and
resources, rather than to an adjunct to health services. WIC is located in the county health
department facilities where other health services are offered, but, because of space limitations,
no other clinies were held simultaneously with WIC. It is possible that, in cases such as this,
growth will lead to separate locations, which might ease the strain and improve staff morale but
could also decrease or complicate WIC’s integration and coordination with other health and social
services.

On the other hand, in some colocated agencies (e.g., Palm Beach County, FL; Delaware; New
York City, NY; Tangipahoa Parish, LA), colocation has had a major role in the integration of
WIC services with other health and social services. In these sites, if WIC outgrows the available
space, service integration and client accessibility could be affected.

Community Constraints: As WIC agencies expand, there are several ways in which the
community would both affect and be affected by the program. Factors such as transportation and
health provider availability would directly effect program growth. Transportation is one of the
most troublesome community constraints on service delivery. This is currently a problem for
many agencies (46% of Local Agency Survey responses), and expansion of the WIC Program
is likely to exacerbate the problem for these agencies and perhaps become a problem for others.
In order to increase program participation, WIC agencies are likely to reach out to people who
have not been participating due to various barriers, one of which may be lack of transportation.
In some sites, such as Palm Beach County, WIC was able to address the transportation issue by
relying on the health clinic van to bring people to the clinic in which they are colocated. They
scheduled their appointments around the participants’ appointments for medical services, since
Medicaid reimbursement is provided for transportation to medical appointments, but not to WIC-
only appointments. If growth would mean moving out of the health clinic site, the van would
no longer be available and transportation would become a major barrier to service delivery.

Process Issues of Growth. Along with the practical concerns about the continuing success of
the WIC Program under a new period of growth, there are several concerns about how growth
might occur. Generally, WIC agency staff are concerned about whether or not the growth
process would include provisions that would help to ensure the program’s integrity and allow for
continued improvement. The remainder of this section outlines some of the specific concerns
voiced by agency staff during the case study site visits.

Consistency of Growth: Since its inception, WIC has grown steadily. However, agencies have
also experienced periods in which they have had to contain program growth or even decrease
their participation. This process is one that greatly concerns many WIC agency staff. One New
York City agency explained the detrimental effect of the constant change from periods of
expansion to periods of contraction. Decreasing participation is often achieved by creating
waiting lists for specific participant categories. When word got out in the community that WIC

Current Operating Capacity and Perspectives on Accommodating Future Growth
Vil-7



Chapter IV. Nutrition Services

In general, the nutrition assessment provides the basis for the particular nutrition education needs
of each participant. As part of the nutrition education session, participants are often asked to
complete a food frequency form, checking the frequency with which each specific food is eaten.
Fourteen of the 22 case study sites used this as part of the dietary assessments. Using this tool,
nutrition staff can determine the patterns of eating rather than relying exclusively on the previous
day’s recall for a measure of how a person usually eats. Nutritionists then talk to participants
about their intake and will suggest ways in which a participant may vary her/his diet so as to
reduce nutritional risk.

Individual Care Plan. The development of an individual care plan (ICP) follows the assessment
process. This plan is most often written as medical notes—Subjective, Objective, Assessment,
and Plan (SOAP) format. The purpose of the plan is to describe the participant’s condition and
suggest actions that might improve that condition. For the most part, an ICP is developed only
for high-risk participants. Eighteen of the case study sites developed ICPs for their high-risk
participants. The ICP is most often documented in the participant’s record. Optimally, the ICP
would be developed with the participant’s input and would be given to the participant as a
learning aid. This was observed at some of the case study sites. For example, in York, PA, the
nutritionist explains the purpose of the individual care plan and the need for more extensive
nutrition education to the client. In Portage-Columbiana, OH, clients work with the dietitian or
nutritionist to develop their own goals for the individual care plan. These goals are written on
the folder provided to the client and discussed at the next visit. However, according to one
nutritionist in a New York City site, there may be little followup on the ICP on subsequent visits
to the WIC clinic if participants see different staff members at each visit. Although the plan is
in the participant’s record, it is not necessarily referred to during subsequent visits.

The final activity in a nutritional assessment is documentation in the participant’s record. A
record review at the 22 case study sites revealed that the records do contain a great deal of
information, as presented in Exhibit IV-2. As is evident from this exhibit, the only item included
by less than half of the sites is followup on referrals. Note that 19 of the 22 sites document the
referrals that are made to other programs. Interviews with WIC staff revealed that they perceive
the documentation process to be a major time consumer.

Il. Nutrition Education

This section describes the delivery of nutrition education and counseling services in WIC,
including qualifications and roles of WIC staff, types of education sessions offered, frequency
and length of sessions, and breastfeeding promotion activities. Factors which affect the delivery
and quality of nutrition education, and local agency perceptions of the quality of nutrition
education are also presented in this section.

Nutrition Services
IV-3



Chapter VII. Current Operating Capacity and Perspectives on Accommodating
Future Growth

health and social service needs of WIC participants and in the service delivery networks in local
communities. WIC local agencies have improved efficiency and stretched resources to respond
to these changes. For the most part, WIC local agencies are optimistic and willing to address
the challenges of further expansion, but are concerned about the implementation of such growth
in light of their current facility and staffing limitations.

Current Operating Capacity and Perspectives on Accommodating Future Growth
vu-9

st U.S. GOVERNMENT PRINTING OFFICE: 1995 386-124/00571



Chapter V. Integration and Coordination with Other Programs

WIC Service Setting Number of Local Agencies
Providing Services in This
Setting
Neighborhood Center* 7
Free-Standing (WIC Only) 8
[Horses Shelter 2
Family Planning Clinic 2
Government Oftice Building 1
Total Service Settings Reported 43

Source: 22 case studies, WIC Dynamics, 1993.

* Not limited to health.

Overall, coordination opportunities and initiatives exist. They succeed to varying degrees based
on the availability and structure of local health care services. Case studies indicate that
communication efforts are sometimes hindered when there is no well-established network and
each provider must be contacted separately. As Exhibit V-4 shows, WIC participants receive
their health care from a variety of sources. Over one-third of the WIC sites visited indicated
three or more provider types as the primary source of health care for their clients. This presents
a challenge to coordination. The following sections describe how such coordination is
implemented.

ill. Integration and Coordination with Specific Health Services

One objective of the case studies was to determine the impact of participation and other changes
on WIC’s integration and coordination with local health care delivery systems. WIC has served
as an important link between an at-risk population of women and children and providers of
maternal and child health services. This is best demonstrated by coordination with high-risk
prenatal care services, well-baby care, immunizations, and screening for Medicaid eligibility.
Several WIC Programs visited in this study have taken significant steps to increase colocation
and coordination with health services since 1988. For example, reorganizations of WIC agencies
in Delaware (1989 and 1991) and Salt Lake City, UT (1989), provided for full WIC services at
clinic sites, colocation of WIC with health services, and closer organizational ties between WIC
and public health. Immunization initiatives were noted as an area of change affecting local
agency operations by nearly all of the sites visited, and Medicaid expansions and related
initiatives (such as Healthy Start) were indicated as an area of change by over two-thirds of the
case study sites.

Integration and Coordination with Other Programs
V-5



Chapter IV. Nutrition Services

In summary, the local case study WIC agencies are active in promoting staff training and
continuing education through in-house programs, programs offered by State WIC agencies, and
professional conferences and educational programs offered by other organizations. In many
instances, educational programs are coordinated with other agencies, particularly health
departments and hospitals.

V. Food Package Delivery Methods

WIC participants receive a monthly food package designed to supplement their diets. The foods
provided are high in protein, calcium, iron, and vitamins A and C. These are the nutrients
frequently lacking in the diets of the program’s target population.

According to the survey findings, there were two changes in the preparation of food instruments
that occurred more often than others: the issuance of multiple food instruments and the more
frequent issuance of standard food packages (packages that are not tailored to meet the
individual’s specific nutritional risk condition). Between 1988 and 1992, 63 percent of the local
agencies, serving 68 percent of the participants, began issuing multiple food instruments. Fifty-
one percent of the agencies, serving 55 percent of the participants, began issuing standard food
packages more frequently. Hence, local agency staff may be spending less time tailoring food
packages for individual WIC participants. This does not necessarily mean, however, that food
packages do not meet individual participant needs. Rather, many WIC State agencies have
developed a range of standard food packages to meet the needs of various categories of WIC
participants. Local agency staff can then prescribe specific food packages for participants based
upon categorical, nutrition risk, and other factors. The use of standard food packages can thus
reduce the level of time and effort spent by local WIC staff on tailoring WIC food packages to
meet individual needs.

Over 40 percent of the agencies began writing food instruments at the local agency level and
began issuing computer-generated food instruments. While the issuance of multiple food
instruments can be viewed as increasing efficiency, it also has the effect of reducing the amount
of staff contact with participants. Many WIC agencies schedule nutrition education concurrently
with issuance to provide an added incentive to attend. During the site visits, researchers observed
that 17 (of the 22) agencies coordinated voucher pickup with individual nutrition education, and
10 agencies coordinated voucher pickup with group nutrition education.

Site visit findings indicate that many local agencies have taken steps to streamline the food
instrument issuance process. In several agencies, checks/vouchers are issued for more than 1
month at a time, thus reducing the number of times the participant must come into the office and
the staff time needed to issue these instruments. At one case study site, the requirement to sign
the vouchers in the WIC office (in addition to signing when the vouchers are actually used) was
eliminated, significantly reducing the amount of time the participant spent receiving the vouchers.

According to the local agency survey data, the actual time spent waiting for and receiving food
instruments varies from less than 5 minutes to more than 30 minutes, with the greatest percentage

Nutrition Services
W-19



Chapter IV. Nutrition Services

For example, in New York City, NY, one site supplemented the State materials with a site-
developed pamphlet illustrated by a clerical staff member. All sites reported State evaluations
occurring at least on a biannual basis. In addition, local agencies reported being required to
submit.a 2-year nutrition plan to the State for approval. Comments on the plan and from the
evaluation were to be used by the local agencies to modify or improve their services. The plan
was updated as necessary on an annual basis.

Qualifications-and Role of the Nutritionist (Standard 9)

STANDARD 9: The State agency assures that a qualified nutritionist provides WIC services and
that the role of the WIC nutritionist is defined.

Although each study site employed “qualified” nutritionists, the definition of "qualified" differed
across States. Some only employ registered dietitians or licensed nutritionists, while others only
require a master’s or bachelor’s degree in nutrition. However, there was a clear definition in
each site that was approved by the States for who qualified as a nutritionist and what that
person’s role was in the WIC Program. These definitions were generally documented in a
program manual and were often given to case study research staff.

Nutrition Staff Training (Standard 10)
STANDARD 10: The State agency assures through training that competent staff perform

certification procedures and provide nutrition education.

As is mentioned above, local staff, particularly nutritionists and WIC directors, attended various
State training sessions. Often the lead nutritionist attends the State meetings and, in turn, trains
other local staff.

Food Package (Standards 11-12)

STANDARD 11: The State agency has uniform policies and guidelines for food package
tailoring in accordance with current authoritative medical and health
information.

STANDARD 12: The State agency has policies and procedures for authorizing WIC foods
that are based on cost, availability, nutritional value, and participant
acceptance.

Most of the case study sites reported that food package tailoring mostly occurs at the State level.
States usually have established a variety of packages that local nutritionists choose from when
working with a participant. Local agencies are still able to customize a food package for
particular special needs, but this was not reported to be a frequent occurrence. State WIC

Nutrition Services
IV-25



Chapter IV. Nutrition Services

cereal, is available for pickup in an emergency situation, so some agencies reported information
on food pickup.

Instruction on voucher use is usually provided by either nutrition staff or the clerk issuing the
vouchers. Participants receive information about who can use vouchers, who can act as a proxy,
how to select and purchase foods, and where approved WIC vendors are located. In one site—
Montgomery County, MD—the agency had a book for participants with pictures of all the various
WIC foods that they could purchase. Other agencies have posters on the walls with WIC foods,
handouts with lists of approved foods, or empty containers of approved WIC foods on a shelf.
Many sites repeat the instruction each time the vouchers are distributed.

Vl. Evaluation Activities and Local Agency Perception of Quality

Evaluation activities. Evaluations of WIC nutrition services are conducted both formally and
informally. The most common formal evaluation is the annual or program audit by the WIC
State agency, which includes areas such as nutrition education, recordkeeping, and
certification/recertification procedures. The majority of local agency directors interviewed during
the case study visits were unaware of the Nutrition Services Standards developed by the National
Association of WIC Directors and FCS. Rather, States often share their guidelines with local
agencies, which in turn use these in developing their nutrition services plan. The State
evaluations are often used to provide feedback to the agency about ways in which they could
improve their services. Interviews with some agencies (for example, Brooklyn, NY, and Palm
Beach County, FL) revealed that staff were often aware of the feedback given in the most recent
evaluation and were incorporating such feedback into their program operations.

This annual review also encourages internal evaluation and nutrition services planning on the part
of local agencies. For example, the WIC Program in Portage-Columbiana, OH writes agency and
nutrition goals every year in its grant application to the State of Ohio. As part of this process,
the local agency staff work together to identify areas in which they need to improve. The WIC
local agency in Wilkes-Barre, PA, produces an annual local agency plan that describes the
Program and the community; presents a nutrition education plan; and evaluates goals and
objectives for the past year and projections for the future. The plan also includes a description
of coordination with other programs. This plan is used by the State agency in planning
operations for the coming year. The State of Pennsylvania also distributes a planning
questionnaire which solicits from the WIC local agencies the areas that need the most State
attention.

