    Food Assistance: Activities and Use of Nonprogram Resources at Six WIC
    Agencies (Letter Report, 09/29/2000, GAO/RCED-00-202).

    Pursuant to a legislative requirement, GAO reviewed the activities and
    use of nonprogram resources at six Special Supplemental Food Program
    for, Women, Infants, and Children (WIC) agencies, focusing on: (1) ways
    WIC agencies deliver nutrition services and administer the program; (2)
    ways staff at WIC agencies allocate their time delivering nutrition
    services and administering the program; and (3) types of nonprogram
    resources used by WIC agencies and the extent to which such resources
    are used to cover the costs of delivering nutrition services.

    GAO noted that: (1) WIC agencies can vary considerably in the ways they
    deliver nutrition services and administer the program; (2) for example,
    the six agencies GAO studied differed in the: (a) manner in which they
    obtained health information, such as the results of a blood test for
    anemia, needed to assess the level of participants' nutritional risk;
    (b) amount and type of nutrition education typically provided to
    participants; and (c) level and nature of breastfeeding support, such as
    visiting a new mother in the hospital after delivery; (3) factors
    affecting the delivery of nutrition services or administration included
    the state program's policies and procedures, the characteristics of the
    sponsoring organization, and resource constraints; (4) because WIC
    agencies differ in how they deliver services and administer the program,
    the amount of time WIC staff spend on specific activities can vary; (5)
    for example, at the six agencies, GAO time studies found that the
    proportion of staff time spent on nutrition services activities as
    opposed to administrative activities varied greatly; (6) at two
    agencies, staff spent more than two-thirds of their time on nutrition
    services activities, while the staff at two other agencies spent less
    than half of their time on these activities; (7) as a result of this
    variation, the agencies differed in the amount of time spent in direct
    contact with participants--either in-person or over the telephone; (8)
    staff at one agency, for example, spent over 60 percent of their time on
    activities involving direct contact with participants, while staff at
    another agency spent about 31 percent; (9) the six WIC agencies GAO
    studied used a variety of nonprogram resources to deliver WIC services,
    the most common being in-kind contributions from their sponsoring
    organizations; (10) the share of costs covered by nonprogram resources
    at the six agencies ranged from about 20 cents to 2 cents for each
    dollar in costs covered with program funds; and (11) the extent to which
    nonprogram resources were used to cover the costs of delivering WIC
    services did not approach the level of 54 cents for every dollar in
    costs covered with WIC funds that was cited in a 1988 research study.

    --------------------------- Indexing Terms -----------------------------

     REPORTNUM:  RCED-00-202
         TITLE:  Food Assistance: Activities and Use of Nonprogram
    	     Resources at Six WIC Agencies
          DATE:  09/29/2000
       SUBJECT:  Food programs for children
    	     Financial management
    	     Program management
    	     Cost analysis
    	     State-administered programs
    	     Health care costs
    	     Health care services
    IDENTIFIER:  Special Supplemental Food Program for Women, Infants, and
    	     Children
    	     Gallatin (MT)
    	     Grady (GA)
    	     Kanabec (MN)
    	     Long Beach (CA)
    	     York (PA)
    	     Zuni (NM)

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    GAO/RCED-00-202

    Appendix I: Scope and Methodology

    28

    Appendix II: Selected Characteristics of the Six Case Study
    Agencies

    35

    Appendix III: Additional Comparisons of the Ways the Six Agencies Deliver
    Nutrition Services and Administer the
    Program

    39

    Appendix IV: Detailed Summaries of the Six Case Studies

    42

    Appendix V: Time Study Results - Percent of Staff time and Staff
    Time Costs Spent on Activities

    100

    Appendix VI: Time Study Results: Approximate Minutes per
    Case-Month Spent on Nutrition Services and
    Administration Activities

    109

    Appendix VII: GAO Contacts and Staff Acknowledgments

    113

    Table 1: Nutrition Services and Administration Activities by Cost
    Category 10

    Table 2: Percent of Total Staff Spent on Nutrition Services and
    Administration Activities 17

    Table 3: Approximate Minutes per Case-Month Spent on Nutrition
    Services and Administration Activities 18

    Table 4: Approximate Minutes per Case-Month Spent on Specific
    Nutrition Education Activities Involving Direct Contact With Participants
    and Percent of Total Staff Time Spent on These Activities 19

    Table 5: Percent of Total Staff Time and Approximate Minutes per Case-Month
    Spent on Activities Involving Direct Participant Contact 20

    Table 6: Categories of Nonprogram Resources Used to Cover
    the Costs of Providing Nutrition Services and Administering
    the Program, Fiscal Year 1999 21

    Table 7: Major In-kind Contributions Made by Sponsoring
    Organizations 22

    Table 8: Description of WIC Activities Used for Time Studies at Six
    Case Study Agencies 29

    Table 9: Time Span of Time Study for Each Agency 33

    Table 10: Characteristics of Case Study Agencies in Terms of
    Sponsoring Agency, Geographic Area Served, and Average Monthly Number Of
    Participants Served 35

    Table 11: Characteristics of Five Local Case Study Agencies
    Compared With Local WIC Agencies Nationwide 36

    Table 12: Selected Staffing Statistics for Each Case Study Agency 37

    Table 13: Six Agencies' Expenditures of WIC Program Funds,
    Fiscal Year 1999 37

    Table 14: Six Agencies' Percent Distribution of WIC Program by
    Budget Category, Fiscal year 1999 38

    Table 15: Number of Gallatin Participants by Category, September
    1998 and July 1999 46

    Table 16: Frequency of Check Issuance by Participant Type at
    Gallatin WIC 48

    Table 17: Gallatin WIC Program Expenditures by Category, Fisca
    Years 1998 and 1999 51

    Table 18: Number of Grady WIC Participants by Category,
    September 1998 and November 2000 56

    Table 19: Grady WIC Program Expenditures by Category, Fiscal
    Years 1998 and 1999 61

    Table 20: Number of Kanabec County Participants by Category,
    September 1998 and September 1999 66

    Table 21: Kanabec County WIC Program Expenditures by
    Category, Fiscal Years 1998 and 1999 70

    Table 22: Number Participants by Category, September 1998 an
    October 1999, at Long Beach WIC 74

    Table 23: Category of Participant and Frequency of Voucher
    Issuance at Long Beach WIC 75

    Table 24: Long Beach WIC Program Expenditures by Category,
    Fiscal Years 1998 and 1999 80

    Table 25: Number of Participants by Category, September 1998 and November
    1999, at York WIC 84

    Table 26: York WIC Program Expenditures by Category, Fiscal
    Years 1998 and 1999 90

    Table 27: Number of Participants by Category, September 1998 and September
    1999, at Zuni WIC 94

    Table 28: Zuni WIC Program Expenditures by Category, Fiscal
    Years 1998 and 1999 98

    Table 29: Percent of Staff Time and Staff Time Costs -Gallatin 100

    Table 30: Percent of Staff Time and Staff Time Costs-Grady 101

    Table 31: Percent of Staff Time and Staff Time Costs -Kanabec 103

    Table 32: Percent of Staff Time and Staff Time Costs--Long Beach 104

    Table 33: Percent of Staff Time and Staff Time Costs--York 106

    Table 34: Percent of Staff Time and Staff Time Costs -Zuni 107

    Table 35: Approximate Minutes per Case-Month Spent on Participant Services
    Activities at the Six Case Study Agencies 109

    Table 36: Approximate Minutes per Case-Month Spent on Nutrition Education
    Activities at the Six Case Study Agencies 110

    Table 37: Approximate Minutes per Case-Month Spent on Specific Breastfeeding
    Promotion and Support Activities at the
    Six Case Study Agencies 111

    Table 38: Approximate Minutes per Case-Month on Specific Program
    Administration Activities at the Six Case Study Agencies 112

    Figure 1: Performing a Blood Test at the York WIC Agency 12

    Figure 2: A Recertification Session at a Long Beach WIC Site 14

    Figure 3: Bar Code Scanner and Sheet Used in Time Study 32

    Figure 4: Topography of the Three County Area Served By
    Gallatin WIC and the Satellite Clinic Locations. 44

    Figure 5: Grady WIC Pediatric Clinic 55

    Figure 6: Kanabec WIC Clinic 65

    Figure 7: Use of Videotapes in the Waiting Area of a Long Beach
    WIC Site 77

    Figure 8: Use of Brochures in the Waiting Area of the Main York
    WIC Clinic 87

    Figure 9: Waiting Area in Zuni WIC Clinic 93

    CPA competent professional authority

    CPC Community Progress Council

    FNS Food and Nutrition Service

    GHS Grady Health System

    HHS Department of Health and Human Services

    ITO Indian Tribal Organization

    ITCA Indian Tribal Council of Arizona

    IHS Indian Health Service

    NSA nutrition services and administration

    USDA U.S. Department of Agriculture

    WIC Special Supplemental Program for Women, Infants, and Children

    Resources, Community, and
    Economic Development Division

    B-286011

    September 29, 2000

    The Honorable Richard G. Lugar
    Chairman
    The Honorable Tom Harkin
    Ranking Minority Member
    Committee on Agriculture, Nutrition, and Forestry
    United States Senate

    The Honorable William F. Goodling
    Chairman
    The Honorable William (Bill) Clay
    Ranking Minority Member
    Committee on Education and the Workforce
    House of Representatives

    The Special Supplemental Nutrition Program for Women, Infants, and Children
    (WIC) is a federally funded nutrition assistance program administered by the
    U.S. Department of Agriculture's (USDA) Food and Nutrition Service (FNS).
    This program provides supplemental foods and nutrition services to
    lower-income pregnant, breastfeeding, and postpartum women, infants, and
    children up to age 5 who are at nutritional risk. In fiscal year 1999, WIC
    benefits and services were provided to a monthly average of 7.3 million
    individuals.

    In fiscal year 1999, the Congress appropriated about $3.9 billion for WIC.
    Almost three-fourths of these funds ($2.8 billion) were used to provide food
    benefits to participants, typically in the form of vouchers used to obtain
    approved foods at authorized retail food stores, commonly referred to as
    vendors. The remaining funds ($1.1 billion) were used to make grants to
    states' WIC agencies for nutrition services and administration. The
    nutrition services supported by federal grant funds are (1) participant
    services--activities, such as certifying that a woman or child is eligible
    to participate in the program, issuing food benefits, and making referrals
    to other health or social services; (2) nutrition education--providing
    individual or group education designed to improve participants' dietary
    habits and health status; and (3) breastfeeding promotion and
    support--educating women about the benefits of breastfeeding their infants
    and providing the support necessary to enable them to breastfeed.
    Administration activities supported are the typical management functions
    necessary to support program operations, such as accounting and
    record-keeping.

