In 2019, Hillsborough County’s total population was 1,422,278 residents. The total population is 70.5% White, 16.8% Black and, 4.1% Asian, 0.3% American Indian or Alaska Native, 0.1% Native Hawaiian and Other Pacific Islander, 3.7% two or more races and 4.6% other.  There are 48,420 WIC eligible residents in Hillsborough County. Prior to COVID-19, our average monthly participation was 30,548 clients. We are currently serving 63.2% of our eligible population. Our participation rate is 82%.  (See FL CHARTS).

FDOH Hillsborough has 7 WIC clinics located throughout the county. Our new practice allowed staff to telework from home without interruption to client services. This followed CDC social distancing guidelines. The need to socially distance to help slow the spread of COVID-19, posed a barrier to WIC client services that required physical presence for participants.  Another barrier was that most WIC clients had their height, weight and/or bloodwork collected in clinics to meet the health data requirement for WIC certification. The USDA issued physical presence waivers; clients were not required to come into the WIC clinic to receive WIC services. The initial findings were that new processes had to be developed and implemented to provide services to eligible clients in a manner that had never occurred prior to the current pandemic.

The goal of the implementation was to reduce the impact on client services and maintain caseload for enrollment and participation. The objective of telework was to reduce exposure to COVID-19 for staff and clients while maintaining number of appointments needed to meet client demands. The telework process was implemented in phases. Clinics with an urgent need were the priority. Priority was given to clinics that were closed or identified as COVID-19 test sites. Staff were trained on the telework process prior to transitioning from working in a clinic to working from home.

Initial findings from chart audits indicated that staff were not appropriately documenting client records according to the new procedures. Staff were retrained on common findings and provided tools and resources to ensure proper documentation.

Staff received information and training regarding their job duties in a Telework Process tool. Staff provided supervisors with daily client services spreadsheets to indicate clients served and clients who required additional contact the following day. Communication through MS Teams and an electronic routing system (eProgress) allowed staff to route clients for WIC services.

Three WIC clinic sites remained open to address access to WIC services for clients who did not have access to internet, email or phone. A partnership with Healthy Start also helped eliminate this barrier for clients who were connected with Healthy Start Women Infants Resource Specialists.

Clients continued receiving services and food benefits from WIC even when offices were closed. We addressed food insecurity in the community as food banks began to see record numbers for demands for assistance. We successfully improved access to WIC services and provided a response to the need for an innovative workforce with a transition to telework from face to face client services.

WIC clinics housed in county buildings were closed or had limited access due to drive through COVID-19 testing sites located at those clinics. This impacted our WIC clientele (pregnant and postpartum women, and children ages 0-5 years), especially those in rural areas.

Due to limited access and issuance of federal waivers for physical presence in response to COVID-19, WIC began to provide services over the phone, with approximately 60% of the staff transitioning to telework from home.  The “Telework Process” tool was a modification of a tool utilized in another county. This document now provides staff with the guidelines to follow for work and break times, as well as responsibilities specific to each position. The tool also detailed a list of steps for meeting various client needs during an appointment for WIC services. Staff also received an additional tool, Guided Script during COVID-19 to assist staff and standardized how services were provided and provide scripts to assist with explaining the new process to clients.

The state of Florida WIC office approved the verbiage for us to create and distribute Public Service Announcements which describe the new procedure, and these were shared on social media. The outreach team developed flyers regarding the new procedure for appointments, and shared them via mail and email with community partners, such as the county school district meal pickup sites, local daycares, medical providers, and food banks.

WIC addresses food insecurity by providing nutrition education, food benefits, and referrals to community resources. According to 2018 Florida Charts data, 12.3% of the residents in Hillsborough County face food insecurities and 17% of the county’s children are affected by food insecurity. Our program also addresses infant mortality, access to care and health inequities of pregnant women and their families, by providing outreach to target populations and forming a partnership with Healthy Start to provide Women and Infant Resource Specialist in five of our seven WIC clinics.

This practice has allowed us to continue the previous level of service, while encouraging social distancing during the COVID-19 pandemic. We successfully improved access to WIC services and provided a response to the need for an innovative workforce with a transition to telework from face to face client services. Transportation is no longer a barrier to client services.

We have utilized Skype for Business and MS Teams for staff to stay connected to each other. We have used eProgress, our client routing system, to indicate to staff the status of each client’s appointment and allow for tracking.  Skype for Business, MS Teams and eProgress are not new programs but the local agency's use of the programs to provide WIC services to enhance telework is a new practice.

We modified existing tools to adhere to new COVID-19 guidance. The implementation of new practices using the tools for guidance helped us met our goals for continuity of client services while staff teleworked from home. The “Telework Process” tool guided staff in each position to provide client services while teleworking. Staff used the tool to safely ensure continuity of WIC client services during the transition to telework.

To start each day, staff notify supervisors and co-workers that they are successfully logged into FL-WiSE and eProgress every morning and when they sign out at the end of their shift using MS Teams. The eProgress system was typically used to route clients through the clinic; now this system is used to connect WIC, Breastfeeding and Health Start staff, whether teleworking or in a clinic; and alerts staff when a client is ready for service or needed to be called for a particular service. Client appointment data from the eProgress system shows we maintained client services. (See attached document, #3.)

