The mission of Tarrant County Public Health (TCPH) is to use our expertise to advance the community's health, through accountability, quality and innovation. TCPH provides services to residents of Tarrant County, TX, a population of approximately 2.1 million. The population is primarily non-Hispanic White (45%), Hispanic (29%), and non-Hispanic Black (18%). TCPH currently employs a staff of more than 370 housed at over 11 locations. Among the programs it offers is Tarrant County WIC.

Tarrant County WIC serves over 30,000 participants monthly.  Prior to COVID-19, participants were served at 16 locations. In March, due to COVID, TCPH discontinued in- person services, and the WIC program had to implement a plan to serve clients in a contactless manner.   Our goal was provision of services in a safe and timely manner with reduced number of clinics strategically open throughout the county to optimize access and minimize barriers.   This resulted in the implementation of curbside services.

Curbside services were implemented in two phases.  In April, with mandates and guidance from our Public Health leaders, we rolled out Phase 1. This entailed 50% of staff working remote and 50% in the clinics doing curbside service with six locations open.  We utilized GoToMeeting for just-in-time training for staff for the rollout of each Phase.  Phase I required participants to upload qualifying document via a weblink that was sent to them by text. Certifications for new clients were completed over the phone and clients received benefits through a curbside approach which required them to physically come to one of our six locations. Once they arrived staff met them at the cars, similar to a Sonic carhop, collected any additional information, obtained benefit cards from the client, loaded benefits while clients waited in their car  and returned the card  to the car. Once returned clients could leave.

By July, we entered Phase 2 after recognizing that some clients were having more difficulty than others with online processes. We transitioned from curbside service to drop box service outside the clinic and mailing cards to those experiencing barriers in physically coming to a WIC location.  Dropbox service eliminated issues with the weather, heat generated by automobiles and appointment availability. We expanded from 6 to 9 clinics and all staff reported to work in a facility. The goal of Phase 2 was to increase access to services.

Phase 1 saw limited impact to staffing and client services remained seamless. Phase 2, staffing was the biggest challenge as spread of illness and quarantine became impactful to keeping all nine locations open. The strategic placement of open locations was the biggest step to minimize health inequity. Consideration for distance between open locations from ones that were closed and access to public transportation, where available, helped improve accessibility with the scaled back model. In terms of the public health impact, WIC services were uninterrupted. The change in how we structured appointments and other processes allowed us to serve new and existing participants in a timely manner. 

The WIC program’s target population is pregnant and breastfeeding moms, infants, and children under the age of 5. Prior to the COVID-19 pandemic, the Tarrant County WIC Program operated with in-person services, including certifications, nutrition education and breastfeeding support. Participant appointment length was up to an hour and half, with multiple families sharing the waiting room at one time. Both presented challenges with COVID-19, as neither followed social distancing or minimal contact with people. Changes in operations aimed to improve both, protecting participants and staff. These innovations included phone certifications, curbside or drop box benefit issuance and mailing of WIC EBT cards. Maintaining WIC services during the entire pandemic, including during stay-at-home orders, allowed our program to continue to reach the underserved in our county. 

In March 2020, the USDA waived several WIC guidelines and procedures that allowed local WIC agencies to change operations to safely serve WIC families. Our practice implemented several of these waivers, including physical presence, completion of anthropometrics and hemoglobin, division of responsibility for certification and benefit issuance at time of certification. The result was a streamlined WIC process that minimized the participant’s time at the WIC office and contact with other families or WIC staff. Participants were certified over the phone, including income screening, nutrition assessment and counseling and breastfeeding support. Once certified, participants without WIC cards were mailed their benefits, and those with WIC cards were scheduled to come to the clinic for curbside or drop box service. For their benefit issuance appointment, curbside and drop box service allowed families to wait in their cars, minimizing contact with other participants or WIC staff. These appointments for benefit issuance are typically completed in less than 15 minutes. Mailing of EBT cards eliminates a trip to the WIC office and increases access to the program for participants without transportation or under quarantine. To date, our program has mailed nearly 2400 EBT cards. 