    By law, in fiscal year 1999, the federal grants for nutrition services and
    administration made to state agencies were based on a national average of
    $11.64 per participant per month.1 In fiscal year 1999, these grants
    supported program operations at 88 state-level WIC agencies (including
    agencies in all 50 states, the District of Columbia, American Samoa, the
    Commonwealth of Puerto Rico, Guam, and the U.S. Virgin Islands, and 33
    Indian tribal organizations). Most state-level WIC agencies retain a portion
    of their grants and pass on the remaining funds to the nearly 1,800 local
    WIC agencies, which are operated by sponsoring organizations such as county
    health departments. Some of the state-level agencies--those that operate the
    program at both the state and local levels--retain all of their WIC grants.

    In addition to federal WIC funds, other resources may be used to support
    nutrition services and administration, such as WIC funds made available by
    state or local governments, and nonprogram resources, such as in-kind
    contributions of space, made by local WIC agencies' sponsoring
    organizations.2 A 1988 study prepared for USDA found that at 16 WIC
    agencies, for every dollar in costs covered with program funds, about 54
    cents in additional costs were covered by nonprogram resources.

    To help the Congress better understand the costs of administering WIC and
    delivering nutrition services, the William F. Goodling Nutrition
    Reauthorization Act of 1998 (P. L. 105-336) directed GAO to assess various
    cost aspects of WIC nutrition services and administration. This report is
    the second in a series responding to this request for information. The first
    report provided information on federal and nonfederal resources obtained and
    expended by state-level and local WIC agencies nationwide for nutrition
    services and administration.3 This report provides in-depth information on
    how WIC agencies deliver nutrition services and administer the program and
    the resources they use. Specifically, it provides information on the (1)
    ways WIC agencies deliver nutrition services and administer the program; (2)
    ways staff at WIC agencies allocate their time delivering nutrition services
    and administering the program; and (3) types of nonprogram resources used by
    WIC agencies and the extent to which such resources are used to cover the
    costs of delivering nutrition services.

    Because it was not practical to obtain in-depth information regarding these
    issues from a statistically representative sample of the over 1,800 agencies
    providing services to participants, we conducted case studies at six WIC
    agencies. We chose the six agencies to provide a range of characteristics,
    such as geographic location, numbers and types of participants served, and
    type of sponsoring organization. The six WIC agencies studied included five
    local agencies: Gallatin WIC in Montana; Grady WIC in Atlanta, Georgia;
    Kanabec WIC in Minnesota; Long Beach WIC in California; and York WIC in
    Pennsylvania; and one Indian tribal organization, Zuni WIC in New Mexico,
    which functions as both a state-level and local WIC agency. In addressing
    our second objective, we conducted 1-month time studies at each of the case
    study agencies. During these studies, we recorded and summarized the amount
    of time WIC staff spent performing various activities. The results of our
    case studies are not generalizable to all WIC agencies.

    We performed our work from July 1999 through August 2000 in accordance with
    generally accepted government auditing standards. Appendix I contains a
    detailed description of the methodology we used to conduct this work.

    WIC agencies can vary considerably in the ways they deliver nutrition
    services and administer the program. For example, the six agencies we
    studied differed in the (1) manner in which they obtained health
    information, such as the results of a blood test for anemia, needed to
    assess the level of participants' nutritional risk; (2) amount and type of
    nutrition education typically provided to participants; and (3) level and
    nature of breastfeeding support, such as visiting a new mother in the
    hospital after delivery. Factors affecting the delivery of nutrition
    services or administration included the state program's policies and
    procedures, the characteristics of the sponsoring organization, and resource
    constraints.

    Because WIC agencies differ in how they deliver services and administer the
    program, the amount of time WIC staff spend on specific activities can vary.
    For example, at the six agencies, our time studies found that the proportion
    of staff time spent on nutrition services activities as opposed to
    administrative activities varied greatly. At two agencies, staff spent more
    than two-thirds of their time on nutrition services activities, while the
    staff at two other agencies spent less than half of their time on these
    activities. As a result of this variation, the agencies differed in the
    amount of time spent in direct contact with participants--either in-person
    or over the telephone. Staff at one agency, for example, spent over 60
    percent of their time on activities involving direct contact with
    participants, while staff at another agency spent about 31 percent.

    The six WIC agencies we studied used a variety of nonprogram resources to
    deliver WIC services, the most common being in-kind contributions from their
    sponsoring organizations. The share of costs covered by nonprogram resources
    at the six agencies ranged from about 20 cents to 2 cents for each dollar in
    costs covered with program funds. The extent to which nonprogam resources
    were used to cover the costs of delivering WIC services did not approach the
    level of 54 cents for every dollar in costs covered with WIC funds that was
    cited in a 1988 research study.

    In fiscal year 1999, state-level and local WIC agencies received
    approximately $1.1 billion in federal grants for nutrition services and
    program administration. States or local governments are not required to
    match any portion of these federal funds. However, as we reported in March
    2000, 10 states and the District of Columbia provided additional funds for
    nutrition services and administration in fiscal year 1998--a total of $38
    million. In addition, 29 percent of the 1,416 local WIC agencies that
    responded to a nationwide survey we conducted in 1999 reported receiving a
    combined total of about $19 million for nutrition services and
    administration from nonfederal sources in fiscal year 1998.4 Nationwide, the
    total of these nonfederal program funds represent a very small portion of
    the program resources used for nutrition services and administration--about
    5 percent in fiscal year 1998.

    In addition to program funds, the WIC program has traditionally used
    nonprogram resources, such as in-kind contributions, to fully operate the
    program. No recent information was available on the value of these
    nonprogram resources used to cover some of the costs of providing nutrition
    services and administering the program. According to a 1988 study of 16 case
    study WIC agencies prepared for USDA by Abt Associates, for every dollar in
    costs covered by WIC program funds, about 54 cents in additional costs were
    covered by other resources--mostly in the form of contributions from WIC
    agencies' sponsoring organizations.5

    Local WIC agencies, which spend over three-quarters of nutrition services
    and administration program funds, are operated by a variety of types of
    public and private organizations; provide services in different types of
    geographic settings (urban, rural); and vary considerably in size in terms
    of the number of participants they serve. WIC agencies can also vary in the
    size and composition of their staff. Appendix II provides information on
    selected characteristics and the staffing at the six agencies we studied.

    WIC agencies use their nutrition services and administration grants to
    support activities in four cost categories: (1) participant services, (2)
    nutrition education, (3) breastfeeding promotion and support, and (4)
    program administration. Table 1 shows some of the specific activities
    conducted by these WIC agencies in each of the categories.

     Cost category              Activities
                                Certifying that individuals meet program
                                eligibility criteria by obtaining and reviewing
                                information regarding (1) income or
                                participation in a qualifying program such as
                                Medicaid; (2) residency; (3) pregnancy or
                                postpartum status, childrens' age; and (4)
                                medical risks, such as anemia, and/or
                                nutritional risk such as inadequate diet.

                                Explaining program policies and procedures.

     Participant services       Scheduling participants for nutrition services,
                                including nutrition education, voucher
                                pick-ups, and recertification.

                                Issuing food benefits--typically in the form of
                                vouchers to be redeemed at grocery stores.a

                                Referring participants to needed health care,
                                such as immunization, and social services, such
                                as the Food Stamp and Medicaid programs, as
                                well as voter registration.

                                Preparing Individual Care Plans
                                Providing individual nutrition sessions.

                                Providing group education sessions.

                                Preparing or obtaining nutrition education
                                materials, such as brochures and videotapes.

                                Interpreting sessions or translating material
     Nutrition education        to facilitate nutrition education of
                                non-English-speaking participants.

                                Consulting with medical providers regarding
                                nutrition education.

                                Providing or receiving training regarding
                                nutrition education promotion.

                                Evaluating and monitoring nutrition education.
                                Providing individual counseling sessions to
                                promote or support breastfeeding at WIC clinics
                                or in the hospital.

                                Providing group breastfeeding support sessions.

                                Providing telephone support to breastfeeding
                                mothers.

                                Maintaining a clinic environment that
     Breastfeeding promotion    encourages breastfeeding.
     and support
                                Consulting with medical providers regarding
                                breastfeeding issues.

                                Preparing and providing breastfeeding
                                educational materials.

                                Providing or receiving training regarding
                                breastfeeding promotion.

                                Monitoring and evaluating breastfeeding
                                promotion activities.
                                Outreach to potential participants and health
                                care providers and social service
                                organizations.

                                Clerical tasks.

                                Accounting, budgeting.

     Administration             Personnel, including recruitment and retention
                                of staff.

                                General management tasks such as planning,
                                developing policies and procedures, and
                                managing the use of space. and equipment.

                                Monitoring vendors.

                                Program reporting.

    aIn addition to vouchers, food benefits can be issued in the form of checks,
    coupons, and other documents. Gallatin WIC, located in Montana, issues WIC
    checks instead of vouchers.

    In general, WIC agencies can use program funds for nutrition services and
    administration for costs that can be classified as either direct or
    indirect. According to the program's regulations, direct costs are those
    that can be identified specifically with WIC-related activities, such as
    salaries for staff who provide nutrition education and breastfeeding
    counseling. Indirect costs are for services that benefit the program but are
    not easily linked specifically to WIC, such as purchasing, communications,
    and accounting services.

    Administer Their Programs

    WIC agencies can vary considerably in the ways they deliver nutrition
    services and administer the program. The five local agencies and Indian
    tribal organization we studied all provided the three types of nutrition
    services--participant services, nutrition education, and breastfeeding
    promotion and support--and conducted administration activities; however,
    they differed in some of the ways they delivered these services and
    administered the program. The following provides examples of this variation.

    � Long Beach staff did not routinely measure participants' height and weight
    and test blood for anemia, as was typically done at the other agencies to
    obtain required medical information (see fig. 1). Instead, Long Beach
    obtained this information from participants' health care providers.

    � Gallatin and Kanabec staff routinely prepared individual care plans for
    all participants while staff at the other agencies did so only for
    participants considered to be high risk.6, 7

    � Kanabec issued vouchers to adult participants who were not considered to
    be at high nutritional risk every 3 months, while the other agencies issued
    vouchers or checks to such participants at least every 2 months.

    � Five of the six agencies--Gallatin, Grady, Long Beach, York and Zuni--to
    varying degrees, offered services during scheduled evening hours. For
    example, Long Beach's main site had extended hours from 6:00 p.m. to 7:00
    p.m. on Mondays and Tuesdays, while York's main clinic stayed open until
    6:30 p.m. 3 days a month. Gallatin and Long Beach also offered scheduled
    weekend hours.

