Executive Summary
cei EEE

The methods for assigning caseloads to local agencies vary greatly. During periods of
rapid growth, a large proportion of States allocate caseload based on requests from local
agencies (30%) or allocate proportionately to all agencies (18%).

Federal Funds Are Supplemented by Other Sources of Funding in 57 Percent of the
State Agencies

Fifty-seven percent of State agencies, serving 81 percent of participants, reported receiving
funds other than Federal WIC funds to support their program. Other funding sources
include private grants, county or local funds, or State appropriations, which 27 percent of
State agencies reported.

Program Performance Standards Are Widespread, but Not Universal

Performance standards are used to monitor local agency compliance with WIC regulations
and the quality of nutrition services provided. These program performance standards vary
among the States. Sixty-one percent of the State agencies, affecting nearly three-fourths
of the local WIC agencies, report that they use performance standards. Smaller States,
serving 11 percent of the participants, reported that they have not developed performance
standards.

State Agency Activities Support Program Coordination and Integration

Most WIC State Agencies (97%) reported that they participate in immunization programs.
Ninety percent participate in joint efforts with other agencies to provide services to women
and children. Other State initiatives in support of coordination and integration include joint
program application forms, integrated data systems, and interagency planning activities.

Automation Has Increased in Local WIC Agencies
Thirty-five of the 77 responding State agencies reported that all of their local agencies used
PC/minicomputers, while 31 State agencies reported that all had mainframe support. Only

11 States (serving less than 1 percent of participants) reported that none of their local
agencies use computer support.

E. Capacity

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

Executive Summary
viii



tration

Chapter II. State Agency Ad

The majority of State agencies (53%) consider both the historical performance of the local
agencies and factors based on the needs of the population in computing administrative funding
for local agencies, while an additional 20 percent use one of these two criteria. However, over
25 percent of the State agencies do not consider either of these factors, but use other measures
when computing the administrative funding level. Examples of other criteria reported by States
include “number of high-priority participants being served, budget submitted, and available
funds," "caseload allocation and inflation," and "staff-to-participant ratio and line-item budget.”
One-third of the States report that the method for determining large agency administrative grants
has been in place less than 4 years; 65 percent have used their current method for more than 4
years.

Caseload Allocation to Local Agencies. In addition to allocating funds to the local agencies,
the State agency is responsible for allocating caseloads. State representatives were asked to
indicate whether a series of 11 factors were "Important" or "Not Important" considerations in
making caseload assignments to local agencies. Exhibit II-5 presents each of these factors and
the percentage of State agencies that indicated that this factor was important. The five factors
identified as "Important" by most of the State agencies are:

° Local agencies’ historical ability to serve the assigned caseload (80%)

. WIC priority groups currently being served (75%)

° The percent of potentially eligible participants being served (72%)

. Management or staffing problems that might hinder the local agencies’ ability to
serve participants (68%)

° The local agencies’ proven ability to grow (67%).

Exhibit II-5

Factors Used in Assigning Caseloads in Local WIC Agencies

Local Agencies’ Historical Ability to Serve
Assigned Caseload

WIC Priority Groups Currently Being Served

Percent of Potentially Eligible Participants
Being Served

Management or Staffing Problems That Might 68 7 76
Hinder Loca! Agencies’ Ability to Serve

Participants.

Local Agencies’ Proven Ability to Grow 67 68 74

State Agency Administration
Us



Chapter Il. | State Agency Administration

The WIC Program functions through three levels of management—Federal, State, and local. At
the Federal level, the Food and Consumer Service (FCS) and its seven regional offices provide
cash grants to State WIC agencies for program administration and operations. FCS also issues
regulations and monitors compliance with these regulations. State WIC agencies set nutritional
risk eligibility standards, allocate funds to local WIC sponsoring agencies, monitor their
compliance with FCS regulations, and provide technical assistance to WIC local agency staff.
This chapter focuses on State agency administration. The data used to prepare this report were
collected through the State Agency Survey. This State mail survey was sent to the universe of
WIC State agencies, which includes the 50 States, Guam, the Virgin Islands, Puerto Rico,
Washington D.C., and 31 Indian Tribal Organizations (ITOs). Of the 85 State agencies, 77
responded. Three States—Hawaii, Idaho, and Oregon—and five ITOs—Indian Township (ME),
Pleasant Point (ME), Pueblo of Isleta (NM), Santo Domingo Tribe (NM), and Ute Mountain
Tribe (CO)—did not respond.

Adjusted analytic procedures were used for those State agencies that do not have traditional local
agencies, because their administrative structures made it inappropriate to answer survey questions
that referred to local agencies. The State agencies without traditional local agencies are:
Delaware, Guam, Puerto Rico, Virgin Islands, Arkansas, Louisiana, and all ITOs. Because of
the diversity of these agencies, some questions regarding local agencies could be answered, but
not others. For example, Puerto Rico has local administrative agencies, but these agencies do
not have separate budgets; Louisiana does not have local agencies, but does contract some
services out. These contractors receive budgets and caseload maximums. For purposes of
analysis, we used the responses to the questions that referred to local agencies if they were
provided by the "State/Local" agency. If they did not respond to these questions, a separate
response category called "Not Applicable to ITOs" or "State/Locals" was used.

The topics covered in the State survey were:
. Funding for States and local agencies;

. New initiatives in response to Federal regulations and guidance regarding administration,
service delivery, and oversight of local agencies;

. The extent to which automation is used to support WIC administration; and

. States’ capacity to serve additional participants.

Findings pertaining to each of these topics are discussed below.

State Agency Administration
1



Chapter Il. State Agency Administration

Exhibit Il-8

Number of Years that Current Food Voucher Issuance
Policies and Procedures Have Been in Place in WIC

State Affected Affected
Number of Years Using Current Issuance : a
Policies and Procedures Ag ie Local ae ncies Pare

1 Year

2 Years

3 Years

4 Years

5 Years

6 to 10 Years

Over 10 Years

Don't Know

Source: Based on responses from 77 State WIC agencies; State Agency Survey. WIC Dynamics, 1993.

Change in WIC Coordination with Other Programs Since 1988. Because coordination with
related services is a major focus of the WIC Program, survey responses indicate that 90 percent
of the State agencies have increased their coordination efforts with other programs since 1988.
Of these, 52 percent reported a substantial increase in effort. Only 3 percent of the State
agencies reported a decrease in coordination efforts.

Program Initiatives and Practices. State agencies reported a variety of programs and activities.
The majority of State agencies (97%) reported that they participate in immunization programs.
These agencies serve 95 percent of the local WIC agencies and 97 percent of the participants.
Survey responses also indicate that 90 percent of the State agencies participate in joint efforts
with other agencies to provide services to women and young children. More than half of the
State agencies (68%) reported that their State has implemented programs targeted toward low-
income women and young children which relate to and coordinate with WIC. These States have,
on average, the larger caseloads, in that 83 percent of the local agencies and 86 percent of the
participants are located in States that have these new programs in place.

More than one-third of the State agencies (36%), serving 29 percent of the local agencies and
serving 41 percent of the participants, reported that prior to certification, participants needed to
visit a physician or non-WIC clinic to obtain biomedical and anthropometric data or verify
pregnancy. According to survey responses, 16 percent of the local agencies, serving 27 percent
of the participants, reportedly use non-WIC-funded medical providers to perform certifications.

“State Agency Administration
1-10



Executive Summary

Effects of Rapid Growth and Other Changes on Local Agency Service Delivery

Program-Related and External Factors Affected Program Operations and Service
Delivery

During the study period (1988-1993), participation increased by 45 percent, and a number
of new Program requirements were introduced. More than half of the local agencies
identified the factors in Exhibit 1 as having had impact on their operations during this
period:

Exhibit 1

Factors That Affected Local WIC Agencies, 1988-1992

LOCAL AFFECTED
FACTOR AGENCIES PARTICIPANTS

% %
Breastfeeding Promotion and Support 88 93
Caseload Increases 86 94
Infant Formula Rebates 86 90
Federal Funding 78 87
Medicaid Expansion 77 83
Economic Downtums 7 82
Food Cost Fluctuations 70 78
Automation Initiatives 68 79
State Funding 63 57
Service Coordination 60 62
Reprioritizing Caseload 60 72
Shortages of Nutritionists 57 74
Drug Abuse Education 57 67

How Local Agencies Reacted

Local agencies responded to the growth and new requirements in a variety of ways. There
was evidence of efforts to increase efficiency and make maximum use of existing
resources. More than 50 percent of local agencies indicated that they took the following
actions or felt the impact in the following ways:

Scheduled less time per participant (57% of the agencies, serving 63% of the
participants).

Executive Summary
ii



Chapter Ill. Local Agency Administration and Operations

Changes Implemented

Conducted Group Certification

Replaced Interview with Self-Administered Forms
Scheduled More Time Per Certification
Dropped Group Certification

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

Exhibit Ill-4

Changes in Local WIC Agency Scheduling Practices

Overbooked WIC Participant Appointments
Implemented/Continued Appointments
Extended Clinic Days of Service

More Flexible Clinic Activity Schedules
Extended Clinic Hours Beyond Regular Hours
Less Flexible Clinic Activity Schedules

Cut Back on Days of Service
Shortened Clinic Hours

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

Determination of Nutritional Risk. As part of performing a certification, a nutritional risk
determination is conducted. This risk determination can be made by a competent professional
authority such as a nutritionist, nurse, physician, or other State or local medically trained
officials, and is based on Federal guidelines. Three major types of nutritional risks are
recognized:

. Medically based risks (designated as “high priority"), such as anemia, low birth weight,
matemal age, history of pregnancy complications, or poor pregnancy outcomes;

. Diet-based risks such as inadequate dietary patterns determined by a 24-hour dietary recall,
food frequency, or a diet history; and

Local Agency Administration ‘and Operations
4



Chapter Ill. Local Agency Administration and Operations

issuance or nutrition education services. For example, one local agency reported one of their sites
was open 1 day per week for issuance of vouchers only. Exhibit IN-2 shows the amount of
participant time spent waiting for and receiving services. The waiting time in clinics for
certification services is less than 15 minutes in 75 percent of the agencies; however, these
agencies serve only 51 percent of the participants. Twenty-six percent of the participants are
served by the 12 percent of agencies where average waits in WIC clinics are longer than 30
minutes for certification. These findings indicate a tendency toward longer waits in larger
agencies. Reported waiting time ranged from 0 to 150 minutes, and the average waiting time
was 22 minutes.

Exhibit Il-2

Time Spent Waiting For and Being Certified For WIC Benefits

1. Less Than 5 Minutes | 2. Less Than 15 Minutes | 3. Less Than 30 Minutes
{Includes Column 1) (includes Columns 1 and 2)

Agencies | Participants Agencies Participants
(%) (%) (%) (%)

Waiting

Certification

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

Case study observations found that scheduling procedures, voucher preparation procedures, clinic
staffing, and provision of integrated services had the greatest impact on waiting times. For
example, in Long Beach, CA, recertification appointments are scheduled at 8:00 am and 9:30 am
only, with afternoons reserved for group classes and voucher distribution. This contributes to
long patient waiting times (as long as 2 hours in some clinics) as participants wait to see the next
available CPA. In San Antonio, TX, waiting times between "stations" in the certification process
were attributed to staffing limitations, inefficient scheduling of clients within a day, and uneven
distribution of appointments throughout the month. In Martinsville, VA, the clinic with three
WIC clerks and one nutritionist often had participants waiting for nutrition education/counseling
after the completion of income, anthropometric, and hematologic measurements. Client flow at
a second site in Martinsville, with one clerk and one nutritionist, was much smoother. The use
of preprinted vouchers was reported to be a time saver in Salt Lake City, UT, reducing the time
required for a client certification visit by about one-third. Integrated services were associated
with increased time spent at the clinic, but not necessarily increased waiting time. In Tangipahoa
Parish, LA, and Delaware, for example, WIC services were fully integrated with maternal and
child health services without increases in client waiting times between services or providers.