Our program was tasked with moving 50% of staff to remote work. Our implemented changes allowed staff to help certify participants from anywhere and decreased the staff demand in the clinic. Clinics were combined based on geographic location and participation size. Except for our satellite location, clinics merging together were an average of 5.7 miles from each other, minimizing the burden of longer travel. Initially, clinics were merged to 6 locations, and in July, 3 locations reopened, with the goal of increasing access for our participants.  

Historically, the WIC program positively impacts several public health issues such as infant and maternal mortality, childhood obesity and breastfeeding duration. Our innovations helped applicants access our services faster and with shorter appointments. In February 2020, applicants to the Tarrant County program were certified and received benefits in an average of 11.8 days. This number has decreased dramatically to 7.6 days in November 2020. This decrease in time also aligns with Texas WIC guidelines and goals of serving pregnant and infant participants within 10 days.  

Our current WIC practices are new to the field of public health, as numerous USDA waivers were utilized nationally for the first time in tandem.  However, we capitalized on new and existing tools and resources. Initially moving part of our work force home allowed us to establish procedures and guidelines, equipping us to maintain operations as more staff are subject to quarantine orders. Additionally, use of technology, including shared drives, such as SharePoint, has allowed managers to virtually move staff to help busier locations without physically moving staff members. We have dramatically increased use of built-in MIS features such as one-way texting and email to communicate with participants. Staff used these features to bring benefit information, nutrition education, referrals and breastfeeding information directly to mobile devices. The Texas WIC agency added MIS features, including a participant portal for uploading documents, completing health history questionnaires and signing required documents. Our program quickly jumped to using these features, including developing communication tools to assist participants with these features. Currently our local agency is one of the highest users of the portal, with close to 80% of invited participants successfully creating an account, and nearly 60% of health histories completed in the portal. Both steps can be completed ahead of the appointment, on the participant’s own time, reducing phone appointment time. 

In the early weeks of the pandemic, Tarrant County was operating under stay-at-home orders. Only essential businesses could operate, increasing the demand for our services, particularly access to food for many families with decreased income. USDA waivers and our program changes allowed us to certify participants quickly and easily to give them access to food, as well as provide essential referrals. As COVID cases rise, we have continued our services with these changes, keeping participants safe and avoiding lapse in benefits. Participants have frequently expressed concerns about coming to their appointment and are relieved to hear they do not have to bring their children or enter our clinics.  As a result, our customer service ratings have increased. Our Net Promoter Score, how likely a participant is to recommend WIC to a friend or colleague, is higher this quarter in comparison to the same quarter in 2019. Our current score of 84.5 is the highest to date. Participant satisfaction increases the likelihood that a participant will recommend the program to a friend or family member, widening the net of potential participants. 

WIC operations aimed to follow CDC-guidance for safety in public health settings. Staff work stations are more than 6 feet apart, with plexiglass used to separate staff. Participants only enter the clinic if there is a case-specific reason. Prior to entering the clinic, all staff, vendors and participants must complete COVID-19 screening, including a temperature check. Staff always wear a mask, unless at their individual workspace. PPE, including masks, face shields and gloves have been provided, in addition to hand sanitizer and cleaning supplies.  

The WIC program’s target population is pregnant and breastfeeding moms, infants, and children under the age of 5. Prior to the COVID-19 pandemic, the Tarrant County WIC Program operated with in-person services, including certifications, nutrition education and breastfeeding support. Participant appointment length was up to an hour and half, with multiple families sharing the waiting room at one time. Both presented challenges with COVID-19, as neither followed social distancing or minimal contact with people. Changes in operations aimed to improve both, protecting participants and staff. These innovations included phone certifications, curbside or drop box benefit issuance and mailing of WIC EBT cards. Maintaining WIC services during the entire pandemic, including during stay-at-home orders, allowed our program to continue to reach the underserved in our county. 