    � Grady, Long Beach, York, and Zuni staff routinely asked participants of
    their interest in registering to vote; Long Beach, York, and Zuni maintained
    a record of the offer. For example, at York, in accordance with state
    policy, staff recorded information regarding voter registration in the
    participant's record, on a data collection form, and in the data system, and
    assisted the participant in completing the form. At Gallatin and Kanabec,
    staff simply made voter registration forms available to participants.

    � Nutrition education was typically provided at all six agencies during the
    participant's certification and/or recertification session (see fig. 2). The
    sessions that we observed, which included nutrition education, lasted from
    10 minutes at Grady to more than 60 minutes at Gallatin.

    � In addition to these sessions, Long Beach provided nutrition education
    through about a dozen classes daily at each of its clinics. Gallatin, Grady,
    and Zuni also offered weekly, bimonthly, or monthly classes, while York and
    Kanabec did not offer nutrition education classes at all.

    � Grady staff, when needed, provided nutrition education that involved
    medical nutrition counseling (to diabetic WIC participants, for example),
    while staff at the other agencies typically referred participants to non-WIC
    dietitians if such counseling was needed.

    � Only Zuni staff offered regular nutrition education to child participants,
    even though children represented at least half of the participants at five
    of the six agencies.

    � Only Grady used computer technology in the form of a touch-screen kiosk to
    provide nutrition education to participants.

    � Like nutrition education, breastfeeding was typically promoted during
    individual sessions. Gallatin, Grady, Long Beach, and Zuni also offered
    breastfeeding classes.

    � Staff at three of the agencies--Grady, Long Beach, and Zuni--routinely
    visited participants in the hospital after childbirth to encourage and
    support breastfeeding.

    � Staff at all of the agencies were trained to promote breastfeeding. In
    addition, Grady, Zuni, and York staff included at least one certified
    lactation consultant.

    � While all of the agencies utilized an automated participant database
    system, Long Beach was the only agency to maintain minimal paper records. In
    contrast, York, because it lacked a sufficient number of computers, relied
    on paper records and data entry staff to enter participant information into
    the state's data system.

    � York staff played a major role in training and monitoring vendors and
    assisted state agency staff in approving vendors' applications. The other
    four local agencies performed limited vendor management activities because
    this was a state-level responsibility. At Zuni--a state-level agency--staff
    were heavily involved in all aspects of vendor management.

    � All of the agencies, except Kanabec, provided services at satellite
    clinics or sites. Gallatin, York and Zuni staff traveled to satellite
    clinics or sites to provide services, while Long Beach and Grady staff did
    not. Kanabec did not operate satellite clinics but did offer participants
    free or reduced-cost transportation, on request.

    A number of factors, including state program policies, the characteristics
    of the sponsoring organization, and resource constraints, affected how the
    agencies delivered services and contributed to some of the variation we
    observed. For example, state policy strongly encourages Long Beach to obtain
    needed medical information from the participants' health care providers.
    Similarly, staff at Gallatin prepared individual care plans for participants
    in accordance with established state program policy.

    The characteristic of the sponsoring agency also affected service delivery.
    For example, because Grady was operated by a hospital, WIC dietitians
    routinely provided medical nutrition counseling to participants in need of
    such services, rather than making referrals to non-WIC dietitians. In
    addition, staff at Zuni WIC, the only state-level agency that we studied,
    carried out some activities, such as those associated with approving vendors
    and reimbursing them for vouchers, that are not typically performed by local
    agencies.

    Finally, agency officials and staff at the five local agencies reported that
    insufficient resources affected how services were delivered. For example,
    York and Grady officials attributed the limited time staff spent providing
    nutrition education and/or breastfeeding promotion and counseling to
    insufficient staffing. Staff constraints are being exacerbated, according to
    some of the agency directors, because it is becoming increasingly difficult
    to retain and recruit staff with the salaries and benefits the program is
    able to offer. For example, according to the York WIC Director, the agency
    offers a nutritionist or dietitian half the hourly rate offered at the area
    hospital.

    Appendix III contains additional information on variations we found in the
    ways the agencies delivered nutrition services and administered the program,
    and appendix IV summarizes these activities for each agency.

    and Administration Activities Varied by Agency

    Our time studies at the six agencies found they varied considerably in the
    amount of time staff spent on different activities. For instance, as shown
    in table 2, at Long Beach and Gallatin, staff spent over 70 percent of their
    time on nutrition services, while at two other agencies staff spent less
    than half of their time on these activities.8 These two agencies were Zuni
    WIC, a state-level agency, and York, the only local agency with major vendor
    management responsibilities.

               Percent of total staff time spent on
               Nutrition services activities
                                      Breastfeeding   Total
     Agency    Participant Nutrition  promotion and   nutrition  Administration
               services    education                             activities
                                      support         services
     Gallatin  52.8        13.6       5.0             71.4       28.6
     Grady     43.2        8.8        6.7             58.7       41.3
     Kanabec   37.9        9.0        5.4             52.3       47.7
     Long
     Beach     48.8        19.2       3.4             71.4       28.7
     York      39.0        4.8        .8              44.6       55.5
     Zuni a    23.6        12.9       7.6             44.1       55.8

    Note: Totals may not add due to rounding.

    aZuni WIC was the only state-level agency. Some staff time at Zuni WIC was
    spent on activities normally performed at state-level agencies, such as
    developing program plans and reimbursing vendors. Our time study did not
    distinguish between state- and local-level activities at Zuni WIC.

    Because the agencies varied somewhat in their participant-to-staff
    ratios--the number of participants served per full-time-equivalent staff--we
    also analyzed the results of our time studies in terms of the minutes per
    participant per month spent on the various activities. (Hereafter, per
    participant per month is referred to as per case-month.) Table 3 shows the
    results of our time studies in terms of the approximate number of minutes
    spent per case-month. Again, there is considerable variation among the
    agencies. Additionally, this table, in combination with table 2, shows that
    agencies devoting similar percentages of staff time to an activity can
    differ in the absolute amount of time spent on that activity. For example,
    while Gallatin and Long Beach staff both spent about 28 percent of their
    time on administrative activities, this amounted to 8.9 minutes per
    case-month at Gallatin and 5.2 minutes at Long Beach. This is because the
    two agencies differed in the total amount of staff time per case-month that
    was available to perform all nutrition services and administrative
    activities.

     Approximate minutes per case-month

               Spent on nutrition services
               activities
                                                                                Total time
                                      Breastfeeding  Total      Spent on        available for
     Agency    Participant Nutrition  promotion and  spent on   administration  all nutrition
               services    education                 nutrition                  services and
                                      support                   activities
                                                     services                   administration
                                                                                activitiesa
     Gallatin  16.4        4.2        1.6            22.2       8.9             31
     Grady     10.8        2.2        1.7            14.7       10.3            25
     Kanabec   8.0         1.9        1.1            11.0       10.0            21
     Long
     Beach     8.8         3.5        .6             12.9       5.2             18
     York      12.5        1.5        .3             14.3       17.8            32
     Zunib     17.0        9.3        5.5            31.8       40.2            72

    Note: Totals may not add due to rounding.

    aRepresents all staff time available to perform nutrition services and
    administration activities, including that of administrative and support
    staff.

    bZuni WIC was the only state-level agency. Some staff time at Zuni WIC was
    spent on activities normally performed at state-level agencies, such as
    developing program plans and reimbursing vendors. Our time study did not
    distinguish between state- and local-level activities at Zuni WIC.

    As might be expected, the amount of time spent on specific activities within
    each of the four categories of activities--participant services, nutrition
    education, breastfeeding promotion and support, and administration--also
    varied among the agencies. This variation is illustrated in the amount of
    time spent on providing nutrition education and breastfeeding promotion and
    support directly to participants in one-on-one or group sessions. Table 4
    shows that Gallatin staff spent 4.5 minutes per case-month on these
    activities, while York and Kanabec spent less than 1 minute.9 This table
    also points out that the amount of time spent providing nutrition and
    breastfeeding education directly to participants, especially at the five
    local agencies, was quite limited. (App. V contains information on the
    percentage of staff time and the percentage of staff time costs spent on
    specific activities in each of the four cost categories. App. VI contains
    information on the approximate number of minutes per case-month spent on the
    specific activities.)

                             Approximate minutes per case-month and the percent
                                               of staff time
     Nutrition education and
     breastfeeding promotion  Gallatin  Grady   Kanabec    Long   York   Zunib
            activitya                                     Beach
     Providing one-on-one
     nutrition education or  2.9        1.1    .5        2.2      .8    2.0
     counseling
     Providing group
     nutrition education     .2         <.1    0         .5       0     3.3
     Providing one-on-one
     breastfeeding education 1.4        .8     .1        .5       .1    3.2
     or counseling
     Providing group
     education breastfeeding <.1        .1     0         <.1      0     .1
     or counseling
     Total time spent on
     these specific          4.5        2.0    .6        3.3      .9    8.6
     activitiesc
     Percent of available
     staff time spent on     15%        8%     3%        18%      3%    12%
     these activities.

    aA description of each nutrition education activity can be found in app. I.

    bZuni WIC was the only state-level agency. Some staff time at Zuni WIC was
    spent on activities normally performed at state-level agencies, such as
    developing program plans and reimbursing vendors. Our time study did not
    distinguish between state- and local-level activities at Zuni WIC.

    cWe observed, and some staff reported to us, that some individual nutrition
    education and breastfeeding promotion/counseling occurred during nutrition
    assessment. Since nutrition assessment was considered to be a participant
    service activity in our time study, our results might underreport the amount
    of time spent on nutrition education and breastfeeding promotion and
    support. For example, if 25 percent of the reported time spent on nutrition
    assessment involved individual nutrition education or breastfeeding
    promotion and support, then the total time spent on these specific
    activities at Gallatin, Grady, Kanabec, Long Beach, York, and Zuni would be
    increased by 1.0, .7, .8, .4, .5, and .4 minutes, respectively.

    The variation in how agencies deliver WIC services affects how much time WIC
    staff spend in direct contact with WIC participants. Table 5 shows the
    percent of staff time and minutes per case month spent on activities
    involving direct participant contact--in person or over the telephone. As
    shown in the table, the five local agencies varied widely in both the
    percent of total time and the minutes per case-month spent in activities
    involving direct participant contact. Percent of time ranged from a high of
    62.5 percent to a low of 26.9 percent and, in terms of minutes per
    case-month, from 19.4 to 7.0. While Zuni staff spent the most time in terms
    of minutes per case-month in direct contact with participants, they spent
    the lowest percent of total time on such activities, in large part because,
    as a state-level agency, Zuni WIC used some staff resources for a variety of
    program planning and management activities not typically performed by local
    agencies, such as developing and updating a state WIC plan and approving and
    reimbursing vendors.

