As WIC providers mobilized to ensure uninterrupted services during the COVID-19 pandemic, Congress recognized the need to waive in-person requirements to permit remote services and telehealth appointments. Since 1998, WIC participants have been required to be physically present at a WIC clinic location to be certified for program services or even recertify for ongoing participation. The Families First Coronavirus Response Act waived physical presence requirements and allowed WIC providers to conduct nutrition risk assessments via telephone or two-way video calls. These waivers were essential to protect WIC clinic staff, participants, and families from increased exposure to COVID-19.
WIC families have long identified physical presence requirements, particularly at recertification, as a barrier to ongoing participation. Parents are required to bring their babies or young children to the clinic, even when facing barriers such as transportation, taking time off work, or arranging childcare for other children. These considerations pose particular challenges in rural communities, where a WIC clinic may be over an hour away. In an increasingly digital world, WIC services must mirror industry practices in healthcare, reducing barriers to access by leveraging technology solutions to engage applicants and participants in WIC’s public health nutrition support. Congress should modify the physical presence requirements to:
allow for greater flexibility to provide health-related data within 90 days by either an in-person visit or information from a physician's office.
Modified Operations during COVID-19
Since March 2020, the majority of WIC clinics swiftly transitioned to phone, video, and curbside services without any disruption to WIC’s public health nutrition service delivery. This necessary step considered the public health and safety needs of WIC clinic staff, participants, and their families, responding to the urgent concern from participants who did not want to put themselves or their children at risk of exposure to COVID-19.
Although some State WIC Agencies have implemented two-way video calls, the majority of states are leveraging telephone appointments to connect with participants. Early evidence suggests that the convenience of phone or video appointments leads to greater attendance and engagement by participants. “Not only have we seen increases in participation and decreases in appointment no-show rates, but we’ve been able to maintain our quality of care and genuine connection to our families through phone and video. WIC serves families with diverse experiences and we need to be able to adapt long-term to effectively serve families where they are,” says Karen Goff of Broadlawns WIC Program in Des Moines, Iowa.
In recent years before the pandemic, WIC providers had looked to web-based technologies to streamline delivery of nutrition education and breastfeeding services. Over 36 State WIC Agencies had provided remote nutrition education before the pandemic, often through an online nutrition education portal or module. States have identified these web-based tools as helpful in communicating the subject matter, allowing for increased face-to-face time with the WIC nutrition counselor that could be spent on questions and individualized support. Over 41 State WIC Agencies likewise provided remote breastfeeding support, more likely through video calls, texting, and app support with credentialed lactation staff or peer counselors. This remote engagement is critical to supporting and empowering mothers in navigating breastfeeding, especially at convenient and relevant times and locations.
Similar technology innovations related to certifications are often smaller in scale, due to the statutory physical presence requirement, but State WIC Agencies were swift to streamline certification processes during the COVID-19 process. Several states have rolled out participant portals, online pre-applications, and document uploader tools during the pandemic to simplify the process and ensure eligible families are efficiently onboarded for WIC services.
These innovations are especially timely, since the majority of states are reporting participation increases since February 2020, with some states reporting increases as high as 20%. The participation increase is particularly fueled by higher child participation rates, counteracting prior trends that demonstrated declining child retention since the height of the Great Recession in 2010. Children face several barriers to remaining on the program until their fifth birthday, including duplicative recertification appointments that traditionally require physical presence at a WIC clinic site.
In a world continuously moving towards technological advancements, it is necessary that WIC also move in this direction and adapt some of the flexibilities and service models that have emerged. “Flexibilities during the pandemic have allowed us to continue providing the nutrition and health support needed to nourish WIC families who were facing increased food insecurity. To continue serving families effectively and eliminate some of the barriers to access like transportation, we need to look to making these flexibilities long-term and using technology to support our families,” said Diane Clifton of the Nebraska WIC Association.
Coordinating with Healthcare
Before the pandemic, WIC typically provides a series of health assessments to identify nutrition deficiencies, inform nutrition risk assessments, and tailor the participant’s nutrition counseling. These health assessments include a nutrition intake interview, measuring height/length and weight, and a hemoglobin screening to assess iron levels. An increasing number of WIC clinics have taken on additional testing responsibilities, including lead screenings. The results of these assessments are generally used to inform individualized education and counseling and identify follow-up needs for medical providers.
At times, this information is readily available in the electronic health records maintained by the participant’s physician, including OB/GYNs and pediatricians. Both physicians and WIC providers could reduce the number of medical tests if information is more seamlessly shared between medical offices and WIC clinics. Especially as families are postponing routine checkups and well visits during the COVID-19 pandemic, information sharing is a critical strategy to ensure that both medical providers and WIC staff have all relevant data points to assess the health, nutrition, and wellbeing of women, infants, and young children.
Health assessments were deferred under the Families First Coronavirus Response Act, but this core public health role will return to WIC once the public health emergency has concluded. There is an opportunity to thoughtfully balance the return of in-person services and health assessments with the increased technology options available to WIC providers and families. For many decades, health assessments were conducted without physical presence requirements; indeed, some families will visit WIC clinics more often than required to attend nutrition education or breastfeeding classes or group sessions. WIC participation should not be conditional on the completion of all health assessments at a WIC clinic location; instead, WIC providers should be authorized to conduct remote assessments and issue benefits while providing an adequate window for families to conduct full health assessments at a convenient time and location, including either at a WIC clinic location or physician’s office.
This is a fresh opportunity to build on the innovation of WIC providers, permanently relax the physical presence requirement, and simultaneously establish national partnerships and technology systems to strengthen collaboration with healthcare providers in order to meet a new generation of families.