In Delaware, the nutrition education coordinator conducts periodic evaluations of each clinic.
These are reviewed with the area WIC supervisors, who discuss each evaluation with the
appropriate clinic manager. They discuss recommendations with clinic staff. The WIC
supervisor also surveys staff on operational issues such as hours and days when changes are
contemplated. Both WIC local agencies visited in Ohio maintain monthly counts of referrals for
each clinic site. Other regular monitoring activities reported in site visits include client surveys,

Nutrition Services
W-21



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Integration and Coordination with Other Programs

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Integration and Coordination with Other Programs



Chapter IV. Nutrition Services

Despite the variety of interpreters and education materials available, language still remains a
barrier in some sites. For example, one nutritionist in New York City, NY, expressed frustration
with group nutrition education classes that include non-English-speaking participants who are
unable to understand the bulk of the session content. Due to a lack of staff time, there is only
one group offered and there is no attempt to address the cultural and language differences of the
participants. In addition, several sites (Palm Beach County, FL; Atlantic City, NJ; Salt Lake
City, UT) reported that not only language differences, but also cultural differences can present
formidable barriers to education and program usage. Cultural habits and patterns may preclude
some of the WIC foods and, without appropriate replacement foods or education on the use of
WIC foods, many people may not be receiving the nutritional benefits intended by the program.

One of the ways in which nutritionists have helped to ease the cultural diversity problem has
been to alter their nutrition education topics to meet the needs and habits of their population.
In Brooklyn, NY, where a large population of the participants are Hasidic Jews, the staff have
learned about the practices involved in keeping kosher and have worked with their participants
within the boundaries of their religious practices. In other sités where there is a large Asian
population, nutritionists have worked with a population whose typical diet does not include milk.
While these cultural differences may become most evident through individual sessions,
nutritionists have learned about the cultural and ethnic habits of their population and are able to
appropriately tailor their group nutrition sessions.

Exhibit 1V-11

Languages Available at Local WIC Agencies

i Interpreters Nutrition Education Provided

Languages Provided in This Language
(%) (%)

Spanish 48 58

Vietnamese 4 8

Cambodian/Khmer 2 7

Laotian 4 9

Thai 0.9 3

Hmong 5 5

Chinese 2 3

Haitian/Creole 2 3

French 7 3

Portuguese . 3 3

Native American Language 6 4

Sign Language 9 7

Other 9 6

Source: Based on estimates for 1,777 local agencies, Local Agency Survey, WIC Dynamics, 1993.

Nutrition Services
W-16



Chapter VI. Synthesis of Reported Changes on State and Local Agency
Operations and Factors Affecting Quality of WIC Services

Exhibit VI-5

Factors That Hinder High-Quality WIC Services.

Factors that Hinder State Agencies (%)
Inadequate Facilities/Materials 65 31
Shortage of Staff 39 49
Lack of Funding/Funding Fluctuations 25 45
Inefficient Operations 24 30
Too Many Requirements/Paperwork 24 40
Not Enough Time 37 21
Geographical/Transportation Issues 37 21
Lack of Support/Training 10 31
Staff Attitude/Tumover - 23
Unresponsive Participants 33 4
Staff - General 7 8
Language/Literacy Barriers 9 4
Lack of Non-WIC Services for Participants 3 9
Weak Infrastructure * 8
Vendor Issues * 6
Lack of Community Support 2 *
Not Enough or Poor Nutrition Education for 2 *
Participants

Other 27 18

= This answer was not frequently reported in this survey.
Source: Local Agency Survey and State Agency Survey, WIC Dynamics, 1993

Factors That Hinder High Quality. Inadequate facilities was the most commonly cited
barrier by local agencies, with 69 percent reporting this factor. Included in this category were
responses indicating the lack of privacy and lack of play areas for children. However, only 31
percent of State agency respondents cited inadequate facilities as a barrier. The next most
frequently cited barrier was shortage of staff. While some agencies specified a particular type
of staff such as nutritionist or bilingual, others reported that there were too few people overall

—Synthesis of Reported Changes on State and Local Agency Operations
and Factors Affecting Quality of WIC Services
Vi-B



Chapter IV. Nutrition Services

Exhibit IV-6

Frequency of Nutrition Education Contacts

High-Risk Participant Non-High-Risk Participant
Frequen
equency Agency Participant Agency Participant
(%) (%) (%) (%)
Once Per 1 8 29 21
Certification Period"
Twice Per 43 46 54 56
Certification Period
Monthly 42 35 10 9
Bimonthly 38 4i 23 31
Other 8 16 3 4
Don’t Know i) oO 0.9 1

Source: Based on estimates for 1,777 local agencies, Local Agency Survey, WIC Dynamics, 1993.

Note: Percents add to greater than 100 percent because local agencies provided contacts at more than one frequency.

*Foliow-up calls revealed that some local agencies do not characterize the initial visit as a nutrition education contact, but rather as a certification.
However, nutrition education and counseling do take place during this initial certification visit.

Local agencies reported that the length of time spent waiting for and participating in nutrition
education sessions also varies widely. Typically, agencies have less than a 10-minute waiting
time for nutrition education (Exhibit IV-7). Sixty-eight percent of agencies have a waiting time
of 10 minutes or less for individual sessions, and 73 percent have the same wait for group

sessions.

Nuirition Services
V-8



Chapter V. Integration and Coordination with Other Programs

Sponsorship by a health agency may facilitate coordination by increasing awareness of programs
sponsored by the same agency and by reducing barriers to sharing of information or staff. Nine
of the 22 sites visited in this study integrated WIC with more than one other health service.
These nine more integrated sites include the three case study sites sponsored by State health
agencies. The other six integrated sites are sponsored by single or multicounty health agencies
(three sites), district health agencies (one site), and hospitals (two sites). State agency
sponsorship facilitates coordination in Delaware, for example, because WIC, Medicaid, and public
health programs use the same automated data processing system. Agreements regarding access
to certain parts of each program’s database are simplified by the fact that all programs report to
the same administrator. In Portage-Columbiana, OH, the use of a Combined Program Application
form implemented by the State in November 1991 facilitates integration. Clients complete this
form when they apply for WIC, Child and Family Health Services, Health and Human Services
programs, and Expedited Medicaid. Application for all of these programs can be made at the
point of entry of any one of them.

Hospital sponsorship promotes integration at the WIC Program sponsored by Yale-New Haven
Hospital in New Haven, CT. The WIC Program is a hospital clinic and is seen as an important
part of the entire pediatric and prenatal care network, both by those inside and outside the WIC
Program. Nearly all pregnant women and young children seen at the hospital’s Primary Care and
Women’s Clinic are referred to WIC. At the same time, WIC staff help identify clients’ health
and social problems that would benefit from other hospital-based services.

Sponsorship and location may not always be identical. For example, a WIC Program sponsored
by a health agency may also operate satellite clinics at a distance from the public health center,
or a Program sponsored by a community agency may rent space from a hospital outpatient
department to facilitate linkages to health care services. In Atlantic City, NJ, the city health
department sponsors the WIC Program, but WIC is not located in the public health centers
because of insufficient space. In San Antonio, TX, the city’s Health District sponsors the WIC
Program, but only 5 of 12 WIC clinic sites are colocated with Health District programs.
However, health agency sponsorship still facilitates coordination in both of these local WIC
agencies. In Atlantic City, the prenatal nutritionist at one health center enrolls patients in WIC,
and all public health clinics provide anthropometric measurement and blood work for WIC at no
charge to the patient or WIC. As part of the Health District, the San Antonio WIC Program is
included in a Memorandum of Understanding that addresses the sharing of patient information
between programs.

Colocating WIC services with health care services can be beneficial to both WIC staff and
participants. Participants can receive their WIC services and health care in one location, while
staff may find it easier to refer WIC clients to and communicate with health care providers.
There are a greater number of WIC sites without on-site health services than might be expected,
given the high proportion of sites sponsored by health agencies. Data from the Local Agency
Survey indicate that, nationally, 14 percent of local agencies, serving 9 percent of participants,
have no WIC clinics with on-site health care. While 52 percent of local agencies report that
health services are available at all of their clinic sites, these agencies only serve 39 percent of
all WIC participants. Exhibit V-2 details the availability of health care services on site.

Integration and Coordination with Other Programs
V-3



Chapter VII. Current Operating Capacity and Perspectives on Accommodating
Future Growth

—————————————————————

Funding. Funding availability is one of the major factors influencing operating capacity. It is
an underlying issue in facilities, staff, and other areas. A number of agencies report that
insufficient funding is a problem for them. One-quarter of local agencies and 45 percent of State
agencies noted that a lack of funds or the fluctuation of funds hindered their operations. Another
issue relating to funding is the use of non-WIC sources of funding. One of the benefits of
sponsorship or colocation that many WIC Programs have experienced is the receipt of in-kind
services. Among the in-kind services received are: facilities, copying or FAX machines,
telephone lines, reception staff, and security staff. Many local agencies report using staff and
non-labor resources not paid for by WIC:

. As noted in earlier sections of this report, 16 percent of local agencies, serving 27 percent
of participants, use non-WIC-funded health care workers to conduct certifications.

° Only 23 percent of local agencies pay for space and utilities with exclusively WIC funds,
while 24 percent report that space and utilities are entirely funded by other sources. The
remainder report a combination of WIC and non-WIC funds.

° In order to obtain hematological measurements for participants, 29 percent of principal
clinics report typically using non-WIC staff on site to conduct this test. In addition, 43
percent report typically using results brought in by the applicant that were conducted by
an outside health care professional, such as a private physician or community health clinic.

From a federal perspective, resource-sharing in WIC may be desirable if it fosters coordination
and integration with other programs and services targeted toward low-income women and
children. Other programs (which recognize WIC’s role as a gateway program) may be willing
to provide resources to WIC to gain access to this target population.

Quality of Nutrition Education. With inadequate space and staff, it becomes even more of a
challenge to provide services of high quality. More than a third of local agencies reported a
decrease in the amount of time per participant spent on nutrition education, whereas 57 percent
reported spending more time on referrals. Additional program requirements may also take time
away from nutrition education. Many agencies reported an increase in use of group nutrition
education, with 66 percent of participants being served by these agencies. Case study findings
indicate that, where group nutrition education has increased, it is being substituted for the second
nutrition education contact, particularly for those participants who are not high-risk. Group
classes may not properly target the specific nutritional risks experienced by those participating
in the group. They also may be inappropriate for some participants due to language and cultural
barriers. Handouts, while presenting information concisely, may not be understood due to
literacy or language barriers. One staff member in New York City, NY, reported that too often
they found their handouts being left in the waiting area or dropped on the ground near the WIC
office. This could also be an indication as reported by many local agencies of the difficulty in
maintaining clients’ interest in nutrition education.

Current Operating Capacity and Perspectives on Accommodating Future Growth
VIF



Chapter Vil. Current Operating Capacity and Perspectives on Accommodating
Future Growth

Il. Perspectives on Accommodating Future Growth

This section presents case study findings about future growth. When available, supporting data
from the Local Agency Survey are included. One of the most powerful findings of the case
studies is the enthusiasm present among the staff for doing as much as possible for the population
being served. During case study interviews, staff consistently spoke about the various things they
might be able to do to accommodate further growth in their programs. However, they also
mentioned concerns they have about what might occur and how it might occur. Before
presenting the issues surrounding future growth as expressed by WIC agency staff, there was a
great deal of uncertainty about the definition of "growth." For the purposes of interview
discussions, staff were told to define growth as serving as many people in their area that were
in need of services.

Tt should also be noted that growth is not anticipated to be a problem for some agencies because
they consider themselves to be already serving most of the eligible population. For example,
WIC staff in New Haven estimate that only 15 percent of the population eligible for WIC in
Connecticut are not on the program. If this is correct, the increased client load may not
dramatically affect current operations. In Wilkes-Barre, staff do not believe there will be an
immediate increase in participants at existing offices because they are currently serving all
Priorities without waiting lists, and expansion will consist of opening new clinics to reach
unserved parts of their catchment area. The WIC Program at Grady Memorial Hospital in
Atlanta has excess capacity because caseload has decreased in response to competition from other
providers. WIC staff in Temple, TX, indicated that they are serving fewer participants than their
targeted caseload, and that they could serve an additional 800 participants without adding staff.

Practical Issues of Growth. The growth of the WIC Program would have several practical
impacts on local agency service delivery. Many of the issues have been discussed in the previous
section regarding current participation status and the growth encountered since 1988. Local
agencies cited factors that they must address concerning future growth.

Space: Space is currently a problem for many of the local agencies. Most of the case study sites
expressed concer about space with respect to future growth. Eighteen of the 22 agencies visited
were concerned about their waiting room space, 16 about space for individual sessions, 16 about
space for group sessions, and 17 about space for voucher distribution. Some sites (e.g., Atlantic
City, NJ, and Martinsville, VA) expressed concern over finding any space in their geographical
location that could accommodate the agency’s needs.

Staff Resources: Agency staff were concerned about the ability to provide all the mandated
services to clients in a timely fashion with their current staffing levels. In the Local Agency
Survey, many of the agencies (58%) indicated that the time per participant was currently too
limited, and this presents a potential barrier to the provision of quality nutrition education.

Part of program growth could involve an expansion of the existing network with which program
staff are involved. Networking is a crucial element for building a referral system and building

Current Operating Capacity and Perspectives on Accommodating Future Growth
VIS



Chapter VII. Current Operating Capacity and Perspectives on Accommodating
Future Growth

community support for the program. Activities include information dissemination, participation
in planning meetings, cooperating in community service activities, and serving on advisory boards
with public and private health providers, breastfeeding promotion groups, health care coalitions,
and schools, Head Start programs, and other community organizations. Agency staff referred to
their already limited time available for participant contact and were concerned that there might
an inadequate amount of time available for increased networking.