     Agency     Percent total Approximate minutes
                staff time    per case-month
     Gallatin   58.5          18.1
     Grady      41.2          10.3
     Kanabec    34.3          7.2
     Long Beach 62.5          11.3
     York       31.4          10.0
     Zunia      26.9          19.4

    aZuni WIC was the only state-level agency. Some staff time at Zuni WIC was
    spent on activities normally performed at state-level agencies, such as
    developing program plans and reimbursing vendors. Our time study did not
    distinguish between state- and local-level activities at Zuni WIC.

    Share of Costs Covered Did Not Approach the Level Cited in a 1988 USDA Study

    The six agencies we studied used a variety of nonprogram resources to cover
    some of the costs of delivering nutrition services and administering the
    program. Most of the nonprogram resources we identified were in-kind
    contributions made by the agencies' sponsoring organizations, and some were
    provided by other organizations, individuals, or grants. The share of costs
    covered by these resources at the agencies we studied did not approach the
    level cited in a 1988 USDA study.

    In fiscal year 1999, the six agencies we studied used a variety of
    nonprogram resources to cover some costs: (1) in-kind contributions from
    their sponsoring organizations, (2) in-kind contributions from other
    organizations or individuals, and (3) grants from other organizations. Most
    of the nonprogram resources we identified were in the first category. Table
    6 shows the categories of nonprogram resources used at each agency.

               In-kind contributions  In-kind contributions
      Agency       by sponsoring     by other organizations  Grants from other
                   organization          or individuals        organizations
     Gallatin  X                     X
     Grady     X
     Kanabec   X                     X
     Long
     Beach     X
     York      X                     X                      X
     Zuni WIC  X                     X                      X

    The following provides information on the nature of nonprogram resources for
    each category.

    In-Kind Contributions by Sponsoring Organizations

    Table 7 describes the major types of in-kind contributions we identified
    that were made by each agency's sponsoring organization.

       Agency     Major in-kind contributions made by sponsoring organization
                Shared space--the waiting area, examination room and classroom
                space for the main clinic is shared with other county programs
     Gallatin   and is provided at no cost to the program.
                General administrative support--utilities, administrative
                personnel.
                Space--the space for the six clinic locations provided at no
                cost to the program.

                Indirect costs--the program was not charged for any indirect
                costs incurred to operate it.
     Grady
                Personnel--the costs of some staff providing WIC services were
                not charged to the program.

                Employee benefits--some of the costs of benefits for WIC staff
                were not charged to the program.
                Space--all space used by the program, including the clinic, was
                provided at no cost to the program.

     Kanabec    Personnel--health care staff provided some nutrition education,
                in conjunction with prenatal care, to WIC participants.

                General administrative support--supplies/materials, equipment,
                and administrative personnel.
                Space--the space used at two sites was provided at no cost to
                the program.

                Indirect costs--the sponsoring organization did not charge the
     Long Beach program for all indirect costs it incurred to operate the
                program.

                General administrative support--utilities for two sites,
                furniture, equipment, and translation services.
                Indirect costs--the sponsoring organization did not charge the
                program for all indirect costs it incurred to operate the
                program.
     York
                Personnel--one part-time administrative support staff provided
                at no cost to the program.

                General administrative support--furniture and supplies.

     Zuni       Space--the land on which the main clinic structure--a
                trailer--is situated.

    In-kind Contributions Made by Other Organizations

    Four agencies--Gallatin, Kanabec, York, and Zuni--received contributions
    from other public entities and private businesses. Again, donated space was
    a common contribution. For instance, Gallatin, which serves not only
    Gallatin County but also two adjacent counties, received donated space for
    three of its four satellite clinics from these counties. Two public high
    schools in Zuni donated space for WIC staff to issue vouchers to teenage WIC
    mothers, while a grocer in a neighboring town provided Zuni WIC with space
    for the issuance of vouchers to Navajo participants. Similarly, the private
    landlord for York's main clinic charged the program a below-market rate for
    rent.

    WIC agencies also received other types of in-kind contributions from public
    and private sources. For instance, the Grady Director indicated that its
    dietitians received free continuing education via teleconference courses
    sponsored by the Centers for Disease Control and Prevention. A local medical
    practice provided the waiting room furniture for York's main clinic, while a
    national medical supply company donated infant feeding supplies to Kanabec.

    Grants

    Three of the agencies, Zuni, Grady, and York, recently received small grants
    from public and private sources to support program services. In 1999, Zuni
    received a $500 grant from a U.S. Indian Health Service diabetes prevention
    program to distribute toys to encourage children's physical activity. In
    fiscal year 1999 York WIC used $2,000 in grant funds from the city of York
    to educate mothers on baby bottle tooth decay. Lastly, Grady received $2,000
    in 1998 from the March of Dimes for breastfeeding supplies and educational
    materials.

    the Level Previously Cited

    The share of costs covered by nonprogram resources at the six agencies we
    studied did not approach the level cited by Abt Associates in its 1988 study
    for USDA--54 cents for every dollar in costs covered with WIC funds. For
    example, at Grady, where the nonprogram resources we identified covered the
    largest share of costs, the share of costs covered by these resources
    amounted to 20 cents for each dollar in costs covered with WIC funds. More
    specifically, the major nonprogram resources we identified at Grady in
    fiscal year 1999 were the sponsoring organization's in-kind contributions,
    which had a total value of approximately $99,000. According to information
    provided by an official of the sponsoring organization, an estimated $88,000
    of this total was in the form of indirect costs incurred by the sponsoring
    organization that were not charged to the program and about $4,000 was to
    subsidize the benefits for WIC employees. According to information provided
    by the WIC Director, nutrition and clerical staff support provided by the
    sponsoring organization was valued at about $7,000. (The $7,000 in salary
    costs for these staff was covered by other federal grant funds.) The $99,300
    in total contributions represents approximately 20 percent of Grady's 1999
    WIC program expenditures, or about 20 cents for every dollar in costs
    covered with program funds.

    We identified the following nonprogram resources at the other five agencies:

    � Long Beach. The major nonprogram resources used in fiscal year 1998 had a
    total value of approximately $333,000 and were in-kind contributions made by
    the sponsoring organization.10 According to information provided by an
    official of the agency's sponsoring organization, about $273,000 of the
    amount was for indirect costs not charged to the program and $60,000 was for
    the value of the space provided to the program at no charge. The estimated
    $333,000 value of nonprogram resources represented about 11 percent of
    program expenditures in fiscal year 1998, or 11 cents for every dollar in
    costs covered with program funds.

    � York. The major nonprogram resources used in fiscal year 1999 had a total
    value of approximately $58,400. According to information provided by
    officials of the sponsoring organization, about $36,400 of this amount was
    the approximate value of its in-kind contributions. About $31,000 of this
    amount was for indirect costs incurred by the sponsor but not charged to the
    program, and about $5,400 was for the wages of one part-time administrative
    staff person assigned to the program at no cost. (In both instances, the
    costs of the contributions made by the sponsor were covered by other federal
    program funds--a Community Services Block Grant and a grant from the
    Department of Labor.) An additional $20,000 in nonprogram resources was,
    according to the WIC Director, the approximate value of the discounted lease
    amount the landlord charged the program for the space at the main clinic.
    The remaining $2,000 was a grant from the city of York to educate mothers on
    baby bottle tooth decay. In total, the value of these nonprogram resources
    ($58,400) represented approximately 11 percent of program expenditures in
    fiscal year 1999, or 11 cents for every dollar in costs covered with program
    funds.

    � Gallatin. The major nonprogram resources used to cover the costs of
    providing nutrition services and administering the program in fiscal year
    1999 were in-kind contributions by both the sponsoring and other
    organizations. The sponsoring organization estimated the value of the
    in-kind contributions of shared space and support from administrative
    personnel to be $10,720. The program also received donated space for three
    of its four satellite clinics from Madison and Park counties. The WIC
    Director estimated the value of space contributed by these adjacent counties
    was about $1,200 per year. The combined total value for the major in-kind
    contributions, $11,920, represented about 8 percent of Gallatin's WIC
    program expenditures in fiscal year 1999, or about 8 cents for every dollar
    in costs covered by program funds.

    � ⋅ Kanabec. The major nonprogram resources in fiscal year 1999 used to
    cover program costs had a value of $3,000. According to a sponsoring agency
    official, in-kind contributions were made by the sponsoring organization of
    dedicated space for the WIC office, use of equipment, and support from
    health care staff. The $3,000 represented about 6 percent of program
    expenditures, or about 6 cents for every dollar in costs covered by program
    funds.

    � Zuni. The major nonprogram resources Zuni WIC used to cover program costs
    in fiscal year 1999 had a value of about $5,500. According to an official of
    the sponsoring agency, $5,000 was in the form of an in-kind contribution of
    rent-free land on which the WIC facility was located. In addition, the WIC
    program received a $500 Indian Health Service grant to distribute toys to
    improve children's physical activity. The $5,500 represented about 2 percent
    of Zuni WIC's program expenditures in fiscal year 1999, or about 2 cents for
    every dollar in costs covered by program funds.

    We provided a draft of this report to USDA's Food and Nutrition Service for
    review and comment. We met with Food and Nutrition Service officials,
    including the Director of the Grants Management Division. The agency
    officials generally agreed with the information presented in this report.
    They provided some technical comments, which we incorporated as appropriate.
    We also provided the case study agencies, their sponsoring organizations,
    and the state-level WIC agencies with the opportunity to review a draft of
    those sections of the report pertaining to their operation. These
    organizations provided us with a number of technical corrections, which we
    incorporated as appropriate.

    We are sending copies of this report to the appropriate congressional
    committees; interested Members of Congress; the Honorable Dan Glickman,
    Secretary of Agriculture; and other interested parties. We will also make
    copies available upon request.

    If you or your staff have any questions about this report, please contact me
    or Thomas E. Slomba at (202) 512-5138. Key contributors to this report are
    listed in appendix VII.
    Robert E. Robertson
    Associate Director, Food and
    Agriculture Issues

    Scope and Methodology

    This report provides information on the (1) approaches WIC agencies use to
    deliver nutrition services and administer the program; (2) way staff at WIC
    agencies allocate their time delivering nutrition services and administering
    the program; and (3) types of nonprogram resources used by WIC agencies and
    the extent to which such resources are used to cover the costs of delivering
    nutrition services.

    To address these issues, we conducted case studies at six judgmentally
    selected WIC agencies. The case study approach enabled us to provide
    detailed information on agency procedures and operations. The case studies
    are not intended to be a statistically valid sample. Consequently, our
    observations and results are not generalizable to all WIC agencies.