In March 2020, the USDA waived several WIC guidelines and procedures that allowed local WIC agencies to change operations to safely serve WIC families. Our practice implemented several of these waivers, including physical presence, completion of anthropometrics and hemoglobin, division of responsibility for certification and benefit issuance at time of certification. The result was a streamlined WIC process that minimized the participant’s time at the WIC office and contact with other families or WIC staff. Participants were certified over the phone, including income screening, nutrition assessment and counseling and breastfeeding support. Once certified, participants without WIC cards were mailed their benefits, and those with WIC cards were scheduled to come to the clinic for curbside or drop box service. For their benefit issuance appointment, curbside and drop box service allowed families to wait in their cars, minimizing contact with other participants or WIC staff. These appointments for benefit issuance are typically completed in less than 15 minutes. Mailing of EBT cards eliminates a trip to the WIC office and increases access to the program for participants without transportation or under quarantine. To date, our program has mailed nearly 2400 EBT cards. 

Our program was tasked with moving 50% of staff to remote work. Our implemented changes allowed staff to help certify participants from anywhere and decreased the staff demand in the clinic. Clinics were combined based on geographic location and participation size. Except for our satellite location, clinics merging together were an average of 5.7 miles from each other, minimizing the burden of longer travel. Initially, clinics were merged to 6 locations, and in July, 3 locations reopened, with the goal of increasing access for our participants.  

Historically, the WIC program positively impacts several public health issues such as infant and maternal mortality, childhood obesity and breastfeeding duration. Our innovations helped applicants access our services faster and with shorter appointments. In February 2020, applicants to the Tarrant County program were certified and received benefits in an average of 11.8 days. This number has decreased dramatically to 7.6 days in November 2020. This decrease in time also aligns with Texas WIC guidelines and goals of serving pregnant and infant participants within 10 days.  

Our current WIC practices are new to the field of public health, as numerous USDA waivers were utilized nationally for the first time in tandem.  However, we capitalized on new and existing tools and resources. Initially moving part of our work force home allowed us to establish procedures and guidelines, equipping us to maintain operations as more staff are subject to quarantine orders. Additionally, use of technology, including shared drives, such as SharePoint, has allowed managers to virtually move staff to help busier locations without physically moving staff members. We have dramatically increased use of built-in MIS features such as one-way texting and email to communicate with participants. Staff used these features to bring benefit information, nutrition education, referrals and breastfeeding information directly to mobile devices. The Texas WIC agency added MIS features, including a participant portal for uploading documents, completing health history questionnaires and signing required documents. Our program quickly jumped to using these features, including developing communication tools to assist participants with these features. Currently our local agency is one of the highest users of the portal, with close to 80% of invited participants successfully creating an account, and nearly 60% of health histories completed in the portal. Both steps can be completed ahead of the appointment, on the participant’s own time, reducing phone appointment time. 

In the early weeks of the pandemic, Tarrant County was operating under stay-at-home orders. Only essential businesses could operate, increasing the demand for our services, particularly access to food for many families with decreased income. USDA waivers and our program changes allowed us to certify participants quickly and easily to give them access to food, as well as provide essential referrals. As COVID cases rise, we have continued our services with these changes, keeping participants safe and avoiding lapse in benefits. Participants have frequently expressed concerns about coming to their appointment and are relieved to hear they do not have to bring their children or enter our clinics.  As a result, our customer service ratings have increased. Our Net Promoter Score, how likely a participant is to recommend WIC to a friend or colleague, is higher this quarter in comparison to the same quarter in 2019. Our current score of 84.5 is the highest to date. Participant satisfaction increases the likelihood that a participant will recommend the program to a friend or family member, widening the net of potential participants. 

WIC operations aimed to follow CDC-guidance for safety in public health settings. Staff work stations are more than 6 feet apart, with plexiglass used to separate staff. Participants only enter the clinic if there is a case-specific reason. Prior to entering the clinic, all staff, vendors and participants must complete COVID-19 screening, including a temperature check. Staff always wear a mask, unless at their individual workspace. PPE, including masks, face shields and gloves have been provided, in addition to hand sanitizer and cleaning supplies.  