In-Kind Services: WIC coordinators of two case study sites expressed concern that, if one of the
results of program growth is the need for separate, larger space, they will no longer be able to
be housed by sponsoring agencies, thus losing in-kind services. The result to the WIC Program
would be an increased per-participant cost. One WIC coordinator noted that there are no
assurances that resources provided by the city will continue if the WIC Program expansions
exceed the amounts the city has available for in-kind support of WIC.

Quality of Services: The quality of services, particularly nutrition and voucher education, is
integrally related to space and staffing issues. While local agencies expressed the view that they
have improved the quality of nutrition education (i.¢., refined instructional materials and
techniques and have better qualified staff), there has been increased use of group education, and
a broader range of relevant counseling topics are covered, with less time devoted to nutrition
education.

Health Care Providers: The availability of health providers could also alter the WIC Program.
If an agency relies on non-WIC providers to complete the medical history needed for certification
(almost half of the case study sites), and there is a lack of appropriate providers in the
community, growth in the WIC Program may affect the certification process and delay enrollment
for many participants. Six case study sites indicated that a shortage of physicians or other health
care providers was a major concern with respect to WIC growth. In some cases, there was an
overall shortage of health providers in the community, while in other cases, there was a shortage
of physicians serving the Medicaid-eligible population.

Referrals: Since part of the WIC Program mandate is to provide referrals to participants for
other health and social services, growth should create an increase in referrals. Several sites
expressed concer that increased referrals from WIC could overburden existing health and social
service delivery systems. For example, WIC Program staff in Delaware noted that, while WIC
services would be able to accommodate full funding, there is not enough sick child care
available, especially in rural areas, and an expansion of WIC and increased referrals could
exacerbate this situation. In Tangipahoa Parish, LA, where WIC is part of a fully integrated
public health unit, many staff interviewed were concermed that increased WIC participation could
rob the community of other health services as health unit personnel struggle to keep up with the
increased WIC caseload.

Colocation Arrangements: As local WIC Programs have continued to grow over the years, some
have outgrown other services with which they are colocated. This imbalance, in some cases, has
caused tension between WIC and other colocated programs. One example of this is the

Turrent Operating Capacity and Perspectives on Accommodating Future Growth
VIKG





Chapter IV. Nutrition Services

Qualifications and Roles of Nutrition Education Staff. Nutrition education is conducted by
nutritionists, dietitians, diet technicians, paraprofessionals, and other health professionals.
Nutritionists may or may not be licensed or registered, depending on the State licensure
requirements. Some States require all people using the title "nutritionist" to meet licensing
requirements, while others require licensing for nutritionists providing therapeutic services (not
including weight loss, for example). Many clinics and hospitals require nutrition staff to be
either licensed or to be a registered dietitian. Whether or not a person is licensed does not reflect
the type of educational degree they have; nutritionists can have either a bachelor’s or a master’s
degree. As presented in Exhibit IV-3, survey data indicate that approximately 25 percent of all
agencies have no licensed or registered nutrition education staff; another 25 percent have 25-50
percent of their nutrition staff licensed or registered; and 22 percent of the agencies have over
three-fourths of their nutrition education staff licensed or registered. In the case study sites, 18
of the agencies had a licensed, registered, or certified nutrition professional providing nutrition
education to participants (see Exhibit IV-1).

Exhibit IV-3

Percent of Local Agencies Whose Total Nutrition Staff Are
Licensed/Registered Staff, Paraprofessional Staff, and Others

Percent of Local Agencies Whose Total Nutrition Staff Is:
Percent of Total
Nutrition Staff Licensed Paraprofessional Other
(%) (%) Professionals

(%)

None 25 67 32

1% to 10% 2 2 2

11% to 25% 17 6 7

26% to 50% 26 12 25

51% to 75% 8 an 12

76% to 100% 22 3 22

Total 100 100 100

Source: Based on estimates for 1,777 local agencies, Local Agency Survey, WIC Dynamics, 1993.

The majority of case study sites used nutritionists to provide nutrition education, although
paraprofessionals also played a role in some sites. Data from the case studies indicate that 5 out
of 22 (23%) of the sites used paraprofessionals with a bachelor’s degree and 8 sites (36%) used
some other paraprofessionals to provide nutrition education. Note that the data collected from
the case studies does not refer to exclusive use of a professional or paraprofessional. Sites often
used a mix of professionals and paraprofessionals as their nutrition team. Data from the Local

Nutrition Services
WV-5



Chapter IV. Nutrition Services

Exhibit IV-2

Case Studies

Record Review Summary

Record Characteristics/Feature

Number of Sites

__]

Content:

WIC Only 13

Integrated with Other Health Records 5
Items Contained in Record

Date of Enroliment 21

Participant Category 21

Height and Weight 22

Date of Birth 22

Data Plotted on Growth Chart 22

Dietary Intake/Food Frequency 22

Dietary Assessment 21

Medical Risks 22

Reasons for Certification 22

income 21

WIC Priority Group 21 7
Current Food Package 22 :
Reasons for Tailoring or Substitutions 15

Referral to Other Programs Outside of WIC 19

Followup of Referrals 10

Source of Referral to WIC 12

Source of Health Care 19

Name of Physician 21

Nutrition Education Topics and Dates 22

Date of Next Certification 22

Individualized Care Plan 17

Notes on Medical Background 17

Notes on Social Background 17

Source: 22 case studies, WIC Dynamics, 1993.

Nutrition Services

Iv-4



Chapter IV. Nutrition Services
ES

Timing of sessions: The timing of nutrition education sessions has been described as a key factor
in participant attendance rates. Almost all of the case study sites (21 of the 22 sites) mentioned
that combining individual education with certification or recertification helped to ensure high
levels of attendance. This applies less to group education sessions—9 of the 22 agencies
combined group sessions with certification. This difference may reflect the nature of certification
procedures. Nutritionists generally spend time speaking individually to participants during the
certification period, providing an easy opportunity for an education session. Voucher pickup was
also a time at ‘which many sites provide education—17 of the case study sites offer individual
sessions and 10 of the sites offer group sessions during this time. Voucher pickup offers other
advantages for combining nutrition education. Nutritionists are not necessarily involved in the
distribution of vouchers and therefore are free to either provide a class or to speak individually
with participants. Several sites (Brooklyn, NY; Montgomery County, MD; Tangipahoa Parish,
LA) used the waiting time before voucher pickup as a time in which to offer both individual and
group sessions. However, other sites expressed the opinion that the chaotic nature of a small
space during voucher pickup and the inability to offer any private or coherent education sessions
made this a poor time for conducting nutrition education.

Iv. Staff Education and Training

Education and training of WIC staff include in-service education, on-the-job training, attendance
at training sessions and meetings offered by WIC State agencies, and attendance at professional
conferences or continuing education programs. Local Agency Survey findings indicate that,
nationally, about one-third of local agencies have cut back on training activities for staff since
1988, while nearly an equal proportion of local agencies reported that they increased training
activities for staff during that period. Of the 22 case study sites, 18 (82%) participate in in-
service training with other agencies.

Several local agencies have staff members specifically designated to arrange and monitor staff
education and training. The Nutrition Education Coordinator in Delaware is responsible for
assuring that each program is aware of new information and that information on programs other
than WIC is updated. This information is kept in the Nutrition Education Handbook or the
Policy and Procedures Manual. The coordinator keeps staff informed of journal offerings, and
information can be requested through an automated system. The Wilkes-Barre, PA, WIC agency
created a position for a training coordinator in 1989. The training coordinator arranges for all
in-service meetings. The training coordinator also conducts training sessions for new employees
(both classroom and on the job). In Brooklyn, NY, the nutrition coordinator is responsible for
the training of professional staff. Palm Beach County, FL, WIC takes advantage of the many
medical conferences and symposia offered by hospitals in South Florida. The County Health
Unit has a nurse that coordinates continuing education, but Palm Beach County WIC also plans
to hire its own staff trainer/development specialist to focus on the needs of WIC staff.

In-service education includes information exchanges about programs that work together, clinical
topics, WIC operational issues and updates, and management skills. In-service training is
generally planned and scheduled at the local level. In many programs, in-service training is

Nutrition Services
1V-17



Chapter IV. Nutrition Services

Exhibit 1V-5

Changes in Nutrition Education Practices Since 1988

Specific Changes in Nutrition Implemented Changes |
Education Operations Agency Participant
(%) (%)

increased group nutrition education 57 66
More group nutrition, fewer individual 26 43
sessions
More individual nutrition, fewer group 27 22
sessions
Placed more emphasis on breastfeeding 97 98
More staff time per participant for 33 33
nutrition education
Less staff time per participant for 35 45
nutrition education
Paraprofessionals deliver nutrition 38 47
education

=
More handouts and pamphlets 56 61
increased class size 41 59

|| Decreased class size 7 ; 10
Other 3 8

Source: Based on estimates for 1.777 local agencies, Local Agency Survey. WIC Dynamics, 1993.

Frequency and Length of Sessions. As stated above, Federal regulation requires WIC agencies
to offer nutrition contacts to each participant twice per certification period. The majority of
agencies report offering nutrition education at least this frequently, and it appears that nutrition
education contacts are made at varying degrees of frequency. Eleven percent reported only one
nutrition education contact for high-risk participants, and 29 percent reported this infrequent
contact with non-high-risk participants. Further analysis of this data revealed that all but 3 of
the 11 percent and 20 of the 29 percent also reported contacts at another frequency (e.g., twice
per certification period). We contacted some respondents who indicated that they made only one
contact. The consistent explanations given indicated that they did not count the nutrition
education provided as part of initial certification as one of the two contacts, so they reported only
one. Therefore, it appears that local agencies are in compliance, but that about 30 percent of
them classify the nutrition education that occurs during certification as a certification activity,
rather than solely a nutrition education contact. However, nutrition education and counseling
does take place during this initial visit.

Nutrition Services
V-7



Chapter IV. Nutrition Services
——_[_;_;__—_—;

Follow-up telephone calls to the Local Agency Survey respondents with this apparent discrepancy
revealed that, although the amount of contact with participants diminished, they believe that they
have refined and improved their materials and that their staff are better prepared. In addition,
local agency staff viewed the increased emphasis on breastfeeding promotion and the broad range
of education topics covered in their sessions (e.g., immunization, child safety, and dental health)
to be indicative of improved quality of nutrition education.

The survey data on improved quality is not supported by the case study data. When case studies
were conducted, there was much discussion by agency staff about the expansion of the WIC
nutrition education to include topics such as substance abuse and immunizations. While these
topics are important, staff believe they often take precedence over providing adequate nutrition
education. Staff frequently spoke of the need to provide more information and to document it
in less time than was previously available. Nutrition education sessions (particularly individual
sessions) last, at most, 30 minutes, but often last less time (5~10 minutes at 21% of sites and
10-15 minutes at 28% of sites). During the time allotted for a session, staff conduct a
Pparticipant’s diet assessment, discuss and document general medical and social information, make
and document referrals, possibly develop an individual care plan, and give or discuss nutrition
education with a participant.

vil. Assessment of Nutrition Services

The case study interview guides and observation checklists incorporated each of the areas
addressed by the FOM Nutrition Services standards. These standards were established for two
reasons:

"1. To provide State WIC directors and nutritionists with a method for evaluating the
quality of nutrition services in their programs, and

2. To encourage States to use their evaluation information to improve nutrition services
in their programs."2

Since the FOM standards are directed to State agencies, and our site visits were to local agencies,
it was not possible to directly evaluate performance against the FOM standards in this study. For
example, some standards that relate specifically to State activities could only be assessed
anecdotally from case study information. Overall, it appears that States have set standards for
performance and have provided guidelines to local agencies that are being followed. The
remainder of this section presents the 12 FOM standards and examples of local agency activities
that relate to the standards, as was ascertained during the case study site visits.

"Introduction. WIC Focus on Management Nutrition Services Standards and Assessment Checklist, Attachment
TI, RFP FNS-90-049SLS, June 1990.

Nutrition Services
IV-23



Chapter IV

Nutrition Services



Chapter V. Integration and Coordination with Other Programs

Exhibit V-9

WIC Services Provided by Non-WIC Staff
at Case Study Sites

Number of Sites with Various Categories of
Non-WIC Staff Providing WIC Services
Service/Activity Physician | Nutritionist | Paraprofessionals | Nurse | Clerk | Other
Income Eligibility 1 2
Determination
Height/Weight 10 2 4 10 1
Blood Testing for Anemia 10 2 4 10
Nutrition Assessment 3 2
Individual Care Plan 3 2
Individual Nutrition Education 3 1
Group Nutrition Education 3
instruction on Use of 1 1
Vouchers
Voucher Distribution 1
Breastfeeding Promotion/ 3 5 2
Support ;

Source: 22 case studies, WIC Dynamics, 1993.

The sharing of staff and resources can facilitate the provision of coordinated, comprehensive
services to clients. However, as the following chapters indicate, the reliance on non-WIC
resources is a source of concern and potential vulnerability for some agencies because the non-
WIC support is often informal and is not guaranteed to continue.

IX. Planning and Special Projects

Coordinated planning and evaluation activities were examined in the case study component of
this study, which provided the information presented in this section. Half of the 22 sites visited
conduct joint planning and evaluation activities with programs outside of WIC. Data sharing
with other programs for purposes of planning, evaluation, or program monitoring occurs at nine
sites (41% of the case study sites). Specific evaluation of coordination activities occurred at only
three of the case study sites.