Hillsborough County had a large spike in positive COVID-19 cases, averaging over 1000 positive cases per day by May 2020. In response to the spike in positive cases, social distancing ordinances made face coverings mandatory, enacted curfews, closed many businesses or limited business hours, and limited the number of occupants in buildings. Limited cleaning supplies and PPE were available throughout the area. Building closures resulted in reduced access to resources for clients in need.

We serve most of our clients without their presence required in the clinic, resulting in reduced need for cleaning supplies. This also allowed for their benefits to continue without interruption. We opened clinics on a limited schedule, for those clients that needed assistance in person.

CDC issued the guidance “Using Telehealth to Expand Access to Essential Health Services during the COVID-19 Pandemic”, updated in June 2020. This guidance emphasized maintaining continuity of care, while reducing potential exposure to COVID-19. Our plan to offer telework to employees and client services over the phone allows for social distancing while still providing nutrition education, referrals, and food benefit issuance.

Additionally, CDC issued guidance regarding quarantine and isolation when a person feels sick, is awaiting COVID-19 test results, or has tested positive. By providing the option for telework, staff can separate themselves from others, but continue to work if they feel well enough.

Prior to the WIC move to telework, Healthy Start transitioned Women Infant Resource Specialist (WIRS) to telework in early March 2020. This transition resulted a significant decrease in the number of clients connected to Healthy Start for services in April 2020. Healthy Start‘s team began to work with the local agency’s IT to provide Women and Infant Resource Specialists (WIRS) access to eProgress remotely. This practice helped us improve WIC staff’s ability to refer clients and connect clients more effectively for WIRS services. The goal when beginning telework was to provide the same level of services to clients, and maintain the number of appointments served, establish a new method of providing client services, and communicate the new process to clients.

WIC worked with the local health departments’ IT to successfully install Remote PC on Healthy Starts’ laptops so they could be connected to the eProgress system which significantly improved our ability to connect clients to WIRS in real time. Clients who were in need were able to receive access to services that they desperately needed as a result of new struggles imposed by the pandemic.

We now have a Healthy Start WIRS representative providing support to clients in all WIC clinics. We worked with Healthy Start to ensure these representatives were provided access to our remote appointment system and could access WIC files. Our partnership with Head Start and Early Childhood Collaborative has resulted in WIC receiving electronic referrals from these programs. Referrals are contacted directly by the outreach team, and provided services over the phone at that time. If a client is new to the WIC program, the outreach staff will schedule a phone appointment for a date in the near future.

By providing remote Healthy Start access, we were now able to serve all seven WIC clinics by a WIRS. Clients services increased from 45 Healthy Start intakes in April 2020 with the onset of telework to 245 Healthy Start intakes in October 2020.

Our Partnership with Healthy Start WIRS has allowed us to provide additional support to clients in need of additional community resources. Additionally, our community partner, Head Start, is not providing onsite services to children, but families still have access to nutrition education, referral to community resources and food benefits through WIC. By working with these community partners, we can reach more families that may need assistance.

Due to teleworking, staff can easily provide coverage for other clinics. Breastfeeding Peer Counselors (BPCs) can now serve clients at clinics that do not traditionally have a BPC present. One such location is our College Hill clinic, and the percentage of moms who have ever breastfeed increased from 77.31% in March to 79.11% in September.

To meet the needs of our staff and the community, all teleworking staff were successfully transitioned within nine days. Clients could continue receiving services and food benefits from WIC even when offices were closed. As telework was underway, additional training was provided on COVID-19 procedures based on chart audit findings. Clinic appointment templates were adjusted to accommodate client service needs and limited clinic access. We successfully provided access to the WIC program for clients who may be isolating, quarantining, or otherwise unable to travel. Through collaboration with partners, we connected our participants with community resources, and received referrals in return. Florida Charts data reports that 74.4% of preventable hospitalizations in Hillsborough county are related to a nutritional deficiency and 17% of children face food insecurity in Hillsborough County.

In order to maintain the level of service of the program, various resources were reallocated. Staff were approved to take home computers and monitors to ensure they had sufficient equipment. Call center staff were provided with headsets, laptops, and software to accommodate the need to provide services over the phone. Staff were reassigned from administration to the call center to accommodate the larger volume of calls.  Headset adapters are now standard when ordering new equipment for staff.  Laptops and tablets were reassigned to staff to permit telework. The IT department worked quickly to install sound bars with microphones on more than half of the desktop computers throughout the agency. Additional funds were reallocated to Language Line services and are projected to reach $20,000 up from $2,500 that was budgeted for this expense.

When the impact of this pandemic was realized and we were forced to cancel required in person trainings and meetings, the local WIC agency transitioned to virtual meetings and training. We were able to facilitate meetings and trainings remotely using MS Teams to overcome the barriers social distancing.  WIC staff are required to receive some mandatory trainings and after months of postponing trainings we resolved to host trainings virtually until the end of the pandemic is declared.

Customer service surveys helped us to adapt services to improve our ability to meet clients’ needs. A client can receive help from any clinic. All WIC clinics, administration and for the outreach team transitioned to eFax to receive documentation and referrals for client services. This allows staff who telework to access to eFax via Outlook and the eFax website.

We plan to continue use of MS Teams to communicate with staff and to host training and meetings remotely; and to use eFax to send and receive approved documentation. In the future, we plan develop phone hub for peer counselors to improve remote communication with clients and increase access to additional peer counselors after hours.

We utilized eProgress monthly and quarterly reports as indicators for meeting client needs.  To recover from a demand that exceeded our availability, we added additional appointments in the templates. We were able to identify the root cause as office closures and holidays.