Local Agency Administration and Operations
M-2


Chapter Ill. Local Agency Administration and Operations

Exhibit tll-7

Local Agency Current Staffing and Growth in Staff Since 1988

Local Agencies Local Agencies Reporting Statf
Using This Staff Increase Since 1988
(%)

Agencies Participants
(%) (%)
53 69
39 55

Professional

Paraprofessional

Clerical/Support

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

It is interesting to note agency responses to the sufficiency of their staff numbers and skills.
When asked about their current sufficiency, 53 percent reported having sufficient numbers of
professional staff and 9 percent reported having less than sufficient staff with appropriate skills
in providing nutrition services. When asked to compare sufficiency now to the situation in 1988,
69 percent reported professional staff numbers as sufficient as or more sufficient than in 1988,
and 88 percent reported having equal or more sufficient nutrition skills. The responses indicate
that for the majority of agencies staffing is sufficient, though there is stil] room for further
improvement with respect to the number of professional staff. These response patterns indicate
that a proportion of the respondents viewed the number of professional staff in 1988 to be
insufficient. During the follow-up calls, one agency director noted that while she had increased
her staff size, the workload had outpaced her hiring ability, so the staff's burden was still too
heavy.

A similar pattem emerged for clerical staff. Responses from 55 percent of the local agencies
indicate a sufficient (or more than sufficient) number of clerical/support staff, and 42 percent of
the local agencies stated they have less than sufficient number of clerical/support staff. More
than one-half of the local agencies (69%) reported that in comparison to the number of
clerical/support staff in 1988, the current level is as sufficient or more sufficient.
Paraprofessionals are present in just over half (51%) of the local agencies, and about half of these
agencies (27% of all agencies) found the number of paraprofessionals to be insufficient.

Local agencies report that all three types of staff have the appropriate level of skills/experiences
to provide both nutrition education and non-nutritional referral services. Exhibit I-8 summarizes
the sufficiency of number of staff and staff skills by percentage of local agencies.

Local Agency Administration and Operations
m8


Chapter Ill. Local Agency Administration and Operations

Exhibit Ill-9

Percent of WIC Local Agencies Reporting Funding Sources
for Non-Labor Items

5

Non-Labor Supported Supported Supported Supported by a
Item Exclusively by Exclusively by Exclusively by Combination of

WIC Funds Non-WIC Gov't Charitable Funding
(%) Funds Funds Sources

(%) (%) (%)
4
5

Computer 54 10 less than 1 - 24
Equipment

Medical
Equipment

less than 1

Education 62 3 less than 1 34
Equipment

Other 3

less than 1

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

Local Agency Equipment. According to survey responses, WIC most often exclusively funds
equipment. As Exhibit III-9 indicates, 62 percent of local agencies exclusively fund educational
equipment, 54 percent fund computer equipment, and 49 percent fund medical equipment
exclusively from WIC grants. Many local agencies (49%) perceived an increase in the level of
exclusive WIC funding for computer and education equipment over the last 5 years. The level
of medical equipment funding was reported to have remained at about the same level by 46
percent of the agencies in comparison to funding in 1988. Large local agencies indicated an
increased level of funding in these areas more often than smaller agencies.

While the local agencies are clearly less dependent on other funding sources for equipment than
for space and facilities, a small proportion of local agencies rely exclusively on non-WIC
government or private funding for equipment. The following list displays the percentages of
local agencies receiving equipment that is exclusively funded by non-WIC sources. These figures
combine both charitable and non-governmental sources as indicated in Exhibit III-9:

* Computer Equipment 11 percent
¢ Medical Equipment 9 percent
* Educational Equipment 4 percent.

Toca! Agency Administration and Operations
m-12







Chapter fi. State Agency Administration

Affected Affected
Local Agencies Participants
(%) (%)

New or Expanded Services for High-Risk
Matemity Patients at Local Agencies

Local Agencies’ Affirmative-Action Ranking

Colocation of Maternity Care

Unserved Areas in the State

Average Food Cost Per Participant

Other Factors

Source: Based on responses from 77 State WIC agencies; State Agency Survey, WIC Dynamics, 1993.

The factors considered “Not Important" in assigning caseload increases or decreases to local
agencies by most of the State agencies are:

° Average food cost per participant (75%)

° Unserved areas in the State (65%)

° Local agency’s affirmative action ranking (60%)
. Colocation of maternity care (60%).

The percentage of States indicating that a factor was important or not important was generally
equal (or reasonably close) to the percentage of local agencies and participants served by that
State. However, there are a few exceptions to this finding. The local agency’s affirmative action
ranking is considered important by only 40 percent of the State agencies, but these agencies serve
51 percent of the affected local agencies and serve 51 percent of participants. The State agencies
that considered the average food cost per participant or the unserved areas of the State to be
important factors were the State agencies with smaller caseloads.

The method for assigning the maximum caseload varied greatly. The most frequently cited
method was based on the number of eligibles meeting specific priorities. This was used by 20
percent of the State agencies serving 30 percent of the local agencies and serving 28 percent of
the participants. The remainder of the States used a variety of methods, including negotiation
with local agencies (10%) or historic levels of caseload (7%). Only 15 percent of the State
agencies have changed their methods of allocating caseload since 1988. Fifty-nine percent have

been using their current method for 5 to 10 years, and 22 percent have been using their current
method over 10 years. It appears that increased funding and participation has had no material
effect on the way State agencies allocate caseload to local WIC agencies.

When experiencing rapid growth in caseload, a large proportion of States allocate caseload based
on requests from local agencies (30%), or allocate proportionately to all agencies (18%).

State Agency Administration
u-6



Acknowledgements

This study could not have been completed without the assistance of many individuals at the
Federal, regional, state, and local levels. We received outstanding cooperation from State and
Local WIC agencies. More than 91 percent of all State Agencies and 95 percent of a nationally
representative sample of Local Agencies completed surveys. Many of them generously gave
explanations and provided more detail when we compiled the data. The information they provided
and the insights they shared are the backbone of this report. The 22 local agencies that
participated in the case study portion of this study added a unique dimension to the understanding
of WIC program operations in a dynamic environment. The dozens of program managers and
service providers who met with us at each site were extremely generous with their tme. Their
cooperation in scheduling site visits, providing requested information, and reviewing case studies

is greatly appreciated.

We also wish to thank our Project Officer, Denise Thomas, who provided guidance and
leadership throughout this study, as well as Julie Kresge, Project Advisor, and many others at
FCS who participated in the design of the project and commented on the draft reports. The
NAWD Research Committee was very helpful in formulating the design of the study and the data
collection forms.

WIC Dynamics combines both survey and case study data to describe the changes that occurred
in local agencies between 1988 and 1993, and several individuals carried out the research. JoAnn
Kuchak was project director and provided overall leadership. Michelle Hearn, Sara Sullivan and
Nancy Hassett played key roles in conducting the surveys and analyzing the survey data. Nancy
Pindus of the Urban Institute managed the case studies. Barbara Cohen of the Urban Institute
synthesized findings concerning nutrition services. Consultants Julie Carroll of Burger, Carroll
and Associates and Sara Ducey, and other staff members from The Urban Institue and Macro
participated in the site visits. Valencia Clark and her publication staff produced the reports.

Aeknowledgements



Chapter II

State Agency Administration



Executive Summary

agencies in your State currently operating?" For both surveys, 69 percent of respondents
indicated that local agencies were operating at or above capacity. This is an important
consideration in determining the program’s ability to accommodate future caseload growth.

Conclusions

Dramatic growth and new requirements have had a two-fold effect on local WIC agencies.
These factors have contributed to WIC’s evolution and development into a major maternal
and child health program. But these factors also present a challenge to local agencies in
providing quality services. WIC Dynamics Study findings indicate that many local
agencies are meeting these challenges by increasing operational efficiency and maximizing
available resources. Such steps include increasing services integration and coordination,
obtaining in-kind contributions, and sharing staff and facilities with other programs. While
services integration and coordination is desirable from the client’s perspective, it can
present significant challenges when other programs and services do not grow at the same
Tate as WIC.

Executive Summary
ix



Chapter I. Introduction

WIC Amendments of 1987, building upon the success of State infant formula cost containment,
required that States adopt, where feasible, cost containment initiatives such as rebates,
competitive bidding, direct food distribution and home delivery systems to help reduce
expenditures for the purchase of supplemental foods. Of these initiatives, infant formula rebates
are the most widely used and have had the greatest effect on cost containment. Under contractual
agreements with infant formula manufacturers, WIC State agencies receive a set rebate amount
for every can of infant formula purchased for WIC participants. Thus, rebates allow WIC to
serve mofe participants without increasing the appropriated food grant. In Fiscal Year 1992,
infant formula rebates totalling over $750 million supported one-fifth, about 1,200,000 million
participants each month, of the WIC caseload.

When infant formula rebate systems were first implemented, the larger caseloads increased the
administrative burden of WIC State and local agencies. While rebates reduced food costs and
allowed more participants to be served with the States’ food grants, considerable strain was
placed on program administrative funds. More participants had to be served on a fixed
administrative grant. The growth in participation, in effect, reduced the amount of administrative
dollars per participant in the program. At some point the growth in participation would be
severely constrained because administrative funding would be insufficient to maintain the level
of administrative services. P.L. 100-237 contained provisions which allowed States, under certain
conditions, to convert a specified portion of the food grant to cover the costs of nutrition services
and program administration for the additional participants added due to food cost savings.

To relieve the administrative funding constraints, P.L. 101-147, the WIC reauthorization
legislation signed into law in November 1989, contained provisions to change the amount of the
Federal appropriation for administrative funding. The basis for food funding remained as before,
with FCS allocating food grants based upon each State agency’s current operating level and
ability to serve those potentially eligible for WIC services, especially those at greatest nutritional
risk. Prior to FY 1989, the administrative portion of the Federal appropriation was a set
percentage of the total, about 20 percent. With the implementation of P.L. 101-147,
administrative funding was changed to a per-participant basis. The administrative per-participant
grant is based upon the national average for FY 1987, the year prior to large-scale
implementation of rebate systems, adjusted annually for inflation. The new funding method
increases the amount available to cover program administration and takes into account the
variance among States’ participation levels and other factors which promote effective program
administration.

At about the same time that participation began to increase dramatically, Congress began to enact
new legislative mandates which expanded the scope of WIC’s intervention with individual
participants. Some of the mandates require local agency staff to counsel and provide
information to WIC participants on a range of nutrition and health related topics. Others, such
as WIC Farmers’ Markets Demonstration Projects, increased benefits available to some WIC
participants. Following is a brief description of some of the Federal legislation enacted since
1988 which contained provisions with potential impact on local agency operations and service
delivery.

Introduction



Chapter |

Introduction





Executive Summary

C. Nutrition Services in the Context of a Period of Change

Almost two-thirds of local WIC agency respondents perceived that since 1988, the quality
of WIC nutrition education has increased. Local Agency staff noted increased emphasis
in breastfeeding promotion and that a broad range of educational topics are covered in
nutrition education sessions.

Most Nutrition Education Is Provided by Trained Nutritionists or Other Professional
Staff

WIC nutrition education staff are composed of nutritionists, dietitians, diet technicians,
paraprofessionals, and other health professionals. Only one-third of the local agencies
reported using paraprofessionals to provide nutrition education. Over 87 percent of local
agencies reported that their professional staff have sufficient or more than sufficient skills
and experience to provide nutrition education. The majority of case study sites used
nutritionists to provide nutrition education, and 75 percent report that they have at least one
licensed or registered nutrition professional. Sites often used a mix of professionals and
paraprofessionals as their nutrition team.