Throughout the pandemic, WIC adapted quickly and creatively to improve practices to continue to successfully serve its population. The aim was to maintain services to meet the collective needs of the participants during this challenging time, with consideration for safety. Changes were rapid in the beginning, as Texas WIC guidelines and expectations changed. We created a committee of staff from various disciplines to ensure different perspectives were included for a more successful planning process and implementation.

As new COVID-related health information became available, WIC had to improve and update its new practices to better achieve its goals.  At the beginning of the pandemic, WIC rearranged its 16 clinics honoring the CDC guidelines of 6-feet social distancing, and the use of PPE and sanitizer. Seating was restricted and floor markers for clients to maintain social distancing were affixed.

 We entered Phase 1 with swift changes to protect both staff and participants. Half of clinic staff worked remotely to minimize the number of staff in one location while maximizing space to ensure CDC guidelines were met. To keep clinics staffed with a reduced in-person workforce, we strategically selected clinics to remain open. This was done while making sure each quadrant of the county was being served by one or more clinics to ensure equitable access for all groups. Additionally, we aimed to improve participant wait and interaction time with staff. We achieved this with a curbside model – keeping participants in their cars with staff at a safe distance. A new temporary scheduling system in SharePoint was developed to better manage the appointments already in existence, while adding new participants to the schedule, so that they were all contacted in a timely manner. 

In the latter part of the pandemic, as cases started going up and control of the virus became more challenging, the method changed once more to allow the clients to have minimal in-person interaction with the staff. As a part of Phase 2, clinics moved from a curbside approach to a drop box or window in front of the clinic.  This process significantly improved staff efficiency and safety. As a result, staff were able to spend more quality time contacting participants. To increase accessibility for participants, we opened 3 additional locations, and returned all staff to the clinics. Greater staff in the clinics allowed us to continue to modify our processes to be more efficient. Clerks and Nutritionists worked together to certify participants and provide contactless nutrition education.

Method and frequency of communication with participants was another process that changed during the pandemic.  In the beginning, the MIS text message appointment reminders and text messages created confusion with participants about clinic procedures.  As a resolution WIC developed a series of individualized text messages that changed as the situation evolved to let participants know what they needed to do.  

To address health equity, once clinic closures occurred, WIC ensured that the ones that remained open were in all four quadrants of the county, and that the distance between the closed clinic and the one that remained open was minimal.  Zip code reports were utilized to aid with this process.    Another way health inequities were reduced was by the ability to mail cards to participants who had no transportation to either their regular location or to the new location assigned to them for benefit pick up. Furthermore, a few of the clinics that remained open were on a bus route to allow for better access. Signage was developed on multiple occasions during this time to help participants with the many changes in clinic procedures. This was to reiterate phone instructions, as well as for people with no appointment, who had a need and showed up at the clinic.  As process changes were finalized, more visible and clear signage was developed, along with a form for them to fill out when they got to the clinic.

For all of this to be possible, resources needed to be reallocated at several points in time.  Staff needed to be placed strategically at each location to meet clinic participation demands and anticipate potential staffing shortages in the future.  Cards were used at the open locations to mail to clients which preferred this option to coming to pick up their cards.  Every staff member had to learn how to use a virtual set-up to have meetings and virtual just-in-time trainings.  The laptops were updated to meet these needs, and to allow staff to work remotely. At the beginning of the pandemic, staff took inventory of critical supplies such as hand sanitizer and disinfecting wipes. These supplies, along with those in our warehouse were redistributed among the open locations.

WIC has a meaningful impact on public health which has been magnified on many levels during COVID. WIC modified the way it operated and maintained accessibility to reach as many people as possible.   Moreover, many babies have been born during the pandemic that needed the immediate support of WIC, and the ability to adapt as the situation changed multiple times was essential to keep serving them.  The main changes that will remain post-pandemic are the ones related to the many upgrades made to the computer program and the new skill set obtained by the WIC staff.  Upload of documents, and the completion of information on a client portal, will minimize wait times for clients once everything goes back to normal.  Other changes could remain, yet that is with approval of the USDA and not an independent WIC decision.  The biggest lesson learned is that WIC can adapt in times of crisis to the ever-changing needs of the population it serves. WIC is an indispensable component of public health and essential in the community.