    In judgmentally selecting individual case study agencies, we sought to
    identify a set of case studies that represented a wide range of agency
    characteristics. Towards that end, we considered over a dozen agency
    characteristics, including WIC enrollment levels, type of sponsoring agency,
    geographic location, rural versus urban operating environments, frequency of
    food instrument issuance, racial/ethnic diversity, and poverty levels. The
    six WIC agencies selected included five local agencies: Gallatin WIC in
    Montana; Grady WIC in Atlanta, Georgia; Kanabec WIC in Minnesota; Long Beach
    WIC in California; and York WIC in Pennsylvania; and one Indian tribal
    organization, Zuni WIC, in New Mexico, which functions as both a state- and
    local-level WIC agency.

    To determine how nutrition services and administration activities are
    performed at each of the case study agencies, we conducted on-site
    interviews with WIC agency management and staff as well as with officials
    and staff of the respective sponsoring organizations and state WIC agencies.
    Interviews were conducted using a standardized interview guide. During our
    site visits, which ranged from 4 to 5 days in length, we observed staff
    perform the various nutrition services and administrative activities,
    including individual and group nutrition education sessions. We also
    gathered and reviewed pertinent documents, including agency policies, staff
    rosters, clinic schedules, and financial and budget documents. After our
    on-site visits, we followed-up as necessary with agency, state, and
    sponsoring organization officials to obtain additional information as
    needed. We did not evaluate whether the local agencies followed state and/or
    federal WIC or grant management guidelines.

    To determine the amount of time that the WIC staff spent performing various
    activities, we conducted time studies at each of agencies. To develop the
    activity categories used in our time studies we reviewed Food and Nutrition
    Service (FNS) documentation, recent WIC research and examples of WIC time
    studies from several states in order to identify and categorize the
    nutrition services and administration (NSA) activities to track during the
    time study. Table 8 lists the activity categories and subcategories that we
    monitored in our review.

    (Continued From Previous Page)

          WIC activity category            Description of activities in each
                                                 activity subcategory
     Participant services
                                       Scheduling appointments, providing phone
     Scheduling participantsa          or in-person reminders, following up on
                                       missed appointments, and rescheduling.
                                       Determining eligibility (income,
                                       category, residence); obtaining
                                       necessary documentation and copying it;
     Determining participants'         completing forms or computer screens;
     eligibilitya                      having support staff obtain
                                       anthropometrics and blood work for the
                                       purpose of determining eligibility;
                                       obtaining and recording immunization
                                       data; handling complaints.
                                       Having competent professional
                                       authoritiesb obtain physical
                                       measurements, such as height and weight,
                                       and bloodwork for the purpose of
                                       assessing risk or intervention level,
     Assessing participants'           completing assessments and tests,
     nutritional riska                 determining appropriate risk factors,
                                       assessing immunization status,
                                       completing forms or computer screens,
                                       discussing nutrition and breastfeeding,
                                       developing a care plan, developing a
                                       food package, reviewing charts and
                                       filing, entering progress notes.
                                       Assisting participants in obtaining
                                       other health or social services (such as
     Making referrals and following    public health services, immunizations,
     upa                               Medicaid, food stamps, and voter
                                       registration) or transferring to another
                                       WIC agency.
     Explaining benefits and           Explaining WIC procedures, rights and
     procedures to participantsa       benefits.
                                       Issuing checks or vouchers, training
     Issuing food benefitsa            participants in using vouchers in a
                                       store, voiding vouchers.
                                       Training staff or volunteers or
                                       receiving training in procedures for
                                       certification, eligibility, scheduling,
                                       WIC client benefits and rights, and
                                       client services; reading related
                                       professional materials; attending or
     Providing or receiving training   holding workshops, meetings, and
     or other professional development conferences. Professional development
                                       refers to time spent by WIC staff either
                                       receiving training, or in providing
                                       training to other WIC support staff
                                       (such as peer counselors, volunteers,
                                       clerical staff) on WIC procedures,
                                       policy or related technical issues.
                                       Making chart notations after client has
     Making record notations           left clinic: completing or revising
                                       nutritional notes, care plan, or other
                                       participant information.
     Nutrition education
                                       Providing a one-on-one
                                       counseling/education session that occurs
                                       outside of certification/recertification
     Providing one-on-one nutrition    process, explaining WIC foods and food
     education or counselinga          preparation, following up, and
                                       documenting meetings. Includes phone
                                       calls and visits to, for example, the
                                       home or a hospital.
     Providing group nutrition         Providing group counseling/education
     educationa                        sessions.
                                       Researching, developing, ordering, and
     Developing educational materials  reviewing materials; planning and
                                       conducting activities, sending out
                                       mailings.
                                       Communicating with medical providers
     Consulting with medical providers regarding the nutrition education of
     regarding nutrition education of  individual participants. Includes phone
     individual participants           calls, mailings, visits, meetings, and
                                       in-services.
                                       Reading professional materials,
     Providing or receiving training   attending workshops and other meetings;
     or other professional development developing and presenting in-services;
                                       training other staff or volunteers.
                                       Monitoring and evaluating nutrition
     Monitoring and evaluating         education activities; compiling and
     nutrition education activities    analyzing data; revising policies and
                                       procedures.
     Breastfeeding promotion and support

     Providing one-on-one              Providing a one-on-one breastfeeding
     breastfeeding                     counseling/education session that occurs
     Instruction/counselinga           outside of certification/recertification
                                       process.
     Providing group breastfeeding     Providing group breastfeeding
     instruction/counselinga           counseling/education.
                                       Researching, developing, ordering, and
     Developing breastfeeding          reviewing materials; planning and
     promotion materials               conducting activities (e.g., incentive
                                       awards), mailings.
                                       Communicating with medical providers
                                       regarding breastfeeding promotion and
     Consulting with medical providers support or coordination of services.
     regarding breastfeeding issues    Includes phone calls, mailings, home
                                       visits, hospital or medical center
                                       visits, meetings, and in-services.
                                       Reading professional materials,
     Providing or receiving training   attending workshops or other meetings;
     or other professional development developing and presenting in-services,
                                       training peer counselors or volunteers.
                                       Monitoring and evaluating breastfeeding
     Monitoring and evaluating         promotion and support activities and
     breastfeeding promotion           breastfeeding rates; compiling and
     activities                        analyzing data; revising policies and
                                       procedures.
     Administration
     Outreach to potential             Providing WIC information to potential
     participantsa                     participants.
                                       All communication (such as phone,
                                       meetings, and mailings) with health care
                                       providers, social service agencies,
                                       schools, public officials, and others;
     Outreach to health care providers encouraging referrals to the WIC
     and other organizations           program; nutrition education or breast
                                       feeding promotion; developing and
                                       distributing outreach materials;
                                       arranging for advertising or
                                       notification; developing or conducting
                                       demonstrations.
                                       Filing, photocopying, ordering supplies
                                       and equipment; purchasing, renting or
                                       repairing equipment; handling
                                       correspondence and data entry; setting
                                       up the clinic; assigning space for group
     Clerical tasks                    sessions, maintaining state or local
                                       licenses, bondage or insurance;
                                       maintaining voucher issuance records;
                                       maintaining lists of authorized vendors;
                                       voiding vouchers; inventorying vouchers;
                                       printing vouchers; and maintaining
                                       voucher stock.
                                       Preparing for travel--such as loading
                                       equipment; traveling to clinics or
     Travel                            other-WIC related destinations;
                                       preparing travel expense reports; and
                                       checking on airfares, hotels, and other
                                       travel needs.
                                       Completing timesheets; processing
     Personnel tasks                   payroll; hiring and terminating staff;
                                       orientating new personnel; supervising
                                       staff; non-WIC staff training.
                                       Processing invoices, preparing reports;
     Accounting and finance            developing and reviewing budgets;
                                       auditing.
                                       Training vendors; responding to
                                       complaints; conducting on-site visits;
     Vendor management                 monitoring; disqualifying vendors;
                                       corresponding with vendors; maintaining
                                       vendor records; authorizing vendors.
                                       Attending staff meetings; conducting
                                       general evaluation of WIC activities;
     Management                        developing policies and procedures;
                                       reviewing reports; scheduling clinic
                                       operations.
                                       Setting priorities for the day's work;
     Organize self/work                turning computers on/off; organizing
                                       desk at end of day.
                                       Time spent on WIC related activity that
     Miscellaneous                     did not fit under other defined
                                       activity.

    aActivity involved direct contact with participant, or in the case of
    outreach with potential participants, either in person or by telephone.

    bA competent professional authority is, according to program regulations, an
    individual on the staff of a local agency who is authorized to determine
    nutritional risk and prescribe supplemental foods. Individuals who can be
    designated as a CPA include nutritionists, dietitians, nurses, and medically
    trained health officials.

    We used two techniques to record and summarize the amounts of time
    individual staff spent on these various activity categories. At five
    agencies we employed a contractor, Work Management Institute, Ltd. of
    Arlington, Virginia, which had developed a recording system utilizing bar
    code technology. Rather than having WIC agency staff manually record how
    they spent their time using traditional timesheets, the bar code technology
    allowed participating staff to sweep a credit-card size bar code scanner
    over specific bar codes as they began each activity throughout the day (see
    fig. 3). The technology and associated procedures were intended not only to
    ease the WIC staffs' data entry burden but also to increase the accuracy of
    the data. The contractor provided training to the staff and subsequent
    monitoring to ensure that the bar code procedures were followed properly.
    Each evening, the data were uploaded to the contractor who collated and
    analyzed the data. The contractor provided reports to each staff member the
    next day for verification. We used the bar code technology to conduct a
    1-month (20 to 22 workdays) time study at five of the WIC case study
    agencies: Gallatin, Grady, Kanabec, York, and Zuni.

    We did not use the bar code technology for the sixth case study--Long
    Beach--because of the increased costs associated with deploying the system
    for the significantly larger number of staff located at the agency. Instead
    we used a paper-and-pencil timesheet approach, which incorporated many of
    the features of the bar code approach. Specifically, Long Beach staff used
    the same activity coding system as the agencies using the bar code
    technology, and agency staff members received on-site training from GAO
    staff members. WIC staff recorded on timesheets how they spent their time
    1-day a week, over a 5-week period. The days for time-use recording were
    pre-assigned, so that staff recorded their times once on each day of the
    week (i.e., once on a Monday, once on a Tuesday). In addition, on any given
    day approximately one-fifth of the staff recorded time use. If a staff
    member could not record times on the assigned day, GAO assigned a substitute
    day. Complete data (5 days) were obtained for 51 of the 53 staff members.
    The recording sheet of each staff member was reviewed once it was received,
    and any problems or concerns about the way times were recorded were
    discussed with the staff member. Table 9 shows the time span of each of the
    six time studies.