Nearly All Agencies Offer Individual Nutrition Education, but Group Education
Programs Have Increased

Ninety-eight percent of all agencies offer individual nutrition education sessions. Since
1988, over half (58%) of the agencies have increased their use of group education
sessions. Ten percent of the agencies serving 18 percent of the participants offer very large
groups (30 people or more). Nearly one-half (49%) of the local agencies, serving 64
percent of the participants, cited too few staff as a barrier to providing quality nutrition
education.

The Range of Topics Covered in Nutrition Education and Counseling Has Broadened
and Includes Health-Related Topics

In addition to nutrition topics, more than 90 percent of the local agencies offer topics such
as dental health and the risks of substance abuse. Case study sites reported other
counseling topics, including the importance of immunization, parenting skills, smoking
cessation, and child safety. More materials, including pamphlets and audio-visual aids, are
available to local WIC agencies.

Executive Summary
vi



Chapter Ill. Local Agency Administration and Operations

One-third of the local agencies cited an increase in the use of contract/consulting staff since 1988.
This is a method for local agencies to fulfill staffing requirements during periods of growth
and/or contraction.

Itinerant Staff. The use of itinerant staff at local agencies was commonly found, primarily in
larger agencies and agencies with 50 to 100 percent growth since 1988. The majority of local
agencies, 69 percent, use at least one itinerant professional staff member to travel from clinic to
clinic, and 48 percent use at least one itinerant clerical/support staff. According to the survey
responses, 42 percent of the local agencies increased the use of itinerant staff.

Based on case study site visit information, itinerant staff permit local agencies to offer more
convenience to participants. The Temple, TX, local agency uses traveling staff teams who are
responsible for operating multiple part-time clinic sites. At the Hudson, NY, local agency, all
staff, with the exception of one or two individuals responsible for staffing the main office, travel
several days each week to part-time clinics. The San Antonio local agency, which does not
regularly assign staff to travel between clinics, will occasionally need staff to travel to other
clinics to fill in for staff temporarily out of the office. These examples indicate that local
agencies use itinerant staff to fulfill a variety of needs.

Staff Vacancies. The majority of local agencies (70%) cited that they did not have any vacant
professional staff positions. Larger agencies cited more vacant positions than the smaller
agencies. At 42 percent of local agencies, there were no vacant paraprofessional positions. Note
that 49 percent of the local agencies do not use paraprofessionals; thus, the majority of agencies
that use paraprofessionals do not have vacancies for this staff position. In addition, 73 percent
of agencies did not have clerical/support vacancies. This information does not imply that local
agencies do not perceive a need for additional staff, but there are no funded positions available.
As noted earlier, 44 percent of local agencies perceived their current number of professional staff
to be less than sufficient.

About one-half of the local agencies (52%) with vacant professional positions cited that it is
difficult to recruit professional staff. Nearly three-fourths of the local agencies report about the
same level of difficulty in recruiting staff now, compared to 1988. Agencies perceived much less
difficulty recruiting for clerical/support positions (14% reported difficulty) and paraprofessional
positions (15% reported difficulty). According to survey data, larger agencies find it more
difficult to recruit professional staff. They also find it less difficult to recruit clerical/support
staff and paraprofessionals.

The survey revealed that several barriers exist when attempting to fill staff vacancies. Fifty-eight
percent of the agencies cited salary and benefits as the most problematic barrier. Shortages of
certain types of staff are also problematic; 21 percent of the local agencies cited a shortage of
nutritionists and 14 percent cited a shortage of dietitians as reasons for not filling vacant
positions. Follow-up telephone conversations with local agency respondents revealed that many
local agencies in rural settings confront difficulties attracting nutritionists and dietitians. This
was also found to be the case during the case study site visits. Hudson, NY, which operates in
a mural area, reported that it attempted to fill a nutritionist position for over 6 months before

Local Agency Administration and Operations
t-10


List of Exhibits (cont'd)

Iv-1
Iv-2
Iv-3

Iv-4
IV-5
IV-6
IV-7
IV-8a
IV-8b

Iv-9
Iv-10

Iv-11

Iv-12 °

IV-13
Iv-14

V-1
V-2
V-3
V-4
V-5

v-6
V-7

v-9

VI-1
VI-2
VI-3
VI4
VI-5

WIC Nutrition Services by Type of Staff (Number of Case Study Sites)
Record Review Summary

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

Group Size for Providing Nutrition Education

Changes in Nutrition Education Practices Since 1988

Frequency of Nutrition Education Contacts

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

Typical Number of Minutes Participants Spend Receiving Group and
Individual Nutrition Education

Typical Number of Minutes Participants Spend Receiving Group and
Individual Nutrition Education at 22 Case Study Sites

Use of Nutrition Education Materials and Methods

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

Languages Available at Local WIC Agencies

Time Spent Waiting For and Receiving Food Instruments

Change in Time Spent Waiting For and Receiving Food Instruments
Degree of Change in the Quality of Nutrition Education Since 1988

Local Agency Sponsorship

Availability of On-Site Health Services

WIC Service Settings for Case Study Sites

Primary Sources of Health Care for WIC Participants at Case Study Sites
Health Service Availability and Coordination/Integration at Case Study
Sites (N=22)

Services Available On Site at Principal WIC Clinics

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

Resource Sharing at Case Study Sites

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

Local Agency Caseload in Local Agencies by Number of Service Sites
Participation Growth in Local Agencies, 1988 - 1992

Initiatives That Impacted State and Local WIC Agency Operations
Factors That Promote High-Quality WIC Services

Factors That Hinder High-Quality WIC Services

Page
Number

IV-2
Iv-4

Iv-5
IV-6
IvV-7
IV-8

Iv-9
IV-10

Iv-10
Iv-12

Iv-14
Iv-16
Tv-20
IV-20
IV-22

V-2
V-4
v-4
V4

V-8
v-9

V-11
V-17
V-18

VI-1
VI-3
VI-5
VI-7
VI-8



Chapter I. introduction

. Chapter VII—State and Local Agencies’ Perspective on Accommodating Future Growth,
discusses the issues and local agency concerns related to growth in the program.

Volumes 2 and 3 provide the detailed tables and reports that support the information contained
in this final report.

Introduction
Fo



Chapter 1. Introduction

State Agencies

4. Assess the impact of increased participation and other changes on State agency
administration and oversight of local WIC programs.

Exhibit I-1 summarizes the topics related to each of these research objectives.

IV. Overview of Methodology

WIC Dynamics is composed of two separate research activities. Research Objectives 1 and 4
were addressed primarily through mail surveys to all 85 State agencies and a nationally
representative sample of 300 local agencies. All survey respondents were asked to identify
changes that occurred in the service delivery system, administration, and caseload management
of WIC since 1988. The focus of the State Agency Survey was on allocation of funding and
caseload to local agencies. The Local Agency Survey documented current operations and
services and indicates which selected services and operations changed during this period of rapid
growth in WIC.

Those agencies: that did not return the survey within a specified period of time were sent follow-
up postcards, and, if necessary, then received a telephone call to remind them to complete the
survey. Responses were received from 77 of the State agencies (91%) and 285 of the sampled
local agencies (95%). Once the data were received and entered into a data file, they were
compared to an edit program that identified missing data and errors. Surveys with errors were
reviewed and follow-up telephone calls were made as necessary to resolve these issues. After
the data were edited and errors corrected, the analysis tables were created. These tables are in
Volume 2.

Research ‘Objectives 2 and 3 were addressed primarily through case studies of 22 local WIC
agencies, although the Local Agency Survey also included some questions relevant to these
objectives. The case study local agencies were selected to be as heterogeneous as possible, with
local agencies selected from all regions, and with at least one local agency per region that had
been included in a prior FCS study (to permit some comparison to earlier findings)” Agency
growth was also considered in the selection so that agencies with increasing, decreasing, or stable
growth were included.

Two-person teams spent 3-4 days on site at each case study local agency in the sample,
depending on the size of the site and the number of clinics to be visited. The data collection was
comprehensive, including interviews with the WIC director, nutritionist, and other staff members,
as well as record reviews of certification and nutrition education data. Interviews were also
conducted with public and private health care providers in the community served by the local
WIC agency and with agencies that were coordinating some activities with WIC.

Report on Findings and Methodologies of WIC Case Study Analyses, Abt Associates, December 1988.

Introduction
6



Table of Contents

Page Number

Executive Summary i
1 Overview of WIC Dynamics 1
I. Major Study Findings i
Chapter I. Introduction I-1
L Brief Description of the WIC Program I-1
IL Changes in the WIC Program 1-1
Ia. Study Purposes and Objectives 15
Iv. Overview of Methodology 1-6
V. Study Limitations 1-8
VI. Overview of the Final Report 1-8
Chapter II. State Agency Administration TI-1
L Funding for State and Local Agencies II-2

IL Practices and Initiatives Affecting Administration, Service Delivery,
and Oversight of Local Agencies Il-7

Ii. The Extent to Which Automation Is Used to Support WIC

Administration I-11
Chapter III. Local Agency Administration and Operations T-1
L Number of Local Agencies and Distribution of Clinics Tl-1
I Certification and Scheduling Procedures In-1
ll. Local Agency Operations Il-6
Iv. Staffing of Local WIC Agencies Tl-7
V. Space and Facilities I-11





Executive Summary

—-—————————————————————

Emphasis on Breastfeeding Promotion Has Increased

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—for example, 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 infants, providing special classes to all pregnant
women, and emphasizing the benefits of breastfeeding in all individual and group sessions
prior to and after delivery.

State Agencies Have Implemented Nutrition Services Standards

“Focus on Management" Nutrition Services Standards have been jointly developed by FCS
and the National Association of WIC Directors. Overall, it appears that State agencies have
implemented standards for delivering nutrition services.

WIC Nutrition Services Meet Standards

The study included an assessment of the nutrition services delivered at the 22 case study
sites. Nutrition services were assessed against the "Focus on Management” Nutrition
Services Standards jointly developed by FCS and the National Association of WIC
Directors. Overall, it appears that the case study agencies provide nutrition services that
comply with these standards.

D.- State Agency Administration and Oversight

State Allocation of Administrative Funds and Caseload to Local Agencies Varies, but Is
Heavily Influenced by Local Agencies’ Unserved Population and Capacities to Serve

States identified the following factors as most important in allocating administrative funds
to local agencies: the local agencies’ historical ability to serve the assigned caseload
(80%); the WIC priority groups currently being served (75%); and the percent of
potentially eligible participants being served (72%).

Administrative fund allocation reflects the economies of scale that larger States can
achieve. Fifty-six States, serving 74 percent of the participants, allocate 60-80 percent of
their administrative funds for local level expenses. Small States allocate lower
percentages of administrative funds (20% of States with 4% of the participants). Forty-five
percent of State agencies use an administrative cost-to-participant ratio to fund local
agencies. These States serve 77 percent of the participants.