Planning. Long-range (3- to 5-year) planning for WIC is generally a State-level activity.
Interagency planning occurs at both the State and local levels. For example, both case study
local agencies visited in Ohio credited the State-level interagency planning committee for

Integration and Coordination with Other Programs
V-18



Chapter IV. Nutrition Services
Exhibit IV-8a
Typical Number of Minutes Participants Spend
Receiving Group and Individual Nutrition Education
Group Nutrition Group Nutrition Individual Nutrition Individual Nutrition
Typical Education Education Education Education
Number (not high-risk) (high-risk) (not high-risk) (high-risk)
of Minutes
Receiving Agency | Participant) Agency Participant | Agency | Participant | Agency | Participant
Service. | (%) (%) (%) (%) (%) (%) (%) (%)
<<
Otod5 0.8 2 0 ) 13 18 4 4
5 to 10 9 9 "1 8 39 35 20 22
10 to 15 23 27 9 15 32 33 28 23
15 to 30 51 54 58 62 14 12 42 42
More than 30 16 9 22 15 2 3 7 10
Total 100 100 100 100 100 100 | 100 100 |
Source: Based on estimates for 1,777 local agencies. Local Agency Survey, WIC Dynamics, 1993.
Exhibit IV-8b
Typical Number of Minutes Participants Spend Receiving Group
and Individual Nutrition Education at 22 Case Study Sites
Typical Number of Individual Group Nutrition
Minutes Waiting Nutrition Education
for Service Education (# of sites)
(# of sites)
al
Otos ) }
5to 10 2 2
10 to 15 12 3
15 to 20 7 3
20 to 25 3 3
25 to 30 oO 3
More than 30 1 2 _|
Source: 22 case studies, WIC Dynamics, 1993.
Nutrition Services

IV-10


Chapter IV. Nutrition Services

Exhibit IV-7

Typical Number of Minutes Participants Wait
for Group and Individual Nutrition Education

Group Nutrition Individual Nutrition

Typical Number of Education Education (%)
Minutes Waitin
for Service 9 Agency Participant Agency Participant

(%) (%) (%) (%)
0105 49 30 38 24
5 to 10 24 24 30 26
10 to 15 14 24 17 18
15 to 30 7 15 12 22
More than 30 4 5 3 9
Total 100 100 100 100

ee

Source: Based on estimates for 1,777 local agencics, Local Agency Survey, WIC Dynamics, 1993.

The amount of time local agencies report that participants spend receiving education was
generally 15 to 30 minutes for all group sessions. Among agencies providing non-high-risk
group education sessions, 51 percent offer 15- to 30-minute sessions; among agencies providing
high-risk group sessions, 58 percent offer sessions of that same length (Exhibit IV-8a). High-risk
individual education was generally longer than non-high-risk education. Approximately 42
percent of agencies provided between 15- and 30-minute sessions for high-risk participants,
compared to 14 percent of agencies providing such lengthy sessions to non-high-risk participants.
Thirteen percent of the agencies reported providing non-high-risk individual sessions that last less
than 5 minutes. Among the case study sites, more than half (12 of the 22) spend between 10 and
15 minutes providing individual nutrition education (see Exhibit IV-8b).

Nutrition Services
V-9



Chapter VI. Synthesis of Reported Changes on State and Local Agency
Operations and Factors Affecting Quality of WIC Services

the WIC Program as the second most frequent factor. This includes support from various
sources such as the community, sponsoring agencies, other service programs, or within the WIC
Program itself. Quality nutrition services was the third most frequently cited factor from the
Local Agency Survey. These included features such as individualized client attention, quality
materials and equipment, and breastfeeding promotion and support activities. State agencies
responded with ongoing program improvement as the third most frequently cited factor.
Aspects of ongoing improvement include training and the use of standards and quality assurance
techniques to evaluate operations and service and to use this information to promote positive
change. Quality clinic operations was the fourth most frequently cited factor in the local agency
survey and fifth most frequently cited by State agencies. Features such as extended or flexible
hours, efficient voucher or scheduling systems, and computers or automation were included in
this factor. Referrals/integration was the fifth most frequently cited factor for local agencies.

Exhibit Vi-4

Factors That Promote High-Quality WIC Services

Factor Local Agencies (%) State Agencies (%)
Caring, Concemed Staff 69 57
Qualified, Well-Trained Staff 53 42
Quality Nutrition Services 49 26
Quality Operations of Clinic 38 36
Referrals/Integration 31 34
Support/Cooperation within the WIC Program . 55
Ongoing Program Improvement * 51
Adequate Facilities 30 23
Support from the Community and Other 28 18
Services

Staff - General 15 27
Ongoing Training/instruction for Staff 17 *
Participant Support 6 .
Vendor Monitoring/Cooperation 2 8
Other 23 13

* This answer was not frequently reported in this survey.
Source: Local Agency Survey and State Agency Survey, WIC Dynamics, 1993.

Synthesis of Reported Changes on State and Local Agency Operations
and Factors Affecting Quality of WIC Services
Vi-7



Chapter V. Integration and Coordination with Other Programs

staff members to assist in making appropriate referrals. Over half of the sites reported
coordinated appointment scheduling, which occurs most often in colocated sites. Appointment
scheduling may be coordinated by checking with the prenatal or well-baby clinic on the client’s
next appointment date, or a more formal scheduling procedure through a single receptionist may
take place. A written procedure or form is used to refer participants from WIC to other providers
in nine of the 22 sites. Over three-quarters of the sites document referrals in the client record.
Thus, many sites do not require a form to initiate a referral, but still document referrals that are
made. In fact, referral codes were standard on intake forms for automated agencies. However,
what constitutes a "documentable" referral varies not only from agency to agency, but also among
WIC staff in the same agency. In some cases, referrals were documented only if a staff member
called a provider or agency on behalf of a participant, in other cases, referrals were documented
if a specific name and telephone number was provided to the participant; and sometimes staff
members recorded referrals if they had simply mentioned the availability of a particular service
or provided a flyer describing the service. While referrals are often a matter of staff judgement,
over one-third of the sites make automatic referrals based on established criteria. For example,
Delaware’s ADP system automatically generates referrals to Medicaid, Food Stamps, and
immunizations, if the client meets eligibility criteria. Several sites indicated that computerized
appointment scheduling, integrated with other public health programs, was planned as an
enhancement of existing systems, but none of the sites visited had yet implemented such a
system.

Although all of the case study sites actively referred participants to a wide range of health and
social services, only seven sites routinely followed up on referrals. In most cases, follow-up
activities were informal and were determined on a case-by-case basis, depending upon the staff
member’s assessment of a client’s need for close monitoring and on the amount of time available.

Referrals to WIC from other providers followed a written procedure or used a form designed for
the purpose of referral in over one-half of the case study sites. The most common example of
this type of referral occurs when a private physician refers a client to WIC and provides the
anthropometric and laboratory information needed for WIC certification. For example, Portage-
Columbiana, OH, WIC has agreements with Child and Family Health Services and two local
clinics to obtain blood work and with Planned Parenthood to obtain pregnancy results. The Local
Agency Survey found that 16 percent of local agencies use non-WIC medical providers for
certification. Some WIC Programs provide physicians and public health clinics with referral
forms for this purpose. Delaware, for example, provides physician referral slips in the form of
pads similar to those used for writing prescriptions. Although information for certification is
accepted from referring physicians and health centers, WIC staff must still complete certification.
Only 3 of the 22 case study sites had CPAs outside of the WIC Program. In Atlantic City, NJ,
the Healthy Start Program at one prenatal clinic provides its own WIC certification (using their
public ‘health nutritionist) for initial WIC certification, including counseling and nutrition
education. This program issues one month of checks, and then clients come to the main WIC
clinic for their second and subsequent contacts. Before certifying someone at Healthy Start, a
call is made to the WIC clinic to make sure that the client is not already enrolled in the program.
In Ft. Duchesne, UT, a public health nurse from the Indian Health Service is authorized to certify
individuals for WIC. She is colocated at the WIC clinic one aftemoon per week to provide

Integration and Coordination with Other Programs
V-14



Chapter V. Integration and Coordination with Other Programs

1988). The 1989 Budget Reconciliation Act (P.L. 109-239) also directed States to set reasonable
Medicaid reimbursement rates for providers.

Il. Integration and Coordination with Local Health Care Delivery
Systems

Each WIC agency must ensure that its clients have available and accessible health care. This
may be facilitated in a number of ways, including organizational sponsorship and program
location. As shown in Exhibit V-1, the Local Agency Survey indicates that about 88 percent of
WIC local agencies are sponsored by a health organization such as a local health department, a
community health agency, or a public hospital. Of the 22 local agencies visited, over three-
fourths are sponsored by health agencies, including one sponsored by a private voluntary hospital
and one by a private proprietary hospital.

Exhibit V-1

Local Agency Sponsorship

Local Agency Sponsorship/Type Local % Local ‘Ageney |
Agencies Covered Case Study
in Survey | Participants Sites

(%) (#)
Health Agencies:
State 2% 9% 3
District 6% 12% 1
Multi-County Te 9% 2
Single-County 48% 28% 2
Municipal 2% 9% 4
[cena 17% WW% Qo
Indian 5% 2% 1
Hospitals 2% 4&% 4
Total: 88% BA% 7
Health Organizations
‘Community Action Programs T% 6% 1
Other 5% 10% 4
Total 100% 100% 22

Source: Based on estimates for 1,777 local WIC agencies, Local Agency Survey, and 22 case studies, WIC Dynamics, 1993.

Integration and Coordination with Other Programs
vV-2



Chapter V. Integration and Coordination with Other Programs

development of the Combined Programs Application. This committee includes WIC, the
Department of Human Services, Child and Family Health Services, and the Children with
Medical Handicaps Program. In Delaware, the State planning process involves joint meetings
among all State programs serving the maternal and child health population. The meetings are
held in three parts of the State at different times in a town-meeting style. There is also a
regional coordinating council, which includes WIC, Medicaid, and Public Health, that meets
quarterly. The Maternal and Child Health Program, which includes WIC, was also a key
participant in the Child Health Task Force, which developed a framework for a Statewide
comprehensive primary health care system for children in Delaware.

At the local level, WIC Programs participate in planning with their sponsoring agencies. The
New Haven, CT, WIC Program participates in the overall planning for Yale-New Haven
Hospital’s Primary Care Center. As a result of this joint planning, WIC was incorporated in
renovation plans to further integrate WIC into Maternal Health Center activities at the hospital
by moving WIC closer to these facilities. In Salt Lake City, UT, the WIC Program participates
in health planning activities with the county health department and with community groups.
Palm Beach County, FL, WIC engages in long-range planning, both at the request of the State
agency and as a way to effectively address the rapid growth and demographic changes in the
community it serves. Working with the director of the county public health unit, the WIC
director used a variety of data sources (including WIC participation data, census data, data on
changes in birth rates, and immigration data) to project caseload. Palm Beach County has an
active health services planning district that provided much of the information used in the planning
process. Caseload projections were used to identify areas which would need additional services
and to project staffing needs. Projections were discussed and compared with those of the health
department and with community organizations, such as the local chapter of the March of Dimes.
Five-year plans were developed for computer needs, staffing (direct service and administrative),
and clinic sites. The entire process of compiling site survey and long-range planning data took
about 2 months, but continues as information is updated and plans are refined.

Special Projects. Both the survey and case study data indicate that local agencies have initiated
a variety of special projects. The survey revealed that 5 percent initiated special projects, and
the case studies collected information on the nature of special projects in case study sites. A
number of these projects reflected an interest in improving integration and in better understanding
the health service needs of WIC participants. For example, the Wilkes-Barre, PA, WIC Program
recently conducted an immunization survey to determine whether children were being immunized
as required and a health insurance study to determine the number of WIC participants who have
health insurance coverage. These surveys were both conducted to provide information for
planning and targeting a Pennsylvania State initiative to coordinate immunization (which is
covered by health insurance by State law) with WIC services. In Delaware, WIC and Maternal
and Child Health have used the computer system to evaluate specific issues. For example, at the
State level, they are looking at the services received or not received for cases of infant mortality
and conducting cross-clinic comparisons on various issues. Since time constraints limit the
number of special projects that can be undertaken, some WIC sites, such as the one in Long
Beach, CA, encourage students interning at the agency to pursue special research projects.

Integration and Coordination with Other Programs
V-19



Chapter V. Integration and Coordination with Other Programs

I Overview

The WIC Program has always functioned as an adjunct to health care, and referral to appropriate
health care is one of the key services provided by the WIC Program. The WIC Dynamics Study
explores the impact of growth and other changes affecting the service delivery environment on
service coordination and integration between WIC and other programs. In the WIC Dynamics
Study, coordination refers to activities such as referrals among providers, the transfer of
information between providers, avoidance of unnecessary duplication of functions, the scheduling
of services in a way that does not interfere with other programs serving the same population, and
joint planning for service delivery or special programs. Integration refers to a set of services
operated and perceived from the client’s point of view as one program. Integration implies
colocation, sharing of staff, sharing of records, etc. One example of integration—One-Stop
Shopping—tefers to the colocation and integration of eligibility processes for WIC, Medicaid,
and maternal and child health programs and service delivery or arrangement for needed services.
In some settings, integration is not possible, but good coordination exists, which provides
participants the services they need.