     Agency     Time span of time study
     Gallatin   October 10, 1999 through November 17, 1999
     Grady      February 28, 2000 through April 3, 2000
     Kanabec    October 25, 1999 through November 22, 1999
     Long Beach January 18, 2000 through February 18, 2000
     York       March 13, 2000 through April 12, 2000
     Zuni       February 10, 2000 through March 16, 2000

    To arrive at the minutes per case-month spent on an activity category at an
    agency, we multiplied the percent of all time staff time spent on a given
    activity category by the approximate number of minutes of staff time,
    including that of administrative and support staff, available to perform all
    nutrition services and administrative activities. To arrive at the
    approximate number of minutes available for all nutrition services and
    administrative activities for each agency, we (1) calculated the number of
    full-time equivalent staff at each agency at the time of our study; (2)
    divided the agency's average monthly participation for fiscal year 1999 by
    the number of full-time equivalent staff to arrive at an approximation of
    the number of participants served per full-time equivalent staff; (3)
    assumed each full-time equivalent staff had approximately 1,920 hours
    available each year and divided 1,920 by the number of participants served
    per full-time equivalent staff to arrive at the number of hours of staff
    time available per participant per year; (4) divided the number of hours
    available per year by 12 and converted the result to minutes to arrive at
    the approximate number of minutes available per participant per
    month--referred to as per case-month.

    To calculate the percent of staff time costs spent on the various activity
    categories we used the loaded hourly wage rate (pay plus benefits) for
    employees at all agencies except Long Beach where we used the unloaded
    hourly wage rate (benefits not included). The time an individual staff
    member spent on an activity category was multiplied by that individual's
    wage rate. The sum of staff costs for an activity category and the sum of
    costs for all activity categories were used to calculate the percentage of
    staff time costs for each activity category.

    Finally, to determine the types of nonprogram resources and the extent to
    which agencies used such resources to cover costs, we requested detailed
    information during our interviews with officials of the WIC agencies and
    their sponsoring officials regarding all nonprogram resources used to
    provide WIC services. We then worked with the officials to establish a value
    for each of the major nonprogram resources used, relying where possible on
    records such as existing indirect cost allocation plans.

    Selected Characteristics of the Six Case Study Agencies

    This appendix presents five tables on selected characteristics of the case
    study agencies.

    Table 10 shows the characteristics of the six case study agencies in terms
    of sponsoring organization, and geographic areas served, and average monthly
    number of participants served in fiscal year 1999.

                                                     Average monthly
     Agency     Sponsoring           Geographic area participation, fiscal year
                organization         served
                                                     1999

     Gallatina  Single county        Rural           1,018
                health agency
     Grady      Public hospital      Urban           4,852

     Kanabec    Single county        Rural           313
                health agency

     Long Beach City health          Urban           28,452
                department

     York       Community action     Urban           4,859
                agency

     Zuni       Indian tribal        Rural           857
                organization

    aGallatin is operated by a single county but provides nutrition services to
    three counties.

    Table 11 compares the characteristics of the five local case study agencies
    with those of local agencies nationwide. The characteristics of the local
    agencies are based on information provided by 1,416 local WIC agencies that
    responded to a nationwide survey we conducted in 1999.11

     Agency setting              Percent of local
                                 agencies nationwide
                                                        Case study agency
     State health agency         3
     District health agency      7.6
     Multicounty health agency   8.6
     Single county health agency 40.6                   Kanabec, Gallatina
     Municipal health agency     2.9                    Long Beach
     Community health agency     15.7
     Community action agency     7.3                    York
     Indian health agency        2.3
     Public hospital             3.5                    Grady
     Private voluntary hospital  1.8
     Private proprietary
     hospital                    0.6
     Other                       5.3
     Geographic service area
     Urban                       24.3                   Long Beach, Grady, York
     Suburban                    7.6
     Rural                       56.1                   Gallatin, Kanabec
     Mixed                       10.5
     Average monthly caseload
     500 or less                 19.8                   Kanabec
     501-999                     15.7
     1,000--2,499                26.5                   Gallatin
     2,500--4,999                17.7                   Grady, York
     5,000--9,999                11.4
     10,000 or more              8.2                    Long Beach
     Unknown                     0.6

    aGallatin is operated by a single county but provides nutrition services to
    three counties

    Table 12 shows the number of full-time equivalent staff and the
    participant-to-staff ratio at the time of our study.

                  Number of        Number of
                                                   Number of
      Agency      full-time       registered       registered     Participants
                  equivalent     dietitians on                     per staff
                    staff           staff       nurses on staff
     Gallatin  3.3             1                0               308
     Grady     12.8            8                0               381
     Kanabec   .7              0                1               460
     Long
     Beach     52.2            16               0               545
     York      16.3            0                2               300
     Zuni      6.6             1                0               134

    Table 13 shows the amount of WIC program resources the six agencies used to
    provide nutrition services and administer the program in fiscal year 1999.
    These expenditures are expressed as expenditures per participant per month.
    The variation among the agencies is due in large part to the amount of
    funding per case-month that flows from USDA to the state-level WIC agencies,
    and from these state-level agencies to the local agencies.

                   Expenditure per
       Agency
                participant per month
     Gallatin   $12.54
     Kanabec    $8.09
     Long Beach $8.43
     Grady      $8.37
     York       $9.47
     Zuni       $25.71

    Notes: The WIC program expenditures refer to the local agency expenditure of
    federal and, in the case of Kanabec, federal and state WIC program funds.
    The per-participant per case-month expenditures for the five local agencies
    do not include program expenditures made at the state level. Some
    state-level expenditures directly support local agency operations. The
    expenditures for Zuni WIC, the only state-level agency, include both
    state-and local-level expenditures.

    Table 14 shows the percent of WIC program funds expended on personnel,
    space, indirect costs, and all other costs for each of the six agencies in
    fiscal year 1999.

     Budget category             Gallatin  Grady  Kanabec  Long     York Zunia
                                                           Beach
     Personnel and benefits,
     excluding expenditures for  79%       96%    89%      50%      84%  68%
     contracted personnel
     Contracted personnel        0         0      0        26       0    0
     Facilities and related
     expenses                    7         0      2        7        8    2
     Equipment and supplies      3         4      2        2        1    4
     Indirect                    4         0      6        5        4    14
     All others                  7         <1     1        10       3    12
     Total                       100%      100%   100%     100%     100% 100%

    a Zuni WIC was the only state-level agency. Some Zuni WIC expenditures were
    for state-level costs.

    Additional Comparisons of the Ways the Six Agencies Deliver Nutrition
    Services and Administer the Program

    This appendix provides additional comparisons of agencies' approaches in
    areas of participant services, nutrition education, breastfeeding promotion,
    and program administration.

    � Managing participants' waiting time. The six agencies used a variety of
    strategies to try to schedule participants' appointments, thus affecting the
    amount of time participants waited to be seen. For example, Gallatin and
    Kanabec saw their participants in the order of their scheduled appointment
    times, and participants typically waited 5 to 10 minutes for service. In
    contrast, while Long Beach scheduled most appointments, participants were
    seen on a "first-come, first-served" basis, regardless of whether or not
    they had an appointment; under this system, participants experienced waiting
    times of about 30 minutes.

    � Handling missed appointments. The agencies used various strategies to deal
    with the problem of missed appointments. At two agencies--Kanabec and
    York--staff routinely called participants to remind them of upcoming
    appointments but did not call them if they had missed appointments. In
    contrast, Grady, Gallatin, and Zuni only made follow-up phone calls or sent
    post cards to participants who missed an appointment. Long Beach uses an
    automated telephone calling system to make recorded calls to remind
    participants of upcoming appointments and to remind them to reschedule a
    missed appointment.

    � Referring participants to other service providers. The agencies varied
    somewhat in how they referred participants to other service providers, but
    no agency consistently followed up on whether participants had acted on the
    referral. Participants may be referred to a variety of health and social
    service providers, such as the public health nurse for immunizations or the
    Medicaid or food stamp offices. In particular, for referrals to public
    health providers, three agencies--Gallatin, Kanabec, and Zuni--used a
    referral form. For other types of referrals at these three agencies and for
    all referrals at the other three agencies, staff typically provided
    participants with information orally and in written form, such as a brochure
    or printed list that identified the provider or providers of the needed
    service. At all of the agencies but Long Beach, staff noted the referral in
    the participant's record.

    � Content of instruction. The six agencies most often provided nutrition
    education to adult participants or caregivers through one-on-one
    discussions. The information provided during these sessions varied
    considerably. We observed that the content of these initial discussions
    ranged from a few general sentences to in-depth explanations and medical
    nutritional counseling.12

    � Other methods used to provide nutrition education. The agencies varied in
    the extent to which they used strategies, other than one-on-one sessions or
    classes, to provide nutrition education. For example, Zuni, which had a
    kitchen in its facility, was the only agency to incorporate cooking
    demonstrations into group sessions. All the agencies also used brochures and
    other education material to provide general nutrition information. At Zuni,
    participants were asked to study a display and answer questions that they
    reviewed with WIC staff. Videotapes on nutrition were typically played in
    waiting rooms at Long Beach, York,13 and Zuni.

    � Tailoring nutrition education to meet participants' language needs.
    Several agencies tailored the nutrition education they provided to meet the
    language needs of specific groups of participants. For instance, four
    agencies--Long Beach, Zuni, Grady, and York--operated in ethnically diverse
    communities and hired bilingual staff to provide nutrition education to
    non-English speaking participants. Long Beach staff developed its own
    brochures to serve its Cambodian population. In contrast, the Grady Director
    told us that the program lacked funding for nutrition education materials in
    languages to serve some segments of the agency's participant population.

    � Content of breastfeeding one-on-one sessions. As with nutrition education,
    the content and the duration of the breastfeeding counseling ranged from a
    brief exchange about whether a woman intended to breastfeed to a 45-minute
    breastfeeding appointment.

    � Using other strategies to promote breastfeeding. In order to sustain
    breastfeeding once the mothers are at home, three agencies--Kanabec, Grady,
    and Zuni--offered telephone support to mothers calling with questions or
    concerns. To make breastfeeding convenient while mothers were visiting WIC
    offices, two agencies--Long Beach and Zuni--dedicated private space for this
    purpose. In addition, staff from three agencies, Zuni, Gallatin, and Long
    Beach, committed their local WIC funding or time volunteered by staff to
    develop breastfeeding promotion material--videos and brochures--for use not
    only by their own agency but also for other agencies in their area.

    � Conducting outreach. Outreach generally includes those activities
    undertaken to attract eligible participants and to ensure that they continue
    to receive the benefits to which they are entitled. All of the agencies but
    Grady described distributing WIC materials to area medical providers,
    community groups, or social service providers, and at area health fairs.
    Several agencies mentioned that they distributed material to area schools
    and/or the Head Start program. The Kanabec WIC Director indicated that
    participants also typically heard about the WIC program through friends and
    family. The Gallatin WIC Director said that the effectiveness of the
    agency's outreach was limited because staff were not trained in outreach
    strategies, and the agency lacked the resources to provide such training.
    Grady WIC conducted minimal outreach because it did not have a defined
    service area and did not want to take participants from neighboring WIC
    agencies. Outreach activities were confined to the WIC caseload,
    hospital-based patients, and hospital-sponsored events, such as an open
    house meant to inform expectant mothers on available hospital services.