Executive Summary
vii



List of Exhibits

1
Tl

TI-1
II-2

II-3
Tl-4
I-5S
II-6
I-7
TI-8

II-9

II-10
Ti-11
TI-12

TH-1
T-2
Il-3
Tl-4
T-5
Tll-6
Il-7
1-8

1-9

Factors That Affected Local WIC Agencies, 1988-1992
Study of WIC Dynamics Research Topics

Current Non-WIC Sources of Funding for WIC

Change in the Availability and Amount of Funding from Non-Federal
Sources for WIC Since 1988

Administrative Funds Allocated to Local Agencies

Average Administrative Cost Per WIC Participant in 1993

Factors Used in Assigning Caseloads in Local WIC Agencies

The Use of Program Performance Standards in WIC

State Sponsorship of Breastfeeding Promotional Activities in WIC
Number of Years that Current Food Voucher Issuance Policies
and Procedures Have Been in Place in WIC

State Reported Use of Mainframe Computers at Local Agencies
Change in Use of Mainframe Computers Since 1988

Change in Use of PC or Minicomputers Since 1988

Automation for Food Instrument Production

Number of Service Sites in Local WIC Agencies

Time Spent Waiting For and Being Certified For WIC Benefits
Changes in Local WIC Agency Certification Practices

Changes in Local WIC Agency Scheduling Practices

WIC Priority Groups

Administrative Changes Reported by Local WIC Agencies

Local Agency Current Staffing and Growth in Staff Since 1988
Percentage of Local Agencies by Sufficiency of Number of Staff
and Staff Skills

Page Number
ii
1-7
I-2

TI-3
1-3
TI-4
1-5
I-8
IL-9

0-10
I-12
I-12
II-13
I-14

TH-1
-2
I-3
m4
T-5
I-7
T-8

I-9

Percent of WIC Local Agency Non-Labor Items by Type of Funding Source I-12
I-10 Percent of Agencies and Participants by Specific Changes in Facilities

I-14



Chapter I. Introduction

|. Brief Description of the WIC Program

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a grant
program administered by the Food and Consumer Service of the U.S. Department of Agriculture.
Enacted by P.L. 92-443 in 1972, the goal of WIC is to improve the health of participants by
providing supplemental foods, nutrition education, and health care referrals.

The Federal Government provides separate grants for food and nutrition services and
administration to 85 State WIC agencies.' In turn, the State agencies fund local WIC agencies
to deliver services to participants. Local agencies certify women, infants, and preschoolers by
establishing that income eligibility guidelines are met (185% of poverty or less) and that a
certified professional authority determines the candidate to be at nutritional risk. Local agencies
provide nutrition education, make referrals to health care and other services, and typically
distribute food instruments (checks, vouchers, bank drafts) that are accepted by participating retail
food stores.2 WIC food instruments are valid only for the purchase of specified foods. In 1992,
an average of 5,396,569 participants received benefits each month through 1,777 local agencies.
Local agencies operated in more than 8,200 clinics, and more than 47,000 food stores participated
in the program.

ll. Changes in the WIC Program

Since its inception, the WIC Program has grown dramatically. Between 1988 and 1992, a 45
percent increase in participation occurred due to increased Federal funding and a State-initiated
cost containment strategy (rebates from infant formula manufacturers). During this period,
Congress also refined and reshaped the WIC Program. New requirements were placed on State
and local agencies to encourage cost containment,’ to provide special accommodation to the
homeless,‘ to provide referrals for drug abuse education,’ to serve incarcerated women, and to

‘Comprised of the 50 States, the District of Columbia, Guam, Puerto Rico, the Virgin Islands, and 31 Indian
Tribal Organizations in existence in 1992.

Mississippi, Vermont, and Ohio use direct distribution or home delivery systems to provide food benefits to
participants.

3P.L. 100-237 and P.L. 100-356, passed in 1988, permit part of the money saved as a result of infant formula
rebates and other cost containment measures to be converted to administrative funds.

“The Hunger Prevention Act of 1988 (P.L. 100-435) required delivery of WIC benefits to the homeless through
special accommodation.

*The Anti-Drug Abuse Act of 1988 (P.L. 100-690) required local agencies to provide drug abuse education to
WIC participants.

Trtroduction
a



The WIC
Dynamics Study

Volume |
Final Report

February 1995



Chapter Il.

State Agency Administration

Exhibit II-9

State Reported Use of Mainframe Computers at Local Agencies

Proportion of Local Using
Mainframe Computers

State Agencies
(%)

Affected Local Affected
Agencies Participants
(%) (%)

Source: Based on responses from 77 State WIC agencies; State Agency Survey, WIC Dynamics, 1993.

Some State agencies reported that they had shifted toward more mainframe equipment in the past
5 years, both at the State and local levels (Exhibit II-10). However, the greatest number of State
agencies reported no significant change since 1988. Larger agencies tended to report a change
in the use, either more or less, as compared with smaller agencies that tended to report no
significant change. The responses indicate that mainframe usage occurs in either all or few-to-
none of the agencies; very few States reported an intermediate level of mainframe usage among

their local agencies.

Exhibit I-10

Change in Use of Mainframe Computers since 1988

Shift in Mainframe Equipment Used
Since 1988 at State Level

~ aftected
Participants
(%)

No Significant Change

Shift in Mainframe Equipment Used
Since 1988 at Local Level

More Used

No Significant Change

Source: Based on responses from 77 State WIC agencies; State Agency Survey, WIC Dynamics, 1993.

State Agency Administration

N-12





Executive Summary



Chapter Ill. Local Agency Administration and Operations

Exhibit lll-8

Percentage of Local Agencies by Sufficiency of Number of Staff
and Staff Skills

PROFESSIONAL
Number of Staff
Nutritional Skills
Non-Nutritional/Referral Skills

PARAPROFESSIONAL
Number of Staff*
Nutritional Skills
Non-Nutritional/Referral Skills

CLERICAL/SUPPORT
Number of Staff
Nutritional Skills
Non-Nutritional/Referral Skills

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

* Only 51 pervent of the local agencies have paraprofessional staff. Responses add up to more than 51 percent. because some agencies that have
no paraprofessionals considered none to be sufficient.

Note: Excludes percent non-responding.

Staff Funding. Survey responses indicate that 90 percent of WIC staff are funded by the WIC
program, and the remaining 10 percent are funded by non-WIC sources. The majority of local
agencies (69%) reported that they were currently receiving more WIC funding for staff currently
than in 1988. This is expected, since administrative funds increase when participation increases.

Almost half of the local agencies (47%) use non-WIC funded staff to some degree. Fifty-two
percent of these agencies report that the level of funding for these staff has remained about the
same since 1988, while 37 percent of these local agencies report an increase in funding.

Augmenting Staff. According to survey responses, 16 percent of the local agencies, serving 27
percent of the participants, reported that they use non-WIC funded medical providers to perform
certifications. The use of contract or consulting staff to provide WIC services is found in 28
percent of the local agencies. This characteristic is more common among the larger agencies.
In Long Beach, CA, most of the staff are either part-time (39 hours per week or less) or contract
staff, because WIC staff are Long Beach City Health Department employees and the WIC
Program budget cannot support the city’s high fringe rate for full benefits. A 1987 site visit to
Long Beach (Abt Associates, 1988) also reported a large number of part-time staff and the
requirement that WIC follow the city’s civil service procedures in hiring staff.

Local Agency Administration and Operations
I-9



Chapter Il. State Agency Administration

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.

Eighty percent of the State agencies reported that their performance standards focus to some
degree on nutrition education. Over one-third of the State agencies (35%) reported that their
performance standards focus primarily on nutrition education.

State agencies most commonly reported (75%) that their performance standards are used for

monitoring local agency performance, evaluation, or both monitoring and evaluation. Exhibit
IL-6 illustrates the use of performance standards by State agencies.

Exhibit I-6

The Use of Program Performance Standards in WIC

Performance Standards Are

Used for Monitoring

Used for Evaluation

Used for Monitoring and Evaluation

Used for Other Activities
Do Not Use Standards

Source: Based on responses from 77 State WIC agencies; Staic Agency Survey, WIC Dynamics, 1993.

State Sponsorship of Breastfeeding Promotional Activities. The 1989 reauthorization
legislation, P.L. 101-147, specified that $8 million be set aside annually from the NSA portion
of the Federal WIC appropriation to fund State breastfeeding promotion and support activities.
These funds are allocated to the WIC State agencies based upon their proportion of the national
caseload. According to State Agency Survey responses, there are a variety of breastfeeding
promotional activities in place. The most common State agency activity is providing printed
materials (reported by 99% of the responding agencies), such as pamphlets and posters, for
participants. Conducting in-service training programs, cosponsoring local activities with other
organizations, and coordinating with hospital maternity wards are promotional breastfeeding
activities sponsored by more than half of the State WIC agencies. Exhibit II-7 illustrates the
types of activities that State agencies are sponsoring to promote breastfeeding among WIC

participants.

“State Agency Administration
1-8



Chapter I. Introduction

For more detailed information on the methodology used and the sampling plan, see the Volumes
2 and 3. Upon completion of each site visit, the site visit team wrote individual case study
reports and sent them to a representative from the local agency for review and verification. The
information from these reports was synthesized in preparation for this report, using cross-site
analysis tables (see Volume 3).

V. Study Limitations

WIC Dynamics focuses on current operations and changes that occurred since 1988. The
measures of change and impact of the changes are primarily based on State and local agency staff
perceptions. Due to budget constraints and the need to limit the data collection burden, their
views were not subjected to independent verification or assessment, although the data were
closely examined for consistency in related areas.

VI. Overview of the Final Report

The purpose of this report is to present findings from both the mail surveys and the site visits.
The State and local surveys primarily provided the quantitative data in this report. The
information obtained during the site visits, along with follow-up telephone discussions with
representatives from different local and State agencies, have supplemented the survey data. The
core of this report consists of six chapters, each of which addresses a specific set of questions
related to the Study Objectives.

. Chapter JI—State Agency Administration, discusses funding issues, automation, and other
changes occurring at the State level that affect the State’s administration of the WIC

Program.

-— Chapter Ifl—Local Agency Administration, covers the day-to-day operations and
procedures followed at the local agencies and the impact of changes in these areas on the
local agencies’ ability to administer the WIC Program.

. Chapter IV—Nutrition Services, deals with nutrition education, breastfeeding promotion,
and food package delivery methods.

. Chapter V—Integration and Coordination with Other Programs, discusses the extent to
which local WIC agencies are integrated/coordinated with other agencies, as well as
outreach and referral activities.

. Chapter VI—Synthesis of Impact of Changes on State and Local Agency Operations,
summarizes the changes in State and local agency characteristics, caseloads, economic
factors, program requirements, and other initiatives and factors during the study period.

Tntroduction



Chapter Il. State Agency Administration

Exhibit 1-11

Change in Use of PC or Minicomputers Since 1988

Affected Local Affected

Shift in PC/Mini Equipment Used Agencies Participants

Since 1988 at State Level (%) (%)

More Used

No Significant Change

Less Used

Affected Local
Agencies
(%)

Shift in PC/Mini Equipment Used
Since 1988 at Local Level

More Used

No Significant Change

Less Used

Source: Based on responses from 77 State WIC agencies: State Agency Survey, WIC Dynamics, 1993.

Automation of WIC Activities. Thirty-five percent of State agencies reported a shift from
central State processing to more locally based processing; about half of all the agencies (55%)
reported no shift between central and local processing. In addition to general issues of
recordkeeping, States reported on the level of automation used in three agency functions:
enrollment, food instrument production, and appointment scheduling.

Enrollment. Forty-three percent of State agencies have a fully automated enrollment system.
Local agencies in these States either enter enrollment information into a micro- or mini-computer
and transmit the data to a central database (29%), or else enter data into terminals that are
directly connected to a central database (14%). Almost half of the State agencies (44%) reported
that locals manually fill out forms for enrollment which are then sent to the State agency for
entry into a central database. Only 3 percent of the States serving less than 1 percent of the
participants are using all-manual systems.

Food Instrument Production. A variety of levels of automation was reported for food instrument
production, as is shown in Exhibit I-12. About one-third of the States reported that local
agencies use a variety of automated production methods. Nearly half of the States (45%, serving
56% of participants) use computer-generated bulk vouchers that are hand-customized by local
agency staff for each participant. Only 8 percent of the States reported all-manual production.
One State reported limited use of an Electronic Benefits Transfer (EBT) card.

State Agency Administration
H13



Chapter I.