The findings presented in this chapter must be considered in the context of the WIC operating
environment, which is characterized by a diversity of program structures and models for
coordination of services. Evidence in the literature (see, for example, Macro 1990; Summer,
1991) as well as the site visit findings of this study confirm that each local WIC Program
functions within a unique and dynamic service delivery system and health care marketplace. As
the WIC Program reaches more eligible women and children, it is possible that the increased
referrals and efforts to coordinate service delivery generated by WIC will place an increasing
strain on an already overburdened health care system (Pindus et al., 1986; Hill, 1988; National
Commission, 1988). Conversely, WIC Programs that have experienced rapid growth may be
forced to limit some of their outreach and referral activities due to limited time, space, or other
constraints (FCS, 1990). A number of Federal as well as State initiatives have affected the

availability and accessibility: of health care in local communities. The 1989 Budget
Reconciliation Act (P.L. 109-239) expanded Medicaid coverage for pregnant women, infants, and
children up to age 6 if family income is below 133 percent of the poverty line. The Act also
tequired State Medicaid programs to provide for coordination between the Medicaid and WIC
Programs. The expansion of Medicaid eligibility and the growth of the WIC Program have
occurred at the same time that the U.S. Department of Health and Human Services funded a
perinatal care initiative in community and migrant health centers (Macro Systems, 1991),
Healthy Start Initiatives in selected communities, and immunization and lead screening initiatives
through State health departments (HRSA, 1993; Biemesderfer, 1993; King, 1993). At the same
time, State health departments have experienced serious strains on their budgets, and economic
downturns have increased the demand for services and changed the profile of the population
seeking assistance in many communities. During the past decade, a malpractice insurance crisis
in many States has limited the availability of obstetrical care for poor women (Lewis-Idema,

Integration and Coordination with Other Programs
V-1



Chapter VII. Current Operating Capacity and Perspectives on Accommodating
Future Growth

reasons for moving, the site visit findings suggest that agencies may move to ameliorate these
problems. However, even though half of the local agencies have moved, more than half still
report inadequate facilities.

The case study findings echoed these space concerns. Fourteen of the 22 agencies visited
reported having space lacking in privacy for individual sessions, 19 agencies reported inadequate
seating for individual sessions, 14 reported the same problem for group sessions, and 15 agencies
reported using space for groups that did not allow all participants to either see or hear the
instructor and audio-visual materials.

Staff. In addition to space, staff and the shortage thereof were reported as one of the main
factors affecting operating capacity. The following examples illustrate the impact that staff issues
have upon capacity.

° Local agencies commonly reported that they had less than sufficient numbers of staff, with
larger agencies reporting this more frequently. Almost two-thirds of participants are being
served by agencies that reported insufficient numbers of staff. This is true even though the
majority of agencies reported that the numbers of staff have increased since 1988. It
appears that, in the view of local agencies, staffing levels have not grown sufficiently to
accommodate the WIC caseload.

. Over half of the local agencies reported that they have difficulty recruiting qualified staff,
particularly for professional positions. This can be a problem even for agencies with
available funds to hire staff. The primary barriers cited were salaries and benefits that were
not competitive, hiring freezes, and labor shortages. It should be noted that these factors
generally are beyond WIC’s control. In those States where WIC staff are State, county,
or municipal employees, recruiting procedures and salary/benefit levels are established
outside of the WIC Program.

. Over one-third of local agencies have reported difficulty in retaining staff once they were
hired, a more common factor for agencies that serve larger numbers of participants.

° When given the opportunity to identify barriers to providing high-quality services, 39
percent of local agencies and 49 percent of States cited staff shortages as a barrier.

. Data from the case studies indicate that 19 of the 22 agencies visited are concerned about
their need for more staff to accommodate future program growth, and 12 of the agencies
were concerned about the shortage of qualified nutritionists in the area. Several of the case
study sites (e.g., New York City, NY; Atlantic City, NJ; Wilkes-Barre, PA) reported that
this shortage was due to the general unavailability of nutrition staff, in particular, and to
the relatively non-competitive salary level of WIC nutritionists.

These findings indicate that the shortage of staff is viewed by both State and local agencies as
having a serious impact on capacity.

Turrent Operating Capacity and Perspectives on Accommodating Future Growth
Vil-2



Chapter IV. Nutrition Services

Agency Survey indicate that one-third of agencies use paraprofessional staff to provide nutrition
education.

Type of Session—Individual or Group. Data from the Local Agency Survey indicate that 98
percent of all agencies offer individual nutrition education sessions (Exhibit IV-4). In addition,
57 percent offer small groups (2-9 people); 47 percent offer medium groups (10-19 people); 21
percent offer large groups (20-29 people); and 10 percent offer very large groups (30 people or
more). When analyzed by the number of participants in these various sites, almost 50 percent
of participants are in agencies offering large groups and 18 percent are in agencies offering very
large groups. Among the 22 case study sites, five offered only individual sessions, five sites had
small groups, nine offered medium groups, one offered large groups, and three offered very large
groups. The study did not investigate the relationship between group and individual sessions.

Exhibit IV-4

Group Size for Providing Nutrition Education

[ croup Size Agency Participant |
(%) (%)

Individual : 98 98 =
Small Group (2-9) 57 64
Medium Group (10-19) 47 62
Large Group (20-29) 24 47
Very Large Group (30+) 9 18

Source: Based on estimates for 1,777 local agencies, Local Agency Survey, WIC Dynamics, 1993.

Since 1988, over half (57%) of the agencies have increased their use of group education sessions
(Exhibit IV-5). However, equal proportions of agencies (slightly more than 25%) reported
switching from one type of session to the other, that is, either offering more group and less
individual sessions, or more individual and less group sessions. Regardless of any changes in
session format, more agencies are offering group sessions. Since 1988, 40 percent of agencies
have increased their class size and 56 percent increased their use of handouts and pamphlets.

Nutrition Services
WvV-6



Chapter IV. Nutrition Services

of people being served within 15 minutes (Exhibit IV-12). One important observation is that the
waiting time is often as long as the time it takes to receive the food instruments, and substantially
longer in the larger agencies than in the smaller ones. In addition, when comparing the waiting
time to the actual issuance time, it appears that while some participants must wait longer than
others, the actual food instrument issuance time remains more consistent between agencies.

Exhibit IV-12

Time Spent Waiting For and Receiving Food Instruments

Less Than 5 Minutes 6 to 15 Minutes 16 to 30 Minutes
i Agency Participant Agency Participant Agency Participant
(%) (%) (%) (%) (%) (%)
Waiting 42 24 44 47 7 21
Issuance 41 | 46 | 47 42 4 6

Source: Based on estimates for 1,777 local WIC Agencies; Local Agency Survey. WIC Dynamics, 1993.

Since 1988, this waiting time decreased in 31 percent of the agencies (Exhibit IV-13). Fifteen
percent of the agencies, serving 20 percent of participants, reported that the waiting time
increased, which again indicates that the waiting time is longer in the larger agencies. Thirty-
three percent of the agencies indicated that the time involved in the actual issuance process
decreased, while 11 percent of the agencies felt that the issuance time increased. Fifty-six
percent of the agencies reported no change in their issuance time.

Exhibit 1V-13

Change in Time Spent Waiting For and Receiving Food Instruments

Increase in Time
Agency Participant Agency Participant
(%) (%)
Waiting 15 20
Issuance 11 11

Source: Based on estimates for 1,777 local WIC Agencies; Local Agency Survey. WIC Dynamics, 1993.

Local Agency Survey responses indicate that both the waiting time and the issuing time for food
pickup are usually less than 10 minutes. There are only three States that continue to deliver food
directly to the participants; however, in several agencies, some food, such as formula or infant

Nutrition Services
Iv-20



Chapter VI. Synthesis of Reported Changes on State and Local Agency
Operations and Factors Affecting Quality of WIC Services

economic conditions caused many more people in their communities to be eligible for WIC,
which strained their ability to deliver services.

Program Requirements. Much of the change in the WIC Program over the past 5 years has
been attributed to increased Federal emphasis on existing program requirements and on new State
requirements. Many agencies report that their programs have been altered by these requirements,
which include increased emphasis on breastfeeding promotion, drug abuse education, homeless
services, immunization coordination, prenatal care initiatives, and vendor management. Each of
these requirements were mentioned by over 60 percent of State agencies as having affected their
programs, as shown in Exhibit VI-3.

Exhibit VI-3

Initiatives That Impacted State and Local WIC Agency Operations

Initiative State Agencies impacted Affected Local Agencies
(%) (%)

Breastfeeding Promotion 88 88

Drug Abuse Education 69 57

Homeless Service 62 34

Immunizations 75 *

Prenatal Care 69 *

Vendor Management 7 ai

+ This information was not collected on the Local Agency Survey.
Source: Local Agency Survey and State Agency Survey. WIC Dynamics, 1993.

Information from the case studies confirm that many of these initiatives have impacted the local
agencies. For example at the Wilkes-Barre, PA, case study site, a breastfeeding coordinator
implemented many promotions such as providing breast pumps to WIC participants and
sponsoring staff training sessions. Peer counselor programs to promote and support breastfeeding
have been implemented in several sites, including Montgomery County, MD, and Delaware. The
San Antonio and Temple, TX, case study sites implemented a State-mandated immunization
initiative. Under this initiative, all service sites have a qualified immunization nurse available
for participants. New York State has also implemented an immunization initiative, and its impact
was evident in several local agency site visits. In the Brooklyn, NY; New York City, NY; and
Hudson, NY, sites, the screening for all required immunizations and updating of the
immunization record are part of the WIC certification process. In some local clinics, participants
who are behind on their immunizations are required to return monthly for WIC vouchers, while
those whose immunizations are current receive their vouchers bimonthly. The impact and the

Synthes!s of Reported Changes on State and Local Agency Operations
and Factors Attecting Quality of WIC Services
VIS





Chapter V. Integration and Coordination with Other Programs

care services were colocated at over half of the sites. Over half of the 22 local agencies reported
colocation of obstetrical/gynecological (ob/gyn) care; family planning; immunizations, AIDS
testing, counseling, or treatment; and sexually transmitted disease clinics. Colocation facilitates
coordination in activities such as client monitoring and information sharing and coordinated
appointment scheduling. Of the 22 case study sites, over three-quarters reported sharing clinical
information with other health care providers. Nine sites indicated that they meet with other
providers to discuss individual cases. In seven sites, the WIC record was integrated with the
patient record used by other providers at the site. Twelve sites coordinate WIC appointments
with appointments for other services. One of the most integrated WIC sites visited is Tangipahoa
Parish, LA. WIC is not considered a separate program here, but simply one of the services
offered by the Health Unit. The staff work for all of the programs simultaneously, and there is
one medical record. All staff are cross-trained so that, for example, clerks in the Health Unit are
as proficient in WIC procedures as in immunizations, family planning services, treatment of
sexually transmitted diseases, or child health services.

Exhibit V-6

Services Available On Site at Principal WIC Clinics

Health Services Principal Non-Health Services Principal WIC
WIC Clinics Clinics
= (%) (%)
Breastfeeding Support 71 Substance Abuse Counseling 30
Program
Immunizations 67 Social Service Programs 29
Family Planning Services 50 Food Assistance Programs 20
Other Health Screening 48 Transportation 19
EPSDT 47 Lee 16
Pediatric Care 44 Housing 13
Medicaid Screening 38 Head Start 12
OB/GYN Care 38 Child Care 10
Dental Care 16 Adult Educ./Job Training 9

Source: Based on estimates for 1,777 local WIC agencies; Local Agency Survey, WIC Dynamics, 1993.

Coordination with health services is not limited to sites where services are colocated, however.
In fact, some sites, such as Atlantic City, that had no health services available on site, developed
good service coordination with other providers as an outgrowth of their reliance on these
providers for WIC anthropometric and hematologic data. In San Antonio, TX, where colocation

Integration and Coordination with Other Programs
v-9



Chapter V. Integration and Coordination with Other Programs

of WIC with full health department services is not possible at all sites, some services are being
specifically targeted to WIC participants at the same time and place as WIC. For example, in
at least one San Antonio WIC clinic, EPSDT program staff are present at WIC clinics, although
this is not a site where the two services are colocated. Intake screening for EPSDT is done at
the same time as WIC certification. Lead screening and hematocrit testing are coordinated, and
both programs use the information. WIC measures height and weight and provides this
information to EPSDT. The client is then certified for WIC, receives EPSDT counseling, and
picks up WIC-vouchers. Case study observations indicated that it did not necessarily take longer
for the participant to receive the additional coordinated services. Time required varied depending
upon the logistical arrangements. For example, in the San Antonio case described above, lead
screening and hematocrit testing are accomplished through a single blood test, and the time spent
receiving EPSDT counseling would otherwise be sent waiting for vouchers to be prepared. On
average, 15 participants are referred each morning and each afternoon of the coordinated clinics.

Medicaid eligibility determination was colocated with WIC at over one-third of the case study
sites. Medicaid eligibility determination was integrated with the WIC certification process at
three of these sites. At the other sites, appointment scheduling for WIC and Medicaid was
coordinated, and WIC staff were aware of income eligibility guidelines and documentation
requirements for Medicaid. Increased coordination of WIC and Medicaid is an outgrowth of the
Medicaid expansions, which required increased coordination and extended adjunctive WIC
income eligibility to a large proportion of women, infants, and children. Local Agency Survey
data indicate that at 14 percent of local agencies, nutrition services are covered by Medicaid. For
example, under Healthy Start in Montgomery County, MD, New Haven, CT, and Palm Beach
County, FL, individual nutrition counseling to high-risk pregnant women is reimbursed by
Medicaid. Although the nutritionist providing the counseling may not be part of the WIC
Program, counseling is scheduled to meet the WIC nutrition education contact requirements in
coordinated programs. Another example is the Califomia Comprehensive Perinatal Services
Program (CPSP), which uses MediCal funds to provide prenatal care to low-income women. At
one program in Long Beach, CA, the nutritionist at one of the CPSP programs does nutrition
screening and counseling for WIC. If her screening indicates that a patient would be eligible for
WIC, she schedules an appointment for her at the WIC clinic and provides the patient with a
copy of her anthropometric measurements, diet assessment, and prenatal weight gain graph. This
level of coordination is extremely helpful to the WIC staff.

IV. Integration and Coordination with Social Services

As the second column in Exhibit V-6 shows, services other than health care are available much
less frequently on site. Nearly one-third of the principal clinics have substance abuse counseling,
social service programs, food assistance programs, transportation, or AFDC on site. Between 9
and 15 percent of the principal clinics have Head Start, child care, housing, and adult
education/job training services on site. However, the ability to apply for the following types of
services is available in at least 25 percent of the principal WIC clinics: social service programs
(35%), food assistance programs (32%), substance abuse counseling (28%), and AFDC (25%).