    Detailed Summaries of the Six Case Studies

    This appendix provides a detailed summary of each of the six case study
    agencies. It includes an overview of the state-level WIC program and
    describes the geographic area served by the agency, the sponsoring
    organization, staffing, clinic operations, the approaches used to deliver
    major nutrition services and administer the program, and the nature of
    nonprogram resources used to provide WIC services.

    The Gallatin County WIC program is one of 43 local agencies providing WIC
    services in Montana. In fiscal year 1999, the average monthly number of
    participants served by these 43 agencies was 21,346. According to our 1999
    national survey of local WIC agencies, most of these agencies operate in
    rural settings and over half are run by a single county public health
    agency.14

    In fiscal year 1999, the Montana WIC program expended federal Nutrition
    Services and Administration (NSA) grant funds totaling $4,178,202, or about
    $16.31 per participant per month (per case-month). Montana provided no state
    funds for WIC nutrition services and administration. About 24 percent of the
    NSA expenditures ($986,655) was made at the state level. The remaining 76
    percent ($3,211,547) was expended by the local agencies. Montana distributes
    WIC program funds to local agencies on the basis of served caseload bands,
    or "per capita funding." The funding allocation is based on the average of
    actual participants served in the most recent 6 or 12 months of
    participation, whichever is greater. For example, in fiscal year 1998,
    Gallatin WIC received $180 per participant per year for the first 100
    participants, $139 per participant per year for the next 101 to 500
    participants, and $133 per participant above 500.

    The Montana WIC program supports the local agencies by providing a statewide
    participant database system, which became fully operational in 1995. The
    state conducts a nightly upload of the participant certification data from
    the local agencies' computers. The statewide automated system is used to
    schedule appointments and collect and record information obtained during
    participant certification and recertification, including nutrition risk
    assessments. It is also used to create custom food packages, calculate the
    value of each food package or food check, and print food checks on demand.
    Local agency staff can also use laptop computers to print food checks on
    demand at satellite clinics.

    The Montana WIC program also supports the local agencies by providing
    program guidance; nutrition and breastfeeding materials, training; peer
    training on breastfeeding; travel and lodging needed to attend training;
    equipment purchases, such as blood-testing equipment and supplies; automated
    data processing equipment and support, including three toll-free 800
    telephone numbers for technical support.

    WIC Program

    The Gallatin County WIC program is located in Bozeman, Montana, and serves
    the residents of Gallatin, Park, and Madison counties. The population in
    Gallatin County grew over 2 percent in just 1 year, from 61,196 in 1997 to
    an estimated 62,545 in 1998. Bozeman is the fifth largest city in the state,
    with an estimated population of 29,936 in 1998. It is situated in
    southwestern Montana, in a large valley surrounded by rugged mountains. The
    climate varies with the elevation. Higher elevations bring lower
    temperatures and higher snowfalls that can make travel difficult at times.
    Figure 4 shows the topography of the tri-county area served by Gallatin WIC.

    Source: Gallatin City-County Health Department, Bozeman, MT.

    In 1993 about 13 percent of Gallatin County's population was at or below the
    poverty level. The recent population growth has made Bozeman more expensive
    to live in, and as a result, low-income individuals and families have moved
    farther from the town's center. Gallatin County is predominantly white, with
    minorities (African-Americans, American Indians, Eskimos and Aleuts,
    Asian/Pacific Islanders, and Hispanics) representing 3.7 percent of the
    total population in 1996.

    Sponsoring Organization

    Gallatin WIC has operated under the auspices of the Gallatin City-County
    Health Department, a single county health agency, since 1976. In addition to
    the WIC program, the Health Department operates adult and child immunization
    clinics, a school nursing program, a well-child clinic, a breastfeeding
    support and education program, and the Maternal/Child Health Home Visitation
    program. The Department provides an integrated service model that provides
    "one-stop-shopping" for those seeking health services in Gallatin County.

    The county charges the WIC program for indirect costs such as accounting,
    data processing, and personnel. Total indirect costs charged to the WIC
    program are based on cost allocation among the various programs. In fiscal
    year 1999 the program was charged for indirect costs that represented 3.9
    percent of program expenditures. The health department provides WIC with
    in-kind contributions of shared space for a waiting room, a classroom,
    storage space, and an examination room used by the main clinic, as well as
    utilities and support from administrative personnel.

    WIC Clinics

    The main Gallatin WIC clinic is in Bozeman and is collocated with the other
    Gallatin health department programs. At the time of our study, the normal
    hours for the main clinic were Monday through Friday, 8:00 a.m. to 5:00 p.m.
    Gallatin WIC offered limited extended hours at the main clinic--evening
    hours on three to four Wednesdays per month and during the lunch hour on
    Tuesdays. In July 1999, over 700 of the 1,045 Gallatin WIC participants were
    receiving services at this clinic.

    To make services more convenient for participants with limited
    transportation, Gallatin WIC opened four additional sites--Three Forks and
    West Yellowstone in Gallatin County, Ennis in Madison County and Livingston
    in Park County (see fig. 4). The distance from the main site in Bozeman to
    the satellite sites ranges from 28 to 90 miles. The farthest three satellite
    clinics are located on the other side of mountain ranges. The satellite
    sites all share space with other public or health agencies--Three Forks in
    the City Hall, Livingston and Ennis in public health clinics, and West
    Yellowstone in a community services building. Services at Livingston are
    provided every Friday and two Wednesdays and one Saturday per month; at
    Ennis, Three Forks, and West Yellowstone, services are provided one day a
    month and a second consecutive day at West Yellowstone, if needed. In July
    1999, the satellite clinics served between 28 and 202 participants.

    Staffing

    At the time of our study, Gallatin WIC had four staff--three of whom worked
    part-time--for a total of 3.3 full-time equivalent staff. The WIC Director
    is a registered dietitian who has been with the program since 1988. She has
    the only full-time, salaried position. The three part-time employees were
    all competent professional authorities (CPAs)15 with bachelor degrees in
    home economics. Gallatin had no support staff--the service staff carried out
    support activities.

    Number of Participants Served

    The Gallatin County WIC program, which served a monthly average of 990
    participants in fiscal year 1998, is one of the largest local WIC agencies
    in the state. In fiscal year 1999, the monthly average participation had
    grown to 1,018. Table 15 shows the number of participants by category served
    in September 1998 and July 1999. In April 2000, 64 percent of the
    participants being served were considered to be high-risk.

                                           Number of participants
     Participant category                  September 1998  July 1999
     Pregnant women                        107             122
     Breastfeeding women                   97              82
     Postpartum women not breastfeeding    52              49
     Infants                               252             246
     Children                              478             548
     Total                                 986             1,047

    Montana State University students represent about 30 to 40 percent of the
    agency's participants, but this figure fluctuates throughout the academic
    year. Participation also fluctuates because the West Yellowstone satellite
    clinic serves transient seasonal service workers.

    Administration

    Participant Services

    During the certification appointments, Gallatin WIC staff routinely measured
    participants for growth and tested their blood for anemia. Growth was also
    measured during recertification and other appointments. Staff reported, and
    we observed, that some nutrition education and breastfeeding promotion and
    support was also provided during the nutrition assessment process. CPAs and
    the dietitian saw both high- and low-risk participants. In accordance with
    Montana WIC guidance, Gallatin developed individual care plans for both
    high- and low-risk participants. The program used individual care plans to
    monitor education contacts, track when the participant attended an
    appointment, record the topic addressed, and evaluate the participant's
    progress. The care plan was kept in hard copy in the participant's record,
    and some information on the participant was entered into the automated
    system.

    Potential participants were strongly encouraged to schedule a certification
    appointment after an initial telephone or walk-in contact. In addition to
    documents such as identification and proof of income, caregivers were
    advised to bring immunization records for child participants. If an
    applicant did not have the required documentation, as much of the
    appointment was completed as possible and another appointment was scheduled
    to complete the certification and issue checks. Participants were generally
    seen by appointment, unless time was available in the schedule to see them
    on a walk-in basis. The WIC Director estimated that if participants were not
    seen immediately, the waiting time to be seen was about 5 to 10 minutes.
    Initial nutrition education appointments typically lasted over 45 minutes.
    If a participant missed an appointment, the staff routinely made a follow-up
    call to reschedule. The program has a policy of scheduling monthly
    appointments for food check pick-ups to coincide with a nutrition/
    breastfeeding education contact. The WIC Director implemented this policy in
    1988 because she believed simultaneous appointments made better use of
    participants' time at the WIC office. Table 16 shows the frequency of check
    issuance for various types of participants.

     Type of participant Frequency of check issuance
     Pregnant women      Monthly
     Postpartum women    Monthly first 4 months, then every 2 months
     Infants             Monthly first 4 months, then every 2 months
     Children--high-risk Every 2 months
     Children--low-risk  Every 3 months

    The state requires Gallatin staff to refer participants to the appropriate
    health care provider or agency as needed or requested by a participant. The
    state also requires documentation of the need for the referral and
    information on the person to whom the participant was referred and on the
    outcome of the referral. Gallatin WIC has established a formal system using
    a pre-printed referral form that is filled out by WIC staff and sent to the
    Gallatin City-County Health Department, Human Services Division for Public
    Health, Pregnancy Services, and the Follow-me Program, as appropriate. This
    formal approach enables Gallatin WIC to track whether the participant was
    seen and to confer with the nurse. Staff also documented the child
    participant's immunization status and made immunization referrals.
    Immunization appointments were coordinated with WIC appointments at all
    sites but Three Forks.

    Gallatin WIC staff did not use a formal system when referring participants
    to other providers, such as substance abuse programs and La Leche League but
    rather simply provided a listing of providers with the necessary contact
    information. A list of the social services available in the county was also
    provided in the packet that the participants received at certification. If
    the Gallatin WIC staff refers the participant to a provider within the
    building, such as another county health department program, they will
    sometimes escort the participant to that office. In addition, referrals are
    made when the staff are unable to provide certain services, such as home
    visits, which may be provided by a county public health nurse.

    Regarding voter registration, the staff had voter registration cards on the
    WIC office desks, but they did not ask the participants whether they had
    registered.