Introduction

Effects of Rapid Growth
and Other Changes on
Local Agency Service
Delivery

A. Effects of Changes on
Local Agency Service
Delivery
1. Nutrition Education

Process
2. Space and Facilities

4. Types of Referrals

B. Effects of Changes on
Program Administration
and Caseload
Mi
1. Certification Process

3. Staffing
4. Waiting Lists/Priority
Systems

C. Effects on Local WIC

2.
3. Total Resources
4

Coordination with
Other Health and
Community Service
Programs

D. Service Quality and
Accommodating Future
Growth
1. Quality of Services,

Work Environment,
Morale
2. Practices to

3. Methods for Referrals 2.

5. Food Package Delivery| 3.

2. Operating Procedures

. Overall Integration and

Accommodate Growth

Exhibit |-1

Study of WIC Dynamics Research Topics

Effect of increased
Participation, Integration,
and Coordination with Local
Health Care Delivery

A. Integration and
Coordination with Local
Health Care Delivery
Systems
1. Relationship with the

Medical Community

Other Matemal and

Child Health Services

Accommodation by

Other Health Care

Delivery Systems of

increased WIC

Referrals

4. Types of Health Care
Providers Accepting
WIC Referrals

5. Requirement That
Applicants Visit a
Physician Prior to WIC
Certification

Assessment of Nutrition
Services

Systems

A. Nutrition Services

1. Nutrition Education
Services

2. Length of Sessions

3. Attendance Promotion

4. Staff Providing
Education

5, Relationship to
Medicaid Enhancement
Service Packages:

6. Relationship to the
Frequency and Content
of Other Nutrition
Education

7. Individual Care Plans

8. Quality and Frequency
of Nutrition Education
Contacts

B. FOM Nutrition Services
Standards:

C. Breastfeeding Promotion

. Funding
1. Allocation of Funds to
Local Agencies
2. Percentage of
Administrative Grant
Retained at the State

Level

3. Conversion of Food
Grant Dollars to Cover
Nutrition Education and
Program Administration

4, Availability or Use of
Alterative State

Funding

New Initiatives in
Response to Changes in
Federal Regulations

, Automation
. States’ Capacity to Serve

State-Level Program

Initiatives

State Agency
Administration and
Oversight of Local WIC

Programs

Introduction
+7



Table of Contents (cont'd)

Chapter IV.

S<<28e-

Chapter V.

nGss<Zee-

Chapter VI.

L
I.
Il.

Nutrition Services

Introduction

Assessment and Care Plan

Nutrition Education

Staff Education and Training

Food Package Delivery Methods

Evaluation Activities and Local Agency Perception of Quality
Assessment of Nutrition Services

Integration and Coordination with Other Programs

Overview

Integration and Coordination with Local Health Care Delivery Systems
Integration and Coordination with Specific Health Services

Integration and Coordination with Social Services

Outreach

Referrals

Relationship with the Medical Community

Sharing of Staff and Resources

Planning and Special Projects

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

Participation Growth
Impact of Changes
Facilitators and Barriers to Providing High-Quality WIC Services

Chapter VII. Current Operating Capacity and Perspectives on Accommodating

Future Growth

Current Operating Capacity
Perspectives on Accommodating Future Growth

Page
Number

VI-1
VI-3
VI-6

Vi-1

VI-1
VII-S





Chapter Ill. Local Agency Administration and Operations

In addition to the changes shown in Exhibit I-6, the majority of the local agencies initiated
some type of special project (51% of the agencies, serving 68% of the participants), and planned
or held regular staff meetings (59% of the agencies, serving 76% of the participants). However,
43 percent of the agencies, serving 56 percent of the participants, postponed or canceled special
projects.

Exhibit III-6

Administrative Changes Reported by Local WIC Agencies

Made Greater Use of Computers
Delayed Completion of Paperwork/Reports

Increased Paperwork

Streamlined Recordkeeping

Expanded Case Management
Postponed or Canceled Special Projects
Limited Caseload to Certain Priorities
Added Priorities Served

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

IV. Staffing of Local WIC Agencies

Local WIC agencies have three categories of staff: professional (e.g., licensed nutritionists,
nurses), paraprofessional (e.g., nutrition assistants), and clerical/support. The Local Agency
Survey found that all but 3 percent of the local agencies use professional staff, and only 8 percent
do not use clerical/support staff. Paraprofessional staff are not as widely used, in that 49 percent
of the local agencies do not have paraprofessionals. Exhibit [1-7 illustrates that the majority of
local agencies reported an increase in the use of all three typ: of staff since 1988. For each of
these staff categories, local agencies serving a large number of participants more commonly cited
an increase in the number of staff.

Local Agency Administration and Operations
7



Chapter Ill. Local Agency Admi

istration and Operations

the case study sites, 17 of 22 reported a change in space or facilities since 1988. Yet, most case
study sites found their existing space to be inadequate. Some case study sites, such as York, PA,
moved specifically to provide more space and privacy for WIC staff and participants. In other
sites, such as Montgomery County, MD, changes in location reflect efforts to accommodate
demographic changes in the county.

Exhibit Ill-10

Percent of Agencies and Participants by Specific Changes in Facilities

Specific Change in Facilities

Moved to New Clinic Sites

Added New Clinic Sites

Eliminated Clinic Sites

Made More Efficient Use of Space
Colocated with Health Care Provider
Other

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

Staff interviewed at most of the 22 case study sites were concerned about space and their ability
to grow further. Between 15 and 18 sites mentioned waiting room space, individual or group
nutrition education space, or voucher distribution space as issues that might be problematic given
future growth. For example, at the case study site in San Antonio, TX, the majority of this
agency’s facilities are colocated or receive space funding from other sources. As the program
continues to expand, it is outgrowing many of its current facilities. Plans are underway to
establish three new clinic sites. The program director reported that these sites will be funded
exclusively by WIC funds. He indicated that this is an expenditure that the agency never really
encountered until now.

Another example of this is the case study site in Atlantic City, NJ. This agency houses its clinics
and administrative offices in space provided by the municipal government, which is the largest
space the city government has available. This WIC site will soon exceed its current space (a
situation noted by the WIC director and confirmed by on-site observation). Further expansion
will mean seeking space from other sources and, for the first time, using WIC funds to rent

space.

Local Agency Administration and Operations
AI-14



Chapter II. State Agency Administration

Exhibit Il-2

Change in the Availability and Amount of
Funding from Non-Federal Sources for WIC Since 1988

State Affected Affected

Availability and Amount of Funding Agencies Local Agencies Participants

(%) (%) (%)

Funding Source
Additional Funding Sources Became Available 23 36 39
Fewer Funding Sources Were Available 8 15 11

Funding Sources Remained the Same

Funding Level
More Funding Became Available 22 32 31
Less Funding Became Available 22 35 41
Amount of Funding Remained the Same ;

Source: Based on responses from 77 State WIC agencies; State Agency Survey, WIC Dynamics, 1993.

Funding Allocation to Local Agencies. As shown in Exhibit [-3, the majority of State
Agencies (56%) allocate 60 to 80 percent of their nutrition services and administrative funds for
local-level expenses. These State agencies serve 74 percent of the participants, and so are, on
average, States with larger caseloads. Those States that allocate a lower percentage of
administrative funds to local operations appear to be smaller State agencies (20% of State
agencies in this category serve 4% of the participants). The study did not investigate the extent
to which administration and management of local agencies differ among the WIC State agencies.

Exhibit ll-3

Administrative Funds Allocated to Local Agencies

Pesala CicareEpenes* | Aamnces | Local gwcie | erent
0% - 20% ') 0 Qo
20.01% - 40% 10 0.35 3
40.01% - 60% 10 3 1
60.01% - 80% 56 65 74

80.01% - 100% 24 32

Source: Based on responses from 77 State WIC agencies; State Agency Survey, WIC Dynamics, 1993.

State Agency Administration
3



Chapter Il. State Agency Ad

Average administrative costs per participant are shown in Exhibit II-4. Forty-five percent of the
State agencies report using an administrative cost/participant ratio to fund local agencies. These
State agencies serve 72 percent of the local agencies and serve 77 percent of the participants. The
average administrative grant to local agencies per participant ranges from less than $6 to greater
than $20. The largest per-participant reimbursements (more than $15) were in the smallest
agencies; 24 percent of State agencies serving less than 2 percent of participants. Conversely,
it appears that larger State agencies experience economies of scale and tend to reimburse at a
lower rate. The single-most frequently cited range of reimbursement per participant (cited by
21% of the State agencies) is between $8.00-$8.99, affecting 38 percent of the local agencies and
36 percent of the participants. States have, for the most part, been using the same method to
compute administrative grants per participant since 1988. Only 17 percent of the State agencies
report having changed their method of computation during this period.

Exhibit ll-4

Average Administrative Cost Per WIC Participant in 1993

Average Administrative Cost Per Participant

Less than $6.00

$9.00 - $9.99
$10.00 - $14.99

$15.00 - $19.99*

{| $20.00 or more*

Source: Based on responses from 77 State WIC agencies; State Agency Survey, WIC Dynamics, 1993.
“These are ITOs and other sparsely populated States that experienced higher administrative costs per participant duc to the relatively small size
of their caseloads.

Note that during this period, the 1989 WIC reauthorization legislation changed the basis for
calculating the portion of the total Federal WIC appropriation to be allocated for NSA expenses.
Prior to 1989, 20 percent of the Federal WIC appropriation was allocated for NSA expenditures.
The 1989 legislation specified that the amount of NSA funds available from the Federal
appropriation would be based upon a national average administrative grant per participant (AGP).
The AGP was indexed to a 1987 base year and is annually adjusted for inflation, using an
economic indicator based upon State and local government personnel costs. The result has been
that a larger proportion (25.5% in 1993) of the Federal WIC appropriation is available for NSA
expenditures.

State Agency Administration
4



Chapter Ill. Local Agency Administration and Operations

Other sites, such as Montgomery County, MD, reported bottlenecks in providing integrated
services due to the limited number of WIC staff available to see referrals from maternal and child
health clinics.

During the study period (since 1988), local agencies reported making changes in the certification
and scheduling processes. The most frequent changes in certification practices were:

. Scheduling less certification time per participant (57% of the agencies, serving 63% of the
participants), and

° Limiting participation to certain priorities (43% of the agencies, serving 54% of the
participants). This practice was also in place in local agencies prior to 1988.

The major changes in scheduling practices were:

. Overbooking participant appointments (71% of the agencies, serving 84% of the
participants),

. Implementing or rigorously holding to an appointment system (55% of the agencies,
serving 58% of the participants), and

° Extending the clinic days of service (51% of the agencies, serving 57% of the participants).
While only 44 percent of the agencies extended clinic hours beyond regular hours, these agencies
serve 64 percent of the participants, indicating that the larger agencies made more changes in

hours of operation than the smaller agencies. Exhibits III-3 and III-4 present the percentage of
agencies that implemented these changes and the proportion of participants these agencies serve.

Exhibit ll-3

Changes in Local WIC Agency Certification Practices

Scheduled Less Time Per Certification 57 63
Limited Caseload to Certain Priorities 43 54
Added Priorities Served 43 44
Reduced Priorities Served 38 48
Started Doing Walk-in Certifications 26 28
Stopped Doing Walk-in Certifications 21 26 |

Local Agency Administration and Operations
m3



Chapter I. Introduction

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

. The Hunger Prevention Act of 1988, P.L. 100-435, provided grants in up to 10 States to
conduct Farmers’ Market Demonstration Projects in which WIC participants receive
vouchers which can be redeemed for fresh fruits and vegetables at local farmers’ markets.

. The Anti-Drug Abuse Act of 1988, P.L. 100-690, requires the WIC Program to provide
information about the dangers of drug abuse; refer participants suspected of drug abuse for
treatment or counseling; and distribute drug abuse materials to participants.

. The Child Nutrition and WIC Amendments of 1989, P.L. 101-147, included over 30
changes to WIC’s administration and operations. Among those affecting local agency
service delivery are adjunctive Medicaid eligibility for Food Stamp, Medicaid, and AFDC
recipients and a set-aside for breastfeeding promotion and support activities.