Thtegration and Coordination with Other Programs
V-10


Chapter VI. Synthesis of Reported Changes on State and Local
Agency Operations and Factors Affecting Quality of WIC
Services

SS

There have been a number of areas in the WIC Program that have changed since 1988.
Increasing caseloads, infant formula rebates, and required initiatives in a variety of areas are just
a few examples of the changes to which local agencies have adjusted. As part of this study, local
and State agencies were asked to describe levels and impacts of many changes. In addition,
questions about the quality of WIC services were included in both surveys. This section reports
on these results.

|. Participation Growth

Growth in WIC participation is probably the most obvious change that has affected local
agencies. Between 1988 and 1992, the number of WIC participants increased by 45 percent
nationwide. The following discussion provides details of the growth.

Exhibit Vi-1

Locai Agency Caseload in Local Agencies by Number of Service Sites

Number of Participants per Local Agency
Local Q 100 1,000 2,000 10,000 | 25,000 | 50,000 Total
Agency to to to to to to or
Number of 99 999 1,999 9,999 24,999 | 49,999 more
Sites (%) (%) (%) (%) (%) (%) (%) (%)
1 Site 20 58 16 6 co) 1) 0 100
2-3 Sites i) 44 31 25 0 0 ) 100
4-5 Sites i) 25 31 43 0.75 i) 0 100
6-10 Sites Ve) 9 20 60 9 0.35 0 100
11-25 Sites oO 5 W 51 26 6 0.58 100
Over 25 o) 0 34 4 32 13 17 100
Sites

Source: Based on estimates for 1,777 local WIC agencies; Local Agency Survey, WIC Dynamics, 1993.

Synthesis of Reported Changes on State and Local Agency Operations
and Factors Affecting Quality of WIC Services
Vi-1



Chapter IV. Nutrition Services

————————————————————————————————————————

administrators were reported to be the decisionmakers about the foods that could be used or
substituted within the WIC food package.

Overall, it appears that State Agencies have implemented standards for delivering nutrition
services and the case study agencies provide nutrition services that comply with these standards.

In summary, the study found positive indicators of WIC nutrition services. Individual participant
assessments, care plans, and nutrition education are carried out by qualified staff. Even with
tremendous growth, nearly all local agencies continue to offer individual nutrition education
sessions to participants. Agencies have increased the use of group sessions and materials as the
nutrition education services offered to participants. Despite caseload growth, most participants
wait 10 minutes or less for nutrition education sessions which cover a range of topics and are
delivered using a variety of methods.

WIC local agencies are aware of the factors that affect and the barriers that complicate the
delivery of high-quality nutrition services. One-third of local agencies have maintained the level
of staff education and training activities, and another third have increased these activities.
Changes in practices have increased the efficiency of the food voucher issuance process. State
Agencies and many sponsoring agencies monitor and evaluate nutrition service delivery at local
agencies on regular basis. While barriers do exist, a majority of local agencies report that they
have maintained or increased the quality of their nutrition services since 1988. It appears that
overall, local agencies have accommodated caseload increases while maintaining the quality of
nutrition services delivered to WIC participants.

Nutrition Services
1V-26


Chapter VI. Synthesis of Reported Changes on State and Local Agency
Operations and Factors Affecting Quality of WIC Services

programs have not been initiatives but rather circumstances, such as a downtum in local
economy. The following sections describe various factors identified by local WIC agencies as
having had an impact.

Changes in Caseload. During the case study site visits, many agencies discussed the difficulties
they experienced managing caseload fluctuations. An increase in caseload was the most common
change reported in the surveys, with 86 percent of local and 87 percent of State agencies
indicating that an increase in caseload had affected their operations. The local agencies that
reported impacts from caseload increases serve 94 percent of the participants. Many local
agencies experienced one or more caseload decreases during the same 5-year period from 1988
to 1993, even if their overall caseload increased over this time period. Agencies decrease
caseload by suspending new enrollment and initiating waiting lists or restricting the categories
or priority groups served. Caseload decreases impacted 30 percent of local agencies. Caseload
increases were more prevalent than decreases. Overall for the entire period, the trend was toward
caseload growth as indicated by FCS data, which show that 92 percent of local agencies
increased caseload from their 1988 levels.

Economic Factors. Based on the response from local and State mail surveys, there were a
number of economic factors that impacted WIC agencies. Infant formula rebates was cited most
often among these factors, with 87 percent of State agencies serving 99 percent of the participants
reporting an impact. A similar percentage of local agencies reported that infant formula rebates
affected their operations (86%).

Another economic factor that affected many agencies was fluctuation in food costs. Both State
and local agencies reported: an effect on operations (92% and 70%, respectively). As learned
through a case study visit, the Delaware State agency implemented a program to attempt to
control the fluctuations of food costs. Retailers that wanted to be WIC vendors were required
to submit a price for each WIC food item each quarter. This price was used to cap charges at
a specific level so that vendors could not charge more than this amount, regardless of shelf price.
However, if the shelf price was lower than the cap, the vendors were required to charge shelf
price. This effort saved the State food dollars and reduced the impact of food cost fluctuations.

Issues related to funding were also reported as having an impact on State and local agency
operations. The increase in Federal funds since 1988 was the most commonly reported issue,
with 78 percent (each) of State and local agencies citing this. Sixty-three percent of local
agencies noted that the availability of State funds impacted them, while only 36 percent of State
agencies did. The difference in these figures may be due to larger States receiving State-
generated funds, where more local agencies would be affected. Of the 22 case study sites, 13
reported that limited resources of their sponsoring agency altered local operations. Finally, a
downturn in the local economy was commonly cited as affecting WIC Programs, as reported by
71 percent of State and 77 percent of local agencies. Seventeen of the case study sites reported
being affected by a poor local economy. Some agencies on our site visits reported that local

Synthesis of Reported Changes on State and Local Agency Operations
and Factors Affecting Quality. of WIC Services
Vi-4



Chapter Vil. Current Operating Capacity and Perspectives on
Accommodating Future Growth

In order to understand the impact of changes and assess the potential for further growth, it is
necessary to first have an understanding of the current operating capacity of WIC agencies.
Operating capacity refers to a local agency’s capability to deliver services effectively relative to
caseload size. Current operating capacity was specifically addressed in both the State and Local
Agency Surveys. The local agency findings are supplemented by case study information. The
case study site visits also explored issues concerning future growth. These findings are presented
in the second part of this chapter.

I. Current Operating Capacity

There are many factors that contribute to a local agency’s capacity to serve its current caseload
and accommodate future growth. These factors include adequacy of current space, staffing,
funding, operating hours, efficiency, and other administrative operating features. The Local
Agency Survey included the following question regarding capacity: "How close are you to
operating at maximum capacity (relative to the size of your WIC caseload and your capacity
to deliver services effectively)?" To get the State Agency’s perspective, a similar question was
included in that survey: “In your opinion, in what capacity are local agencies in your State
currently operating?” For both surveys, 69 percent of respondents indicated that local agencies
were operating above capacity. This is an important consideration when determining the
program’s ability to accommodate future caseload growth. Following is a discussion of some
of the factors which affect local agency capacity.

Capacity To Serve. State agencies were asked to characterize the capacity of their local
agencies with regard to the level at which the existing local agencies are currently operating.
While 43 percent of the State agencies (less than half), characterized their local agencies as being
above capacity, those State agencies represent 60 percent of all WIC local agencies and 61
percent of WIC participants. Thirty percent of the State agencies indicated that their local
agencies are below capacity; however, they account for only 9 percent of all local WIC agencies.
Thus, the capacity for growth, as portrayed from the State-level perspective, is lowest in the
agencies serving larger numbers of participants.

Space and Facilities. In order to be able to serve participants adequately, the facilities in which
WIC operates must be of adequate size, appropriately partitioned, with sufficient waiting room
space, furniture, play areas, etc. When local agencies were asked if their current space was
adequate, only 33 percent replied that it was. The 67 percent of agencies that reported
inadequate space served 82 percent of participants, so the larger agencies reported this problem
more frequently. When given the opportunity to discuss general barriers to high-quality services,
65 percent of local agencies wrote that inadequate facilities or materials were a problem. Some
comments included were that the space was too small, located in a dangerous area, there was not
enough privacy, or there was no area for children. Almost half of the local agencies surveyed
teported moving to a new facility. Although the survey did not collect information on the

ing an on MMo ig Future Growl
Vil-1



Chapter IV. Nutrition Services

——— ee ——————

As indicated in Exhibit IV-1, 18 of the 22 case study sites had registered dietitians or licensed
nutritionists conducting the nutrition assessments. Other staff completing this function include
other professional nutritionists, paraprofessionals, and nurses.

The dietary assessment process often begins with the participant providing a diet history or 24-
hour recall form on the food eaten by the participating family member. All of the case study
sites used the 24-hour recall instrument as the method for assessing the participant’s dietary
Status.

Exhibit 1V-1
WIC Nutrition Services by Type of Staff
(Number of Case Study Sites)
Staff Category--WiC Steff or Consultants
Service/Activity RD or Other Paraprof. Other Clerk | Nurse| Lactation | Other
Licensed | Nutritionist | Bachelor's | Paraprof. Consultant
Nutritionist Level
Income Eligibility 4 1 2 9 15 0
Determination
Measure 9 4 2 6 1 4 1 oO
HeightWeight
Perform Blood 7 3 2 5 iY) 5 1 U0)
Testing for Anemia
Nutrition Risk 18 10 3 7 0 2 0 i)
Determination
Develop Indiv. Care 16 8 2 2 fo) 2 0 c)
Plan
Provide Indiv. 18 11 5 8 2 2 0 i)
Nutrition Education
Conduct Group 14 8 4 5 1 1 0 0
Nutrition Education
instruct on Use of 10 4. 3 8 16 0 ° 1
Vouchers
Issue Voucher 7 4 2 9 14 1 () 1
Breastfeeding 17 9 4 9 1 2 9 2
Promotion/Support

Source: 22 case studies, WIC Dynamics, 1993.

Nutrition Services
IV-2


Chapter V. Integration and Coordination with Other Programs

Exhibit V-8

Resource Sharing at Case Study Sites

Indicator/Activity Number of Sites
[ wic Services Provided by Staff of Other Programs 12
Administration/Support Provided by Staff of Other Programs 6

WIC Pays for Services Received from Other Programs

WIC Provides Services to Other Programs

Shared Facilities 19

Shared Equipment 6

Source: 22 case studies, WIC Dynamics, 1993.

Sharing of staff occurs for both administrative and clerical functions. Administrative functions
include building security and maintenance, shared reception staff, and the processing of financial
and administrative matters by WIC’s sponsoring agency. Sharing of clinical staff occurs
primarily in WIC clinics that are colocated or closely coordinated with health services and share
staff for the purpose of obtaining anthropometric and hematological measurements. Based on
the survey of local agencies, 29 percent of local agencies use non-WIC on-site staff for
hematological measurements at their principal clinic sites. Interestingly, over one-fourth of the
sites in the Local Agency Survey responded that they did not know whether hematological
Measurements were provided on site by non-WIC staff. An example from one of the site visits
provides a possible insight. Staff in Tangipahoa Parish were "stumped" by the question, "Is
there sharing of staff and resources?" Their programs are, in fact, so integrated that WIC is
considered as a service of the public health unit, not a separate program. All staff participate in
all programs. No fees are charged to WIC for rent, security, maintenance, or other building
services. Nursing staff provide height, weight, and blood work for WIC patients, and this service
is not charged to the WIC Program. Local agency staff did not know whether an indirect cost
rate was charged to WIC because this is handled at the State level in Louisiana.

Programs that are well integrated might well have difficulty identifying whether certain services
are provided by non-WIC or WIC staff. Exhibit V-9 summarizes site visit observations
concerning the provision of services by non-WIC staff. Physicians and nurses were the most
likely non-WIC staff to be involved in service provision for anthropometric measurements and
blood work. Non-WIC nutritionists are used for a wider range of services, including nutrition
couns. :ing and breastfeeding promotion. At site visits, health aides, nurses, and nutritionists at
colocated sites were often observed taking heights and weights of WIC participants if the WIC
staff were running behind schedule, and staff of public health clinics that had obtained
certification information as part of a prenatal or well-child visit provided the information to the
WIC nutritionist on a slip of paper.

Integration and Coordination with Other Programs
V-17



Chapter V. Integration and Coordination with Other Programs

immunizations and other services, which facilitates communication of eligibility determinations
to WIC staff. In Delaware, public health nutritionists are authorized to certify for WIC. Since
WIC is fully integrated with public health and each public health clinic client has one medical
record, WIC certification information is readily available to WIC staff.

Vil. Relationship with the Medical Community

An increasing number of WIC participants are receiving care from private providers as a result
of initiatives that have expanded Medicaid eligibility for pregnant women and children and
provided incentives for physicians to accept Medicaid patients. Thus, WIC Programs are
coordinating with the private medical community to a greater extent. In some cases, interaction
with the medical community prior to these initiatives was very limited because of the small role
of these providers in caring for WIC participants. This has been an area of considerable change.