. The FY 1992 Agriculture Appropriations Act, P.L. 102-142, directed USDA to work
closely with States to better target participation to the most nutritionally at risk and work
to enroll hard-to-reach eligible women, infants, children.

. The WIC Farmers’ Market Nutrition Act of 1992, P.L. 102-314, established and
authorized the WIC Farmers’ Market Nutrition Program (FMNP) through 1994. This act
expanded the Farmers’ Market Program to more States and extended Farmers’ Market
benefits to WIC applicants on waiting lists.

. The FY 1993 Agriculture Appropriations Act, P.L. 102-341, directed USDA to continue
efforts to involve the WIC Program in the "Weed and Seed" Initiative administered by the
U.S. Department of Justice. The Weed and Seed Program promotes neighborhood
revitalization and attempts to reclaim communities embattled by drugs and crime. The Act
also directed the WIC Program to better target participation to those most nutritionally at
risk and to work to enroll hard-to-reach eligibles. WIC was instructed to include
immunization education as part of the services provided to participants.

. The Child Nutrition Amendments of 1992, P.L. 102-342, included a provision to make
homelessness and migrancy predisposing nutritional risk criteria for WIC eligibility. The
Act also directed USDA to conduct several activities to increase breastfeeding promotion.

. The WIC Infant Formula Procurement Act of 1992, P.L. 102-512, contained provisions
directed at USDA and WIC State agencies in procuring infant formula rebates. However,
one provision which had the greatest potential impact on WIC local agencies requires
States to include, in their annual State plans, a description of how they will reduce the
purchase of unprescribed low-iron formula by WIC participants.

. The National Voter Registration Act of 1993, P.L. 103-31, requires States to designate
as voter registration agencies all offices in the State that provide “public assistance." The
Act defines public assistance to include those State agencies that administer or provide
services under the WIC, Food Stamp, AFDC, and Medicaid programs.

Introduction



Chapter Ill. Local Agency Administration and Operations

The measures that are used to determine the risk status are often taken from the medical history
provided on a participant’s record or from the anthropometric measurements that can be taken
by WIC or non-WIC staff. Data collected from the case study sites indicate that among WIC
staff, nutritionists are most likely to take these measurements (13 of the 22 sites), while among
non-WIC staff, equal numbers of sites reported using physician- or nurse-generated information.
This information may be sent to the WIC Program as a result of visits by the participant with the
medical provider. If information is taken from patient medical records, there is generally a time
period within which the measurements must be taken (e.g., 60 days prior to certification).

The method for obtaining hematological measurements differs among clinics in local agencies.
The survey responses indicated that at least 71 percent of the principal clinics conduct blood tests
on site. This figure includes principal clinics where the hematological work is conducted on site
by WIC staff or by non-WIC staff. The responses also indicated that 52 percent of the principal
clinics accept hematological reports prepared off site by health care personnel. Thus,
hematological data may be obtained through both on-site and off-site measurements.

During the case study site visits, it was found that although many WIC clinics take their own
anthropometric and hemoglobin/hematocrit measurements, others rely solely on outside providers
to provide this information. Case study information indicated that New York State tends to rely
on medical providers to do all the blood work for their participants. In addition, the sites visited
also relied on those providers to complete medical forms prior to certification that specified
participants’ anthropometric measures. In fact, the medical form required for certification also
includes information on other measures that might be used in the risk assessment (e.g.,
developmental disorders, chronic medical conditions, emotional/psychological problems, or
substance abuse). Staff at one of the New York case study sites were concerned about relying
on outside providers, particularly private providers, to obtain this information. Often, there
appeared to be little, if any, contact between WIC staff and private providers. The staff felt that
private providers are reticent about divulging what may be considered "confidential" information
about their patients to WIC offices. They do not perceive WIC staff to be fully part of the health
system, but rather as part of the welfare system; therefore, they are uncomfortable about sending
forms that include such "private" information.

lll. Local Agency Operations

Both the survey responses and the site visits indicated that many agencies have changed the day-
to-day operations of their programs since 1988, as illustrated by Exhibit III-6. Some of these
changes could be considered beneficial changes (they tend to make the process run more
efficiently), but others may be detrimental. For example, about one-half of local agencies
streamlined their recordkeeping. Sixty-two percent of the agencies, serving 68 percent of the
participants, delayed the completion of paperwork or reports. In addition, 59 percent of the
agencies, serving 64 percent of the participants, reportedly increased the amount of paperwork.
This finding by itself is interesting because 68 percent of the agencies, serving 80 percent of the
participants, made greater use of computers. Exhibit III-6 details administrative changes reported
by local agencies.

Local Agency Administration and Operations
M-6



Chapter Ill. Local Agency Administration and Operations

As the preceding discussion indicates, local agencies have undertaken various steps to increase
their clinic space or use their current facilities in more efficient ways. While these efforts may
have helped to absorb the caseload growth, there remains concern about the adequacy of their
existing space to serve current caseloads or accommodate future growth.

Local Agency Administration and Operations
(15





Chapter Il. State Agency Administration

The majority of State agencies (79%) reported that their State’s Medicaid program does not
reimburse for WIC services. However, services such as laboratory work used for WIC
certification are covered when provided by a Medicaid participating provider (such as a private
physician, hospital, or county health department or health center). In some States, Medicaid also
reimburses for enhanced services, such as nutrition counseling and case management, for high-
risk pregnant women. Thus, in some States, Medicaid resources are used to fund some WIC
service to program participants.

Il. The Extent to Which Automation Is Used to Support WIC
Administration

The use of computers and the automation of various activities in the WIC Program have
increased over the past 5 years. This mirrors the rapid increase in the use of computers in many
segments of society. However, the level of automation and the amount of change that occurred
since 1988 vary substantially among agencies. The State survey included a number of questions
regarding the current state of automation and how it has changed since 1988.

Use of PC or Mini and Mainframe Equipment. State agencies were asked what proportion
of their local agencies used PC or minicomputer support and what proportion used a mainframe.
Their responses are shown in Exhibit II-9. Forty-five percent reported that all of their local
agencies used PCs or minis, while 41 percent reported that all of their locals had mainframe
support. Note that the two categories are not mutually exclusive, as an agency could use
mainframe support for some functions while using PCs for other activities.

State agencies were also asked whether a shift occurred in the use of PCs or minicomputers since
1988 (Exhibit II-11). Most State agencies reported that more PC or mini-equipment is being used
now at the State level, as compared with 5 years ago, and nearly all participants (97%) are in
such States. PC or minicomputer usage also increased in local agencies, with two-thirds of the
local agencies and three-fourths of the participants in States reporting increased usage at the local
level. As mentioned earlier, State responses to mainframe and PC or minicomputer equipment
questions are independent, so there may legitimately be an increase in the use of both types
within a State.

State Agency Administration
u-11



Exhibit I-7

State Sponsorship of Breastfeeding Promotional Activities in WIC

Affected Affected
Breastfeeding Promotional Activity Agencies Local Agencies Participants
(%) (%)

Providing Materials 99
In-Service Training Programs 91 95 98
Cosponsoring Local Activities 66 83 84
Coordinating with Hospital Maternity Wards 53 59 54
Peer Counseling Program Training 47 51 70

Public Service Announcements

Hot Lines:

Source: Based on responses from 77 State WIC agencies; State Agency Survey, WIC Dynamics, 1993.

Various responses, other than those listed above, were given by a small percent of the States.
These included coalitions, task forces, lactation consultants, breastfeeding consultants, and general
media activities. For all responses included in the "other" categories, less than 10 percent of the
State agencies responded for any one of these categories.

Food Instrument Issuance Practices. The most common frequencies of issuing food vouchers
or instruments are once per month (43% of State agencies) or once every 2 months (39% of State
agencies). A small number of State agencies (6%) reported that they are direct distribution
agencies and do not issue food vouchers or instruments to participants. Survey responses indicate
that voucher issuance does not vary greatly within State agencies. Only 5 percent of the State
agencies reported a significant variation in issuance frequency among their local agencies,
whereas 49 percent of the State agencies reported no variation in issuance frequency among their
local agencies. Thirty-four agencies were unable to respond to this issue because they were
sponsored by Indian Tribal Organizations (ITOs) or State Agencies, which do not have local
agencies.

The majority of State agencies (64%) have had a change in their voucher issuance schedule since
1988. These State agencies serve 68 percent of local agencies and 78 percent of WIC
participants. Survey responses indicate a wide variation among State agencies in the number of
years they have been using their current issuance policies and procedures. Exhibit II-8 illustrates
this variation.

State Agency Administration
u-9



Executive Summary

Made changes in nutrition education. More than half of the agencies increased use of
group nutrition education (57%) and used more handouts and pamphlets in delivering
nutrition education (56%).

Changed content of food package and frequency of issuance. Sixty-three percent of
agencies issued multiple food instruments, which reduced the number of times that
participants visited the agency to pick up instruments. Fifty-one percent of local agencies
spent less time tailoring food packages and issued standard food packages more often.
Standard packages are specific quantities of supplemental foods for sub-categories of WIC
participants, designed to address categorical, nutrition risk, and other factors. The use of
standard food packages can reduce the level of time and effort needed to tailor individual
food packages.

Changed administrative procedures. The study period found local agencies overbooking
appointments (71%) and extending clinic days of service (51%) to respond to the new
requirements and other factors. More than half indicated that they made greater use of
computers (68%). Yet, 62 percent reported that they delayed completion of paperwork
and 59 percent reported increased paperwork. At the same time, 51 percent reported that
they streamlined recordkeeping.

Changed space use. Seventy-two percent of the local agencies reported making more
efficient use of space. Although somewhat fewer than half of the agencies reported this,
note that 48 percent, serving 66 percent of the participants, moved to new facilities, and
40 percent, serving 66 percent of the participants, added new clinic sites.

Local Agency Concerns about Facilities and Staff

The majority of local agencies (67%), serving 82 percent of the participants, reported their
current space to be inadequate. The most frequently (65%) reported factor that hindered
high-quality WIC services was inadequate facilities and materials.

Almost two-thirds (61%) of the participants are being served in local agencies that perceive
their number of staff to be less than sufficient. Yet the majority of local agencies cited
that they did not have any vacant staff positions. About one-half of the local agencies
(52%) found it difficult to recruit professional staff. The most problematic barrier cited
to filling staff vacancies was salary and benefits which were not competitive. Shortages
of certain types of staff were also problematic; for instance, 21 percent of the local
agencies reported a shortage of nutritionists and 14 percent cited a shortage of dietitians
as reasons for not filling vacant positions.

Executive Summary
iii



Chapter Ill. Local Agency Administration and Operations

. Conditions that predispose persons to medically based or diet-based risks, such as
alcoholism or drug addiction.

Each risk criterion is specifically coded and corresponds to a priority level. The priority levels
are not only based on the risk criteria, but also vary on the participant category. For example,
an infant or pregnant woman with a low hemoglobin count is considered to be in the first priority
category, compared to a child who would be in the third priority level. A lactating or pregnant
woman at dietary risk would be in the fourth priority level. While the risk assessment is used
to determine program eligibility, the priority level is most important when, due to resource
constraints, agencies must limit the number of participants. Exhibit III-5 describes the WIC

Priority groups.

Exhibit 1-5

WIC Priority Groups

Pregnant and breastfeeding women and infants, at nutritional risk as
demonstrated by anthropometric or hematological assessment or by other
documented nutritionally related medical condition.

Infants up to 6 months of age of mothers who participated in WIC during
pregnancy, or who would have been eligible to participate under Priority |
documented medical condition. This priority may also be assigned to a
breastfeeding mother of an infant who is classified as Priority Il.

Children at nutritional risk, as demonstrated by anthropometric or hematological
assessment of other documented medical condition. Can also include high-risk
postpartum women.

Pregnant and breastfeeding women and infants, at nutritional risk as
demonstrated by inadequate dietary pattern. Can also include high-risk
postpartum women.

Children at nutritional risk due to inadequate dietary pattem. Can also include
high-risk postpartum women.

Postpartum women, not breastfeeding, at nutritional risk on either medical or
dietary criteria.

Previously certified participants likely to regress in nutritional status without
continuation of supplemental foods.

Local Agency Administration and Operations
U-5



Chapter Ill. Local Agency Administration and Operations

finding a qualified candidate. Sixteen percent of the local agencies cited hiring freezes as the
reason for not filling vacant positions.

Staff Retention. About one-third, thirty-four percent of local agencies, serving 47 percent of
participants, report that retaining professional staff is difficult. Only 13 percent of the local
agencies find it difficult to retain paraprofessional staff and 18 percent find it difficult to retain
clerical/support staff. Salary and benefits are reported by 43 percent of the local agencies as a
factor contributing to poor staff retention, and just less than one-third (32%) of the local agencies
report workload as affecting retention. Low morale is cited by 18 percent of the local agencies
as a factor contributing to high turnover, and 17 percent of the local agencies cite "staff attitude
and tumover” as a factor that hinders high-quality WIC services.

Nearly two-thirds (65%) of the local agencies report no change in the level of difficulty in
retaining staff positions since 1988. This characteristic is more prevalent among the smaller
agencies.

The majority of local agencies perceived the staff at their agencies to be the primary contributor
to high-quality WIC services. More than half (53%) of the agencies report that they have
qualified, well-trained staff that contribute to high-quality services; 60 percent of the respondents
attribute high-quality WIC services at their agencies to their staff. Staff tumover was perceived
by 39 percent of agencies to be a barrier to providing high quality services.

V. Space and Facilities

Currently, only 23 percent of local agencies exclusively fund their space from their WIC budget,
indicating that space is a major benefit of resource sharing for WIC. Approximately the same
proportion of agencies fund their space exclusively by non-WIC government agencies or private
sources. About half the local agencies receive funding from a combination of WIC and non-WIC
sources for their space and utilities. Exhibit III-9 presents local agency funding sources. The
availability of space and facilities to support the WIC Program, and the funding for such, was
cited as a major area of concer for further growth of the WIC Program. If local WIC agencies’
space requirements increase with caseload growth, they may need to seek increases in the level
of non-WIC funding or devote more of their WIC funds to cover space costs.

Local agencies most often reported that WIC funding allocated by their State agencies for both
space (41%, serving 29% of participants) and utilities (48%, serving 32% of participants)
remained at about the same level in comparison to 1988. Local agencies serving a larger number
of participants reported an increase in WIC funding for space and utilities more often than
smaller agencies.

Tocal Agency Administration and Operations
W141



Executive Summary

poverty line; required State Medicaid programs to provide for coordination between the
Medicaid and WIC Programs; and directed States to set reasonable Medicaid
reimbursement rates for providers.

In some locales, WIC is not as well coordinated with private providers as it is with public
health departments. The case studies suggested several reasons for this. Communication
efforts are sometimes hindered when there is no well-established network, and each
provider must be contacted separately. 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.

Availability of Non-Health Services

Fewer than one-third of the principal clinics have social service programs, food assistance
programs, transportation, or AFDC on site. Less than 15 percent of the principal clinics
have Head Start, child care, housing, and adult education/job training services on site.
Application forms for non-health services are available more frequently: social service
programs (35%), food assistance programs (32%), and AFDC (25%).

Services Funded by Other Sources

Only one-fourth of the local agencies use only WIC funds to pay for space (23%) and
utilities (24%). A little more than half of the local agencies use a combination of WIC and
non-WIC funds for space and utilities. WIC funds are used exclusively for educational
materials in 62 percent of the local agencies; for computer equipment in 54 percent of the
local agencies; and for medical equipment in 49 percent of the local agencies.

Twenty-nine percent of the principal clinics use non-WIC on-site staff for hematological
measurements. Interestingly, over one-fourth of the sites responded that they did not know
whether hematological measurements were provided on site by non-WIC staff. In highly
integrated sites, agency staff tend to be unaware of funding sources for WIC services,
staffing, or facilities.

WIC’s dependence on other programs for funding, staffing, and other assistance is an
indication of the high degree of resource sharing with other programs serving the same

target group.

Executive Summary
v



“ir

Final Report — WIC Dynamics
Volume 1

Contract No. 53-3198-0-049

Submitted to:

USDA, Food and Consumer Service
3101 Park Center Drive - Room 201
Alexandria VA 22302
Denise Thomas, Project Officer

by:

Macro International Inc.

11785 Beltsville Drive
Calverton, Maryland 20705
JoAnn Kuchak, Project Director
and
The Urban institute
2100 M Street, N.W.
Washington, DC 20037
Nancy M. Pindus, Subcontract Director

February 1995



Chapter Il. State Agency Administration

1. Funding for State and Local Agencies

The WIC Program is funded primarily with Federal funds. In FY 1988, Federal funding for this
program totaled $1.8 billion, and in FY 1992, approximately $2.6 billion—an increase of
44 percent. In addition to Federal funds, many State agencies support the WIC Program with
funds from other sources.

Sources of Non-Federal Funding. Over half of the 77 responding State agencies and Tribal
Organizations (57%) reported using non-Federal sources of funding to support WIC Program
operations. These State agencies serve 81 percent of the total WIC participants. Twenty-seven
percent of the State agencies use State appropriations, and 11 percent of these State agencies are
permitted to "carry forward" these funds from one year to the next. Twenty-two percent of the
State agencies are using county or other local funds, and about 5 percent use private grants.
Sources of non-Federal WIC funding included tribal funds, non-WIC Federal grants, and in-kind
services. Some States are using multiple sources of non-Federal funds, as shown in Exhibit II-1.

Exhibit 1-1

Current Non-WIC Sources of Funding for WIC

Sources of Non-WIC Funding

None

| state Appropriations 27 38
Private Grants 5 5
County or Local Funds 22 45
Other Sources 23 22

Source: Based on responses from 77 State WIC agencies; State Agency Survey, WIC Dynamics Study, 1993.
Note: Totals exceed 100% because more than one funding source could be cited by each agency.

Most State agencies (69%) reported that the availability of non-Federal funds for WIC has not
changed since 1988. Those States reporting that additional funding sources had become available
had, on average, larger caseloads. The 23 percent of State agencies reporting increased
availability of non-Federal sources of funding serve 39 percent of WIC participants and 36
percent of the local agencies. The actual amount of non-Federal funding reportedly remained the
same for over half of the State agencies.

State Agency Administration
N-2



Chapter I. Introduction

improve accessibility for working women.° In addition, local agencies were required to place
further emphasis on breastfeeding promotion and to encourage immunizations in children. Other
programs also had impact. Eligibility for Medicaid expanded, and increased coordination and
referrals between Medicaid and WIC were also required.’*

Legislative Mandates

In its 20-year history, the Special Supplemental Food Program for Women, Infants, and Children
(WIC) has experienced two phases of caseload growth. During the first phase, from 1974 to
1987, the program’s caseload expanded steadily from year-to-year. Various legislative and
regulatory actions implemented during this period refined WIC’s funding, administration, and
services. During this first phase, the program developed and matured. In the second phase,
which started around Fiscal Year 1988, WIC began to experience large annual increases in
participation, due primarily to the infusion of more funds, in the form of infant formula rebates
and large annual appropriation increases. Monthly participation in Fiscal Year 1988 averaged
3.6 million, but one year later in Fiscal Year 1989, average participation climbed to 4.1 million,
an increase of 500,000. In January 1994, 6.3 million women, infants, and children participated
in WIC.

This report, The WIC Dynamics Study, focuses on the second and current phase which began
in 1988 and is distinguished by two significant factors. First, as stated earlier, WIC began to
experience extraordinary program growth with annual average monthly participation increases
approaching and exceeding 500,000 persons. Secondly, and perhaps more significantly, WIC’s
role in the spectrum of maternal and child health services took a major shift. WIC evolved from
being an adjunct to maternal and child health services to becoming the gateway program through
which many low-income households enter the public health system. As Congress and others
became aware of WIC’s expanded role, they began to view the program as a vehicle to increase
services to low-income mothers and their children. Through WIC, participants are informed
about and referred to a range of programs and services including immunizations, food assistance,
AFDC, Medicaid, drug and alcohol abuse counseling, and smoking cessation programs. The
results have been two-fold—WIC local agency responsibilities have expanded but many WIC
local agencies have become "one-stop shopping" sites for an array of health and social services.

The WIC Dynamics Study examined, among other factors, the effects of increased caseloads
generated by infant formula rebates. Until Fiscal Year 1988, WIC food costs increased steadily
each year. In Fiscal Year 1988, P.L. 100-237, The Commodity Distribution Reform Act and

“In 1989, P.L. 101-147 required service to incarcerated women at State option and more accessible clinic hours
for working women.

"The Budget Reconciliation Act of 1989 expanded Medicaid eligibility, required that all pregnant women and
preschool children receiving Medicaid be notified of WIC, and required a single application for Maternal and Child
Health, Medicaid, WIC, and other programs.

*P L. 101-147 required WIC to refer participants to Medicaid, AFDC, and Food Stamps.

Tntroduction





Chapter II. State Agency Administration

Exhibit ll-12

Automation for Food Instrument Production

Affected

Method of Food Instrument Participants

Production (%)

On First Visit, Local Agencies Produce
Instrument Using On-Line Terminals;
on Subsequent Visits, Instruments are
State-Produced

Local Agencies Produce All Food
Instruments On Site Using On-Line
Terminals

Electronic Benefits Transfer Card”

Local Agencies Hand-Customize
Instruments Produced by State

All-Manual Production

Combination of Above Methods

Source: Based on responses from 77 State WIC agencies; State Agency Survey, WIC Dynamics, 1993.
* EBT used only in one small area of one State.

Appointment Scheduling. Sixteen percent of State agencies reported that scheduling is automated
at the local level, but that it was not part of a statewide system, while 4 percent reported a
statewide automated scheduling system. However, over three-quarters of the local agencies
schedule manually (78% of agencies, serving 71% of participants).

Benefits of Automation. While automation is prevalent in many agencies, one cannot assume
that the use of computers is always viewed as beneficial. Therefore, we asked State agencies to
rate the effect that automation had on both productivity and quality in the WIC Program. A large
majority of agencies reported that automation resulted in some or substantial improvement in
productivity (83%) and quality (79%), while only 3 percent of agencies reported a decline in
either quality or productivity. As more agencies move toward automating their services, these
reports of benefits in quality and productivity are encouraging.

State Agency Administration
14





Chapter Il. State Agency Administration

Twenty-five percent of State agencies reported not having had rapid participation growth;
however, these State agencies only serve 7 percent of the local agencies and serve 5 percent of
the participants.

Staff Ratios. The majority of States (51%) report that they have not set participant-to-staff ratios
under which local agencies operate. Thirty percent of States noted that they used staff ratios but
did not specify that ratio. Only 13 percent of States reported using these ratios for less than 4
years. Of those agencies that reported a ratio, some have separate ratios for professional versus
paraprofessional/clerical, while others have a single ratio that encompasses all staff.

Il. Practices and Initiatives Affecting Administration, Service Delivery,
and Oversight of Local Agencies

As discussed in the Introduction, since 1988, major changes in Federal regulations and program
requirements were instituted that directly affected the WIC Program. These include increased
emphasis on breastfeeding promotional activities and requirements concerning food issuance
practices. While some of the initiatives were Federal requirements, others have been initiated
by the States. The effect of each of these changes on State agency administration is discussed
below.