In Louisiana, KIDMED—a Medicaid initiative—raised the reimbursement rates for private
physicians seeing Medicaid patients to one of the highest in the Nation. As a result, the private
physicians are very willing to take on new Medicaid patients. The result for the WIC Program
and the Tangipahoa Parish Health Unit has been that children continue to come to the Health
Unit for WIC vouchers and nutrition education, but private physicians do medical screening.
Physicians do not certify for WIC, but complete a "Referral to WIC Certification" form, which
includes anthropometric and hematological information. In Hudson, NY, managed care providers
have asked to conduct presentations about the Medicaid program at WIC clinics. In San Antonio,
TX, the Health District is finding that private physicians are increasingly serving Medicaid
patients and that prenatal clients are going to private providers instead of public health clinics.
This is creating the need for WIC to strengthen its association with private providers and
community-based hospitals. A dramatic example of the change in source of care is Palm Beach
County, where several Medicaid HMOs have entered the market. Staff at two of the WIC
program’s six clinic sites estimated that the proportion of their clients who are being seen by
private providers has increased from 5 percent to about 50 percent in less than 1 year. WIC staff
have begun working with the HMOs and have found that some are very active in referring clients
to WIC and distributing WIC materials to clients, while others are less interested in increasing
coordination with WIC. The WIC Program sends a staff member to do WIC certification on site
at one HMO.

Sites that rely on physicians for height, weight, and hematocrit measurements have more
established relationships with the private medical community. Nearly half of the case study sites
used physicians for this service, at least for some WIC clients. However, coordination with the
private medical community is difficult, because there is no central contact point for all providers.
WIC staff must work with each provider, group practice, non-profit clinic, and HMO separately.
WIC staff in Palm Beach County are finding that they obtain less information on a client referred
to them by a private physician, and it is harder to reach physicians by telephone to follow up for
more information.

Integration and Coordination with Other Programs
V-15



Chapter VII. Current Operating Capacity and Perspectives on Accommodating

Future Growth
Neen eee eee ee a

Local Agency Operations Factors. The following factors may also alter an agency’s capacity
to serve participants.

Waiting Time: The amount of time that participants have to wait in the clinic before receiving
services is an indication of an agency’s capacity. Over 26 percent of participants are served by
local agencies that report the typical waiting time to be certified for WIC exceeds 30 minutes.
Some local agencies reported waits of 2 hours or more. During one site visit, researchers
observed signs in the waiting room notifying participants to plan for a 2-hour wait prior to their
appointment.

Extended hours/days of clinic service: Almost half of all local agencies reported extending their
clinic service schedule, by either extending the days of service or the hours the clinic was open.
P.L. 101-147 mandated extended hours to serve working participants. In addition to improving
access for working participants, extended clinic hours and days of service increase clinic capacity
by permitting the clinic to serve more participants in the same facilities.

Efficiency Increased: Some of the questions on the Local Agency Survey were related to the
efficiency of operations at the agency. Fifty-one percent of agencies reported streamlining
recordkeeping, and 68 percent made greater use of computers. In addition, 72 percent reported
making more efficient use of their space and facilities during the study period. Other factors that
might indicate increased efficiency in the last 5 years is the shift toward more automation, group
nutrition education, and the issuance of multiple food vouchers at a single appointment.

Specific Changes in Administrative Operations: More than half of local agencies reported an
increase in the amount of paperwork they were doing, and 62 percent reported that the
completion of paperwork or reports was delayed. Special projects were postponed or canceled
by 43 percent of agencies. Administrative functions are forced to be a lower priority for
agencies. This is supported by the answers to the open-ended question regarding barriers to high-
quality services, where many agencies responded that "Not Enough Time" was a barrier.
Similarly, 57 percent of agencies reported spending more time on referrals.

These areas related to capacity show that many agencies have pursued options and have been
successful in increasing the efficiency of their operations. However, agencies continue to be
constrained by inadequate facilities, staff, time, and funds, at a time when caseloads continue to
increase. When specifically asked at what capacity they were operating, 30 percent reported that
they were operating below capacity, 50 percent reported that they were operating at capacity, and
only 20 percent reported being above capacity. Follow-up telephone calls to agencies that gave
apparently contradictory responses regarding space and other issues and capacity revealed that
many responded relative to their State-assigned caseload—if below assigned caseload, they
indicated that they had excess capacity. Others said that they were willing to serve more
participants, and assuming an infusion of sufficient resources, felt that they could do so.
Although case study sites were not specifically asked about current operating capacity, most sites
were operating at or above capacity, based on on-site observation and interviews with WIC staff.
Three sites appeared to be operating below capacity.

Turrent Operating Capacity and Perspectives on Accommodating Future Growth
Vil-4



Chapter IV. Nutrition Services

Breastfeeding Promotion and Support. The most frequently mentioned change in nutrition
education since 1988 has been the increased emphasis placed on breastfeeding (97% of agencies).
Fourteen of the case study sites also reported this as a significant change in their agency’s
operations. Breastfeeding promotion has taken various forms, e.g., the use of peer support groups,
the employment of or coordination with lactation consultants, the screening of all education
materials distributed to exclude those promoting bottlefeeding, the development or use of written
and audio-visual materials on breastfeeding, contacting women while they are still in the hospital
after delivering their infant, providing special classes to all pregnant women, and emphasizing
the benefits of breastfeeding in all individual and group sessions prior to and after delivery.

According to case study findings, both WIC and non-WIC staff have been involved in
breastfeeding promotion. Among the WIC staff, the most commonly used staff were registered
dietitians or licensed nutritionists (17 agencies); equally used were other nutritionists, non-degree
paraprofessionals, and lactation consultants (9 agencies). Non-WIC staff mentioned were nurses
(5 sites) and other nutritionists (3 sites).

Some of the case study sites were quite active in their breastfeeding promotion and support
activities. Both Montgomery County, MD, and Palm Beach, FL, emphasized peer counseling
programs. Both agencies rely on volunteers from the community who receive some formal
training on breastfeeding counseling and make themselves available to WIC participants both
before and after their delivery dates. Palm Beach County reported that the peer counseling
program was instrumental in increasing the number of breastfeeding WIC participants from 164
to 312. Another effort to promote breastfeeding was reported in Wilkes-Barre, PA, whose agency
started a free breast pump pilot program. They purchased 120 manual breast pumps and -
distributed them, at no cost, to WIC participants.

Barriers to Providing Education. Local agencies reported several difficulties they face in
providing nutrition education. As illustrated in Exhibit IV-10, between 45 and 65 percent of the
local agencies surveyed reported the following factors as barriers (listed in rank order of
frequency of being mentioned): participant interest, space, too little staff time per participant,
participant time, too few staff, child care, and transportation.

Participant interest was the barrier most frequently reported by agencies (64% of agencies,
serving 57% of the participants). Although reported less frequently by agencies, space was a
barrier cited by agencies serving 77 percent of the participants, and too little staff time per
participant was cited by agencies serving 68 percent of the participants. The following sections
discuss these barriers in greater detail.

Nutrition Services
I-13



Chapter VI. Synthesis of Reported Changes on State and Local Agency
Operations and Factors Affecting Quality of WIC Services

Exhibit VI-2

Participation Growth in Local Agencies, 1988 - 1992

Growth in Participation Local Agencies Participants
Experiencing this Served by These

Rate of Growth (%) Agencies (%)

Less than 15% 21 13

15% to 33% 22 22

33% to 50% 18 19

50% to 100% 28 34

Greater than 100% 8 1

Not Applicable 2 0.7

Total 100 100

Source: FCS 191 Files, 1988 and 1992.

Note: Growth was calculated by comparing participation figures from the 1988 FCS 191 files with the 1992 figures. There were four local
agencies in the survey that did not exist in 1988, so a growth rate could not be calculated for them. Whenever two local agencies consolidated
between 1988 and 1992, the growth rate was calculated by comparing the sum of the number of participants for each local agency in 1988 to
the number of participants in the consolidated agency in 1992. Similarly, whenever a local agency split into two agencies between 1988 and 1992,
the growth rate was calculated by comparing the number of participants for the local agency in 1988 to the sum of the number of participants
for each of the split agencies in 1992.

Geographic Service Area. The responses from the State Agency Survey indicate that WIC is
operating in almost every county in the United States. Of the 77 State agencies that responded
to the mail survey, 67 agencies reported that WIC operates in all areas of the State (or Tribal
boundaries). Of the 10 agencies that did not serve the entire State, seven had three or fewer
counties unserved in their State. Some counties are served by more than one State agency, as
is the case with some of the Indian Tribal Organizations. The local agency case study site in
Wilkes-Barre, PA, serves a large geographic area in a fairly rural part of the State. This agency
plans to add clinics as a way of increasing its caseload and serving more participants.

ll. Impact of Changes

One of the objectives of this study is to describe the impact of new requirements and initiatives
on local and State WIC agencies. There have been quite a number of requirements and
initiatives. Some of these started at the local or State level, such as contracts with infant formula
manufacturers for a rebate. Other requirements, such as substance abuse counseling and
coordination with homeless services, were initiated by Congress. Other factors that have affected

Synthesis of Reported Changes on State and Local Agency Operations
and Factors Affecting Quality of WIC Services
VI-3



Chapter VI. Synthesis of Reported Changes on State and Local Agency
Operations and Factors Affecting Quality of WIC Services

to handle the caseload. Again there was a discrepancy between local and State agency’s
perceptions of the issue. Staff shortage was the most frequently cited barrier, 49 percent, by
State agencies. A related barrier is staff attitude/turnover, which was cited by 17 percent of
the local agencies. The next most frequently cited barrier for local agencies was not enough
time and geographical/transportation, each reported by 37 percent of agencies. Only 21
percent of the State agency responses listed these two barriers. The fifth most frequently cited
barrier among local agencies was unresponsive participants, 33 percent.

It is interesting to note the discrepancies between the perceptions of State and local agency staff
on the factors that affect quality in WIC. The most striking observation from Exhibits VI-4 and
VI-5 is the differences in the ranking of factors by the two types of respondents. Perhaps this
can be attributed to the differences in perspectives of WIC local agency directors and State
agency directors. Local agency directors may focus more on those factors that influence their
daily encounters with WIC participants. However, State Agency directors may focus more on
the broader policy issues related to managing the program statewide and have fewer opportunities
to interact with participants or provide direct service delivery.

Synthesis of Reported Changes on State and Local Agency Operations
and Factors Affecting Quality of WIC Services
VI-9



Chapter IV. Nutrition Services
a ——————————————— EEE

Small areas for group counseling may create physical discomfort and result in a distracted,
disinterested audience.

Staff at the case study sites expressed concern over continued program growth without an
increase in available space. Many sites have already moved to larger space and foresee another
move in the not-too-distant future. Staff at sites in Atlantic City, NJ, and Martinsville, VA,
expressed concern that in their localities, large enough space may not be available. Other sites
report that more spacious facilities would require them to leave space that is being provided as
an in-kind service, and therefore, would greatly affect their budget.

Staff time and availability. Survey respondents cited restricted staff time for nutrition education
as a problem affecting local agencies serving 68 percent of the participants; it was also one of
the most commonly mentioned issues in the case studies. As the WIC Program has expanded
its scope (providing more referrals, addressing topics such as substance abuse, focusing on
immunizations), and as general documentation requirements have increased, staff time with
clients has been reduced. This limited time can easily result in less education being provided.
Case study site staff also commented that methods of presentation may change to non-human
contact such as the exclusive use of videos, pamphlets, or audio materials. In the Local Agency
Survey, since 1988, approximately one-third of the agencies have reported having more staff time
per participant, while slightly more than one-third reported having less time (Exhibit IV-4).

The availability of staff can also be a barrier to the provision of nutrition education. As
discussed above, most agencies use nutrition professionals to provide their education. However,
many of these same agencies report having problems attracting nutritionists. One of the issues
discussed has been the licensure issue. For example, Virginia staff reported that only licensed
nutritionists can be hired; yet, to become licensed, a nutritionist must first have a job. This limits
the pool of available licensed nutritionists and changes the hiring practices for the program.
Competition from other service environments creates another strain on nutritionists available to
the WIC Program. For example, hospital dietitians are reported to receive higher pay than WIC
nutritionists. However, WIC does not customarily require evening or weekend hours, which is
attractive to many nutritionists. Other competing job opportunities include private practice
nutritionists, nutritionists working in physicians’ offices, and nutritionists working for specialized
weight loss or health care programs.

Language/Cultural Issues: Given the ethnic diversity of the WIC population, it is not surprising
that language was reported as a barrier to provision of WIC nutrition education by about one-
quarter of the agencies, serving 36 percent of participants. To respond to the need for
multilingual service provision, many of the sites are offering their education sessions, or at least
materials, in a variety of languages. Exhibit IV-11 presents data that indicate the variety of
languages (12 in all) in which nutrition education is available. Education in Spanish is the most
predominant non-English language for WIC—48 percent of agencies have Spanish interpreters,
and 58 percent provide nutrition education in Spanish. This type of pattern is evident for almost
all of the languages for which interpreters are available, i.e., more sites offer written materials
than have interpreters for a language.

Nutrition Services
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Chapter IV. Nutrition Services

|. Introduction

This chapter describes and assesses nutrition services provided by WIC local agencies, based on
both Local Agency Survey data and case study information. The assessment is based, in part,
upon nutrition services standards jointly developed by the Food and Consumer Service (FCS) and
the National Association of WIC Directors (NAWD) as part of the "Focus on Management"
(FOM) initiative. In addition, our assessment considers the impact of growth on the delivery and
quality of nutrition services. The FOM Nutrition Services Standards apply to the following
nutrition services components:

. Nutrition/Health Assessment

. Nutrition Services Plan

° Nutrition Education

. Qualifications and Roles of Nutritionists
. Nutrition Staff Training

. Food Packages.

Each of these areas is addressed below, within the context of local agency operations. For
example, preparation of a nutrition services plan, primarily a State activity, is discussed in the
context of local agency evaluation activities.

Il. Assessment and Care Plan

Nutrition assessment is technically part of both the certification process and the nutrition
education process. The participants’ nutritional risk must be determined before certification can
take place. In most cases, eligibility is determined at the time of application, but all applicants
must be notified of their eligibility within 20 days. Development of a care plan is based upon
the nutrition/health assessment.

Nutrition/Health Assessment. The WIC eligibility process requires certification of nutritional
risk. The participants’ nutritional status is determined through an assessment of medical/health
history, diet, anthropometric status, and blood work status.! Blood tests to determine iron levels
are administered, height and weight measurements are taken, and a dietary assessment is
completed. Using this information, the nutritionist or nutrition staff member determines whether
the participant has any nutritional risks.

"Young infants are exempted from blood work requirement.

Nutrition Services
W-1



Chapter V. Integration and Coordination with Other Programs

Exhibit V-5

Health Service Availability and
Coordination/integration at Case Study Sites (N=22)

Service Integrated | Colocated | Referrals No Service Not
Interaction | Available Locally
Early and Periodic 2 10 8 2 1
Screening,
Diagnosis, and
Treatment
(EPSDT)
Lead Screening 2 6 6 3
Other Health 2 7 6 2
Screening
Breastfeeding 18 4 3 1
Support
Dental Care 1 W 12 1
Family Planning 12 10 1
Immunizations 6 11 8
Ob/Gyn Care 1 12 10 1
Well-Baby/ 3 15 13
Pediatric Care
Routine Primary 13 16
Care
Health Education 4 15 7 1
AIDS Testing, 3 12 1
Counseling,
Treatment
Sexually
Transmitted
Disease (STD)
Clinic
Medicaid Eligibility
Determination

* This WIC site scrved only children.
Source: 22 case studies, WIC Dynamics, 1993.
Numbers do not total to 22 because of more than one applicable answer.

Integration and Coordination with Other Programs
vV-8



Chapter IV. Nutrition Services

Nutrition/Health Assessment (Standards 1-3)

STANDARD 1: The State agency has documented nutrition risk criteria referenced as necessary
by current'scientific research, that are applied consistently by all local agencies
in the State.

STANDARD 2: The State agency has standardized dietary assessment procedures based on
- current practice which are used consistently by all local agencies in the State.

STANDARD 3: The State agency has standardized anthropometric and biochemical assessment
procedures, based on current practice, which are used consistently by all local
agencies in the State.

All case study sites used intake and assessment forms that were distributed from their State’s
WIC office. These forms all included standardized growth charts and criteria for evaluating food
intake data and biochemical data. States did vary in some ways—e.g., some obtain hematocrit
results, while others obtain hemoglobin results to test for blood iron content. In addition, some
States rely solely on food frequencies to conduct a dietary assessment, while others rely on 24-
hour recall, and some use both methods. Local agencies are usually free to add any additional
information to their records but must complete the State forms for each participant.

Nutrition Education/Services Plan (Standards 4-8)

STANDARD 4: The State agency has standard policies for all nutrition education contacts,
which include type and number of contacts appropriate for participants’ risk
status.

STANDARD 5: The State agency has standard evaluation procedures for monitoring the
nutrition education provided in local WIC agencies.

STANDARD 6: The State agency promotes the use of appropriate, quality, and accurate
nutrition education materials.

STANDARD 7: The State agency develops and updates annually a WIC nutrition services plan
that includes a needs assessment, long-term and short-term goals and
objectives, and an evaluation component as part of the State plan.

STANDARD 8: The State agency assures that local agencies develop an annual nutrition
education plan to include a needs assessment, goals, objectives, action plans,
and an evaluation component.

The majority of case study sites reported that their staff participated in some State training
sessions. These sessions covered topics ranging from administration of WIC services to
techniques for providing nutrition education. The nutrition education materials that were used
by case study sites were a combination of State-issued materials and locally developed materials.

Nutrition Services
IV-24





Chapter V. Integration and Coordination with Other Programs

While both the survey and the case study sites reported a wide array of special projects, the Local
Agency Survey indicated that, nationally, 43 percent of local agencies postponed or canceled
special projects between 1988 and 1992.

Tntegration and Coordination with Other Programs
V-20



Chapter V. Integration and Coordination with Other Programs

According to the survey, obtaining health care services for WIC participants is typically a
problem in 29 percent of the sites.

Exhibit V-2

Availability of On-Site Health Services

On-Site Health Service Local Agencies | Participants Affected
Available at: in Survey (%)
(%)

No Sites 14 9
c of sites 8 4
|| % - 3 of sites 19 19
|| > % of sites 7 20
|| all sites 52 39
Total 100 100

Source: Based on estimates for 1,777 local WIC agencies; Local Agency Survey, WIC Dynamics, 1993.

The case studies provide additional information on the availability of health services on site. The
22 local agencies visited reported having from | to 5 different service settings each for all of
their clinic sites. As shown in Exhibit V-3, the service setting reported most often (nearly two-
thirds) was a public health clinic. Fourteen agencies reported other settings that have health
services available. Therefore, well over half of the service settings included in the local agency
site visits were colocated with health services. However, the range of health services available
varies in each location. For example, all public health clinics do not provide dental care and
routine primary care, and family planning clinics do not provide services for infants and children.

Exhibit V-3

WIC Service Settings for Case Study Sites

WIC Service Setting Number of Local Agencies
Providing Services In This
Setting
Public Health Clinic 13
Hospital 5
Community Health Center 3 =
Migrant Health Center 1
Indian Health Center 1

Tntegration and Coordination with Other Programs
vA



Chapter V. Integration and Coordination with Other Programs

Temple, TX, worked with Head Start in targeting children for outreach. Participation in
community health fairs was reported by WIC Programs in Palm Beach County, FL; Portage-
Columbiana, OH; Hudson, NY; and New Haven, CT. WIC Programs in Salt Lake City, UT;
New Haven, CT; and Delaware participated in "Baby Your Baby" media outreach campaigns to
low-income pregnant children. WIC Programs in Atlantic City, NJ; San Antonio, TX; Long
Beach, CA; and Hudson, NY, targeted outreach to teens through teen parent programs and high
schools.

Itinerant/Mobile Services. Another type of outreach to participants—the use of vans, mobile
units, or other motorized facilities—was reported to be used by 7 percent of WIC local agencies
surveyed, affecting 11 percent of participants. The case studies revealed that the use of such
vehicles was often shared or coordinated with other agencies. For example, the Palm Beach
County WIC Program is working with Catholic Charities to provide nutrition education on the
mobile health van operated by that organization. Other participant outreach activities involve
providing WIC services on site to “hard-to-reach" participants. The MHRA WIC Program in
New York City and the Salt Lake City WIC Program provide services at homeless shelters;
Montgomery County WIC has one clinic location at a Hispanic community center; and Delaware
WIC coordinates with public health field nurses who make home visits to assure that newborns
of high-risk mothers are on WIC.

VI. Referrals

As the previous sections on coordination with health care and social services indicate, all local
agencies refer at least some of their participants to other services or agencies. However, the
frequency of these referrals, the methods for determining who to refer, and tracking that referral
vary from agency to agency. The referral process has several parts: the procedures followed in
making a referral, either by WIC to other providers or by other providers referring clients to
WIC; documentation of the referral in the patient record and/or in other clinic reports; and
followup of referrals. Referrals vary according to each agency’s concept of "referral," the
location and capacity of the referral services, and the existence of established working
relationships with other agencies that facilitate the referral process. The survey of local agencies
found that the two most common barriers to referring clients to other agencies are that services
are not available or are only available on a limited basis (in 40% of the agencies); and the lack
of or limited transportation to services (in 46% of the agencies). When comparing procedures
in 1988 versus 1992, the responses indicate that the amount of staff time spent on referrals is
somewhat more in 37 percent of the principal clinic sites, and substantially more in 20 percent
of the principal clinic sites.

The concept of referral can vary from simply informing a client that a service is available, to
providing a client with an application for another program, to calling the other agency and
arranging an appointment for the client. In some colocated programs, a referral is completed by
walking with the client from the WIC clinic to the referred service, such as the prenatal or child
health clinic. The case study sites provided some insights into the variations in referral
procedures. Over two-thirds of the sites have resource directories or guides available to WIC

Integration and Coordination with Other Programs
V-13



Chapter V

Integration and Coordination with Other Programs



Chapter IV. Nutrition Services
aS

Topics and Methods of Presentation. From a list of 14 potential nutrition education topics,
more than 90 percent of the WIC local agencies said they offered each of the following 13
topics:

. Management of individual nutrition risk
. Importance of nutrition to health status
. Description of basic good diet

. Major nutrients provided by WIC package
Other sources of particular nutrients
Importance of diet for fetal growth
Breastfeeding

Handling of infant formula

Solid and table foods

Importance of nutrition for growth
Nutritious snacks

Dental health

Risks of substance abuse.

Eighty-nine percent said they covered the 14th topic—use of whole cow’s milk. In addition,
5 percent of the respondents wrote in topics related to food preparation/shopping/safety, while
8 percent said they covered other additional topics.

During the case study site visit observations, it was found that local agency procedures on the
frequency and audience for the sessions differed across sites. Some agencies used a rotating
topic schedule and did not direct the topics toward any specific group. Others rotated their
topics, but controlled who the audience would be by having different categories of participants
receive group education on different days. Others gave a series of topics targeted to a specific
group—for example, pregnant and postpartum women generally were taught about the importance
of diet on fetal growth, breastfeeding, and infant feeding.

In general, all agencies use a variety of presentation methods in their nutrition education sessions
(Exhibit IV-9). For individual sessions, all agencies used verbal discussion and pamphlets. Other
popular methods include food models (84%), films or videos (63%), and flip charts (58%).
Computer-assisted instruction was used by only 3 percent of the agencies. In presenting group
sessions, compared to individual sessions, agencies use less discussion (77%) and pamphlets
(80%) in groups. There is a slightly greater use of films or videos (77%) and approximately the
same amount of use of flip charts (61%). Food models are used less often (67%), but food
demonstrations are more common (51%). Computer-assisted instruction is used by only 2 percent
of sites during group instruction. These findings are similar to those from the case studies, which
are also described in Exhibit IV-9.

Nutrition Services
W-11



Chapter Vil

Current Operating Capacity and Perspectives

on Accommodating Future Growth



Chapter V. Integration and Coordination with Other Programs

——————————————————————————————————

REFERENCES (Chapter V)

Biemesderfer, Susan C. 1993. Healthy babies: State initiatives for pregnant women at risk.
Washington, DC: National Conference of State Legislatures.

Hill, LT. 1988. Reaching women who need prenatal care. Washington, DC: National
Governor’s Association.

King, Martha P. 1993. Healthy kids: State initiatives to improve children’s health. Washington,
DC: National Conference of State Legislatures.

Lewis-Idema, Deborah. 1988. Increasing provider participation. Washington, DC: National
Governor’s Association.

Macro Systems, Inc. 1990. One-stop shopping for perinatal services: Identification and
assessment of implementation methodologies. Washington, DC: National Center for
Education in Matemal and Child Health.

Macro Systems, Inc. 1991. Assessment of the comprehensive perinatal care program: Final
report and recommendations. Washington, DC: U.S. Government Printing Office.

National Commission to Prevent Infant Mortality. 1988. Death before life: The tragedy of infant
mortality. Washington, DC: Publisher.

Pindus, N., Duggar, B., and Schultz, C. 1986. Improving MCH/WIC coordination: Final report
and guide to good practices. Washington, DC: U.S. Department of Health and Human
Services.

Summer, Laura. 1991. Working together: A guide to coordinating WIC and Medicaid services.
Washington, DC: Center on Budget and Policy Priorities.

U.S. Department of Agriculture, Food and Consumer Service. 1990. WIC Dynamics study, RFP
FCS-90-049SLS. Alexandria, VA.

U.S. Department of Health and Human Services, Health Resources and Services Administration.
(1993). National evaluation of the healthy start program, RFP HRSA 240-OA-12(3).
Rockville, MD.

Integration and Coordination with Other Programs
V-21



Chapter VI

Synthesis of Reported Changes on
State and Local Agency Operations
and Factors Affecting Quality
of WIC Services



Chapter IV. Nutrition Services

Exhibit tV-10

Factors That May Act as Barriers to Providing High-Quality Nutrition Education

[ere Agency Participant
(%) (%)
‘race Interest 64 57
Space 59 77
Too Little Staff Time Per Participant 58 68
Participant Time 50 56
Too Few Staff 49 64
Child Care 46 56
Transportation 45 36
Cultural !ssues/Language Difficulties 27 36
Difficulty Recruiting Qualified Staff 19 32
Other 8 6

Source: Based on estimates for 1,777 local agencies, Local Agency Survey, WIC Dynamics, 1993.

Participant interest and time: Maintaining participant interest is always a concern when trying
to provide lengthy services to clients who may have several young children with them and may
also be spending long periods of time at other service providers. Several nutritionists in the case
study sites reflected on the difficulty in sustaining the interest of participants whose physicians
show little or no interest in the issues and are either not supportive of the information being
provided or actually contradict the information. One nutritionist gave the example of a
participant with a child whose weight was seriously low. The child’s physician did not believe
that this was either a current problem or an indicator of other problems; therefore, when
approached by the nutritionist, the parent was disinterested and refused to change any behaviors
that might improve the child’s weight.

Space: Limited space is a problem that was reported in the Local Agency Survey by 59 percent
of the agencies. When analyzed by the number of participants affected, this problem is a barrier
to the greatest proportion of participants (77%, or 4.15 million people). However, in the case
studies, about two-thirds of the sites reported that their space provided adequate privacy for
individual education sessions. Only one-third of the case study sites reported adequate privacy
for group sessions. Relatively small space was cited as a major problem in many of the sites.
For example, counseling that occurs in a room close to a crowded lobby tends be noisy, creating
a distracting and potentially stressful environment. Counseling in a large room where other
participants are also being counseled lacks necessary privacy. Group classes conducted in a
waiting area may have to contend with constant movement of people in and out of the area.

Nutrition Services
IV-14