Program Performance Standards. Performance standards developed by States address issues
such as staffing . ratios; staff training and staff qualifications; certification procedures;
documentation; voucher preparation and distribution; client flow and waiting times; and nutrition
education content, frequency, and quality. In 1987, the Food and Consumer Service (FCS) and
the National Association of WIC Directors (NAWD) jointly developed nutrition services
standards as part of the "Focus on Management" (FOM) initiative. The purpose of these
standards was to provide WIC directors and nutritionists with a method for evaluating the quality
of nutrition services and to encourage the use of evaluation information to improve program
services. While the State Agency Survey did not specifically ask about implementation of the
FOM Nutrition Services Standards, information obtained during case study site visits indicates
that many States have developed their own standards, which incorporate and adapt the FOM
standards to their particular situations, or build on existing State guidelines.

Sixty-one percent of the State agencies have developed and implemented program performance
standards, which affect nearly three-fourths of the local agencies (71%) and participants (71%).
Approximately one-fourth of the State agencies (24%), serving 11 percent of the participants,
reported that they have not developed performance standards. State agencies that serve a smaller
number of participants are using program performance standards to a lesser degree.

States used the performance standards to provide training for local agency WIC staff on topics
ranging from administration of WIC services to techniques for providing nutrition education. All
case study sites reported State evaluations occurring on at least a biannual basis. In addition,
local agencies reported being required to submit a 2-year nutrition plan to the State for approval.

State Agency Administration
U7



Chapter I. Introduction

. The FY 1994 Agriculture Appropriations Act, P.L. 103-111, included funds for a major
expansion of the WIC FMNP. The Act also prohibited any FY 1994 WIC administrative
funds from being used by any clinic providing WIC services if that clinic allows smoking
within the space used to administer the program. In addition, WIC food packages must be
tailored to include foods that are rich in folic acid, and WIC nutrition education, including
exit counseling, must cover the benefits of such foods. The Act also specified that the
dangers of tobacco use and exposure to second-hand smoke are to be included in alcohol
and substance abuse prevention counseling in WIC. WIC clinics are also directed to
provide immunization education to WIC participants.

The Federal level is not the only source of mandates which affect local WIC service delivery.
State-initiated policies and actions also affect operations and service delivery at local WIC
agencies. Individual WIC State agencies have considerable latitude to establish and implement
their own policies and operating standards within the Federal regulatory framework. For
example, Federal regulations specify the type and maximum prescribable quantities of foods
provided in the WIC food packages. However, most of the State agencies have established
policies which restrict the brand, form, and packaging of foods which can be purchased with WIC
vouchers. WIC infant formula rebates, a very successful cost containment strategy, are another
example of State-initiated practices. The effects of infant formula rebates were immediate and
obvious, larger caseloads at the local WIC agencies. Combined, these Federal and State
mandates have affected local agencies and their ability to serve growing numbers of WIC
participants. The WIC Dynamics Study sought to examine this effect and to produce some
national-level estimates of the impact of these changes on local agency operations.

Ill. Study Purposes and Objectives

The overall goal of the WIC Dynamics Study is to describe selected components of WIC service
delivery at the State and local agency levels, and to focus on the impact of rapid growth and
other factors that affected the local agencies since 1988. The research objectives are:

Local cies

1. Determine the effects of rapid growth and other changes on local WIC agencies’
service delivery.

2. Determine the impact of increased participation and other changes on the program’s
integration and coordination with local health care delivery systems.

3. Assess the nutrition services provided to WIC participants in the context of a period
of change.

Introduction



Executive Summary

1. Overview of WIC Dynamics

The Food and Consumer Service of the U.S. Department of Agriculture administers the Special
Supplemental Nutrition Program for Women, Infants, and Children (WIC), a grant program
enacted by P.L. 92-443 in 1972. The goal of WIC is to improve the health of participants by
providing supplemental foods, nutrition education, and health care referrals.

WIC Dynamics is a study of the impact of participation growth associated with infant formula
rebates, new regulatory and legislative requirements, and economic factors that occurred since
1988. Mail surveys were used to collect data from all! State agencies and a nationally
representative sample” of local agencies. Case studies were performed at 22 local agencies.
WIC Dynamics describes selected components of WIC service delivery, the impact of rapid
growth and other factors on local agencies, and local agencies’ responses to those factors. The
objectives are to:

1. Determine the effects of rapid growth and other changes on local WIC agencies’ service
delivery;

2. Determine the impact of increased participation and other changes on the program's
integration and coordination with local health care delivery systems;

3. Assess the nutrition services provided to WIC participants in the context of a period of
change; and

4. Assess the impact of increased participation and other changes on State agency
administration and oversight of local WIC programs.

Il. Major Study Findings

One finding of the WIC Dynamics case study component is the enthusiasm and willingness of
local agencies to do as much as possible for the population being served. While the study
findings suggest that many local agencies may be stretching their available resources to meet
program growth, the findings also indicate that WIC staff are approaching this growth with
commilient, creativity, energy, and enthusiasm. Consideration of the extent to which local
agencies have extended themselves to meet the challenges of the past years, and being sensitive
to the "process" of growth—the need for planning, time to phase it in, and the need for stability
in both program requirements and growth pace—will go a long way in assuring that service
quality is sufficient to support positive program outcomes.

‘Seventy-seven (91%) of the 85 State agencies responded.

2 95 percent response rate was achieved from the sample of 300 local agencies surveyed.

Executive Summary
i



Chapter Ill. Local Agency Admini: ion and Operations

Vans or Mobile Units. According to survey responses, 7 percent of local agencies, serving 11
percent of participants, reported using vans, mobile units, or other motorized facilities. Clearly,
the majority of local agencies do not have this equipment; however, case study site visits revealed
that there are agencies where this type of equipment is needed. Hudson, NY, an agency with 10
service sites located in a rural, sparsely populated area, expressed the need for a "WIC Mobile"
to store and transport all WIC files, materials, and equipment needed at the agency’s nine part-
time sites. Agency staff explained to the case study team that they currently load and unload
their personal: vehicles when traveling to each clinic site. The agency director reported that the
use of a van would create greater operating efficiency for the agency by decreasing the time staff
spend loading files and supplies to transport to the next site. Conceivably this would free up
staff time to devote to direct client services.

Adequacy of Space at Local Agencies. The Local Agency Survey included the following
questions regarding space and facilities: "In your opinion, is your local agency’s current space
adequate for the number of staff, participants, and program responsibilities?" and "Do you think
the adequacy of your space and facilities has changed since 1988?" The majority of local
agencies (67%), serving 82 percent of the participants, perceive their current space to be
inadequate. This perception is supported by the large number of respondents (65%) who
indicated that high-quality WIC services were hindered by inadequate facilities and materials.
These reports of inadequacy coincide with case study findings in which many staff cited concerns
regarding waiting areas, space for individual and group sessions, and food instrument pick-up
space. While this perception was more prevalent among larger agencies, small agencies also
voiced this concern. For example, in Hudson, NY, the facilities lacked privacy for individual
sessions, were not conducive to conducting group sessions, had crowded and/or chaotic waiting
areas, and lacked adequate areas for children to play. At several of the case study sites, some
nutrition counseling areas were too small to accommodate an observer from the study team.

Based on the mail survey response, 39 percent of the local agencies perceived a decrease in
adequacy of their current space in comparison to 1988. The majority (72%) of local agencies
reported making more efficient use of space over the last 5 years.

Elimination, Addition, and Movement of Clinic Sites. Sixteen percent of the local agencies,
serving 30 percent of the participants, reported the elimination of clinic sites during the last 5
years. Elimination appears to be a characteristic of larger agencies. Observations from the case
study at Wilkes-Barre, PA, support these findings. In the past 5 years, this large agency has
consolidated several clinic sites in order to make agency operations more efficient. This was
necessary because of the large geographic area covered and the growing number of participants
served.

During the last 5 years, 48 percent of local agencies, serving 66 percent of the participants,
reported that they moved to new facilities (Exhibit III-10). Forty percent of local agencies, also
serving 66 percent of the participants, cite that they have added new facilities. It is interesting
to note that 67 percent of the local agencies characterize their current space as inadequate. This
indicates that, despite changes, facilities remain inadequate. It could also indicate that agencies
have moved into new facilities or added sites that are less adequate than their previous sites. Of

Tocal Agency Administration and Operations
i-13,



Chapter III

Local Agency Administration and Operations



Chapter Ill. | Local Agency Administration and Operations

Most WIC programs are administered by local agencies under the supervision of a State agency.
The exceptions to this rule are the six State agencies that also function as local agencies! and
the 31 Indian Tribal Organizations (ITOs). The funds received by local WIC agencies are used
to provide supplemental foods and nutrition education to WIC participants and to pay operating
costs. This includes the costs of certifying applicants for eligibility and providing nutrition
education and counseling services at WIC clinics and other service sites (¢.g., 1-day-a-week
voucher distribution in a church basement). During the project development process, the project
study team noted that some practices varied by clinic within large agencies. Therefore, local
WIC directors were asked to report on up to six of their largest clinics separately (to minimize
burden). These are referred to as “principal clinics" throughout this report, and represent the
5,874 largest clinics, up to 6 per agency, in local WIC agencies nationwide. This chapter
addresses local agency administration of WIC-selected operations and changes that have occurred
since 1988. It includes results from the nationally representative Local Agency Survey and
findings from the 22 case studies.

I. Number of Local Agencies and Distribution of Clinics

In 1992, there were 1,777 local WIC agencies providing services at 8,992 sites to an average of
5.4 million participants monthly. This is a participation increase of 45 percent compared to 1988,
when there were 1,719 local agencies serving 3.7 million participants at 7,890 sites. Between
1988 and 1992, the total number of WIC local agencies increased by 3.4 percent while the
number of clinic sites increased 14 percent. Of the 1,777 local WIC agencies in 1992, the
Majority have three or fewer clinic sites. Exhibit [I-1 lists the distribution of service sites by
local WIC agencies.

Exhibit Ill-1

Number of Service Sites in Local WIC Agencies

2-3 Sites it 6-10 Sites 11-25 Sites Over 25 Sites
(%) (%) (%) (%)

[|_2 | 2 18 10 1

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

il. Certification and Scheduling Procedures

Respondents reported that certification services were provided in the majority of the service sites
supported by these agencies; however, there are a few service sites that provide only food

‘The six State agencies are Arkansas, Louisiana, Delaware, Puerto Rico, Guam, and the U.S. Virgin Islands.

Local Agency Administration and Operations
m1



Executive Summary

Integration and Coordination with Other Programs

The WIC Dynamics Study explored service coordination and integration between WIC and
other programs. 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 features such as colocation, sharing of staff, sharing
of records, and combined eligibility determination procedures.

Coordination with Health Care

The study found that WIC local agencies appear to be well coordinated with other health
and social programs. Examples of coordination that were identified in WIC Dynamics
included coordination (and sometimes integration) of Medicaid and WIC eligibility;
integration of WIC and immunization services; coordination of nutrition education with
case management of high-risk pregnant women, and sharing of client demographic,
eligibility, and service use information through automated data processing systems.

Health organizations such as a local health department, a community health agency, or a
public hospital sponsor about 88 percent of the local agencies. There are a greater number
of WIC sites without on-site health services than might be expected, given the high
proportion of agencies that are sponsored by health organizations. In 52 percent of local
agencies, all clinics have on-site health care, but these agencies serve only 39 percent of
all participants. Nationally, only 14 percent of local agencies (serving 9% of the
participants) provide no health care services at any of their sites. Twenty-nine percent of
the local agencies reported that they have difficulty obtaining health care services for WIC
participants at their principal clinic sites.

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 Diagnostic Testing (EPSDT), and pediatric
care. Less than 40 percent of the principal WIC clinics have obstetrical/gynecological,
Medicaid screening, or dental care available on site.

Local WIC Agencies Coordinate with a Diverse Set of Providers

A number of Federal, as well as State initiatives, have been implemented in an effort to
increase 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

“Executive Summary
iv