    Nutrition Education

    Nutrition education was typically provided in one-on-one sessions with
    participants during certification, recertification, and check pick-up
    appointments. One-on-one nutrition education discussions began during the
    nutrition assessment phase of the certification process, when the CPA
    provided feedback on the participant's reported diet. For instance, during
    one recertification appointment, the WIC Director explained to a mother that
    her toddler was drinking twice as much milk in a day as he needed and that
    by drinking less milk he might be able to eat more meat. The certification
    and recertification appointments that we observed lasted from between 25
    minutes to over 1 hour. Staff handed out brochures to supplement their
    nutrition education discussions, and the agency displayed posters
    illustrating general nutrition information, such as the Food Pyramid. The
    content of these individual discussions focused on the individual's dietary
    needs and included in-depth explanations, such as describing the benefits of
    different vitamins and ways to identify vegetables that were good sources of
    particular vitamins, and strategies to improve their diet, such as
    moderating a child's intake of juice to avoid unnecessary calories. However,
    in accordance with the state WIC policy, the WIC Director referred
    participants who needed medical nutrition counseling to the registered
    dietitian at the local hospital. In addition, the Gallatin WIC Director
    indicated that funding constraints limited the amount of time staff had to
    spend with participants. For instance, she reported that, over the past 2
    years, the program had to schedule the staff for fewer days per month
    because of budget constraints. The Director also indicated that staff time
    or the space was not available to provide formal nutrition education to the
    child participants. She reported that the older children were frequently
    given coloring sheets with food subjects, and the WIC staff then discussed
    the sheet with the child. Two other strategies the program uses to provide
    nutrition education to participants were the following:

    � Holding monthly scheduled video sessions on a variety of nutrition and
    related topics. These topics include breastfeeding, infant care and
    development, menu planning, food selection storage and safety, infant and
    child feeding behaviors, and parenting; and

    � Sending participants to 45-minute monthly classes offered by the WIC
    program and by the public health nurses in the health department. The WIC
    staff taught classes every other week on the topics of prenatal nutrition,
    infant feeding, and breastfeeding/postpartum nutrition, and, twice a month,
    on starting your baby on solid foods. These classes were offered at all the
    WIC clinics. The public health nurses teach classes monthly on
    breastfeeding; infant care; the toddler years--nutrition, behavior, and
    discipline; pregnancy--fetal growth/development, nutrition, and healthy
    lifestyle; and labor and delivery. The classes taught by the public health
    nurses are offered monthly and were developed in collaboration with the WIC
    program.

    Breastfeeding Promotion and Support

    Gallatin's WIC Director also served as the breastfeeding coordinator,
    although all of the staff received breastfeeding training. The agency's
    policy was to encourage all mothers to try breastfeeding at least once. This
    effort was made in one-on-one sessions with pregnant women; during the
    prenatal nutrition and monthly breastfeeding classes; in videos; and through
    promotional materials, including infant feeding review and infant nutrition
    questionnaires. The Gallatin Director developed breastfeeding promotion and
    other WIC-related brochures for use not only by her own agency but also by
    the rest of the state.

    In 1998, the program had a breastfeeding initiation rate of 83 percent.16 In
    1998, the breastfeeding initiation rate for the state of Montana was 73
    percent.

    Administration

    Maintaining participants' records. The statewide automated system is used to
    schedule appointments, collect and record information obtained during
    participant certification and recertification, including nutrition risk
    assessments, create custom food packages, calculate the value of each food
    package or food check and print food checks on demand. While a substantial
    amount of participant and program data is maintained on the system,
    individual hard-copy participant records were also maintained.

    Managing vendors. Gallatin WIC staff played little role in vendor selection
    and compliance activities because these were handled by the state WIC
    agency. The staff's involvement in vendor management was typically limited
    to vendor training and monitoring, such as referring any problems that came
    to their attention to the state agency.

    Outreach. Gallatin WIC is primarily responsible for running outreach
    campaigns at the local level. It has conducted outreach to the following:
    the annual Head Start carnival; local school officials; area physicians; a
    homeless service provider (in Bozeman, a shelter is in the planning stage);
    other social service providers; and professional groups. The program
    provided notices or advertisements in local newspapers, television public
    service announcements, radio public service announcements, display booths or
    tables at community fairs; mailed program literature to interested persons;
    and encouraged referrals by participants. The Director indicated that
    effective outreach requires specialized training that the local agencies do
    not have and lack the money or time to acquire.

    Travel. All of the Gallatin staff traveled to the four satellite clinics to
    provide services. Travel to some clinics, across mountain ranges, can be
    difficult, especially in winter, when roads close because of bad weather.

    Retaining and recruiting personnel. The WIC Director reported having some
    problems maintaining an adequate staffing level. She believed the state
    WIC's policy prohibiting medical nutrition counseling served as a
    disincentive to prospective applicants who were registered dietitians.

    Gallatin's expenditures per participant per month in fiscal year 1999 was
    $12.54. Table 17 shows the fiscal year 1998 and 1999 program expenditures
    the agency made by category.

                               Fiscal Year 1998          Fiscal Year 1999

     Category                  Amount       Percent of   Amount      Percent of
                                            total                    total
     Personnel and benefits
     excluding expenditures    $118,789.56  77%          $121,404.93 79%
     for contracted personnel
     Contracted personnel      380.00       0%           105.12      0%
     Equipment and supplies    19,596.25    13%          5,327.10    3%
     Facilities and related
     expenses including
     utilities, maintenance,   9,268.86     6%           10,604.09   7%
     rent and telephone
     Indirect costs            5,280.00     3%           5,757.50    4%
     All other                 0            0%           10,017.16   7%
     Total                     $153,314.67  100%         $153,215.90 100%

    Note: Percents may not total to 100 percent due to rounding.

    The major nonprogram resources used to cover the costs of providing
    nutrition services and administering the program were in-kind contributions
    by both the sponsoring organization and the government agencies in Madison
    and Park counties. The Health Officer for Gallatin County estimated the
    value of the in-kind contributions of shared space and support from
    administrative personnel to be $10,720. The program also received donated
    space for three of its four satellite clinics from Madison and Park
    counties. The WIC Director estimated that the value of space contributed by
    these counties to be about $1,200 per year. The combined total value for the
    in-kind contributions, $11,920, represents about 8 percent of Gallatin's WIC
    program expenditures in fiscal year 1999, or about 8 cents for every dollar
    in costs covered by program funds.

    Other minor in-kind contributions from other public or health agencies
    include utilities, furniture, and equipment. We did not obtain an estimate
    for the value of these contributions.

    Grady WIC is one of 21 local agencies providing WIC services in Georgia. In
    fiscal year 1999, the average monthly number of participants served by these
    21 agencies was 224,031. The local agencies ranged in size from 1,488 to
    17,346 participants in an average month. According to Georgia WIC officials,
    19 of the 21 WIC agencies are administered by district health officials and
    2 are administered by hospitals. Of the 15 Georgia local agencies that
    responded to our 1999 national survey of local WIC agencies, 7 operated in
    rural settings, 3 in urban areas, 2 in suburban areas, and 3 in mixed
    geographic settings.

    In fiscal year 1999, the Georgia WIC program expended $30,839,839 in federal
    NSA grant funds, or about $11.47 per participant per month. According to
    state WIC officials, Georgia provided no appropriated funds for WIC
    nutrition services and administration. About 16.5 percent of the NSA
    expenditures ($5,080,115) were made at the state level, and the remaining
    83.5 percent ($25,759,724) at the local agency level. In fiscal year 1999,
    Georgia distributed WIC program funds to local agencies on the basis of a
    flat calculation of yearly cost per participant per month. Funding was
    allocated to local agencies twice a year. In fiscal year 1999, the per
    participant per month cost was $8.55.

    The Georgia WIC began automating recordkeeping of participant data by local
    agencies in 1991. The state agency staff can provide the local agencies with
    both standard and customized reports. Local agency program staff can call
    state computer staff for assistance with issues such as installing hardware
    and software, and maintenance. State WIC computer staff will also travel to
    the local agency to resolve system problems. In February 2000, a state WIC
    official reported that the local agencies used five separate automated
    systems, in addition to the system developed by the state program. The local
    agency systems are not integrated with each other, but each can interact
    with the third-party data processor. Grady WIC and two other local agencies
    use one of the five local agency systems--Grady since 1992. Grady WIC's
    system has the capability to enroll participants and issue food instruments.
    It operates in real time and has the capability to print both standard and
    customized reports. Grady WIC's participant data are uploaded to the state's
    third party processor system and a voucher printing contractor on a daily
    basis. According to a state WIC official, Grady's system is scheduled to be
    upgraded during 2000 to print vouchers on demand.

    Other types of support the Georgia state WIC agency provided to local
    agencies included general program policy as well as nutrition education and
    breastfeeding guidance and materials, and vendor management.

    Program

    The Grady WIC program is located in Atlanta, Georgia's capital and the
    government seat of Fulton County. Atlanta is mostly in Fulton County, with
    about 8 percent of its population in DeKalb County. Grady WIC provides
    services to residents from throughout Georgia, although its service area
    primarily overlaps with Fulton and DeKalb counties' WIC agencies. Fulton
    County had a total population of about 722,540 in 1997, and in 1999, Atlanta
    had a population of 431,126.

    According to 1993 Census data, 23 percent of all Fulton County residents
    lived below the poverty level. In 1999, 67.8 percent of Atlanta's population
    was nonwhite. In November 1999, about 61 percent of the Grady WIC
    participants were African-American; 37 percent, Hispanic; and 2 percent,
    other. The WIC Director estimated that about one-third of Grady WIC
    participants do not speak English as their primary language. Grady WIC staff
    reported a high incidence of obesity among the population they serve.

    Sponsoring Organization

    Since 1983, the Grady WIC program has operated under the auspices of the
    Fulton-DeKalb Hospital Authority. The authority is responsible for
    administering the Grady Health System (GHS), which includes Grady Memorial
    Hospital, Hughes Spalding Children's Hospital, a nursing facility, various
    health and trauma centers, and a managed care organization. Grady Memorial
    Hospital, a public, nonprofit hospital, aims to provide healthcare services
    for medically underserved and indigent citizens in the community. The Grady
    WIC program is located within the hospital's Maternal Child Health Nutrition
    Department. As one of the two contract WIC agencies in Georgia operated by
    hospitals, Grady WIC can enroll participants in its program or in any of the
    other WIC programs in the state.

    GHS provides the WIC program with several types of in-kind contributions.
    First, GHS does not charge the WIC program for any indirect or space costs
    associated with operating the program. Second, the system provides the WIC
    program with some clerical and staff support. Lastly, GHS partially pays for
    the benefits for WIC staff--the WIC program was charged 17.5 percent of
    personnel salaries for employees' benefits, although the actual cost for the
    benefits was 18.6 percent.

    WIC Clinics

    To make services more convenient to participants with limited
    transportation, Grady WIC operated, at the time of our study, a total of six
    clinics located in GHS-operated facilities in Atlanta. The WIC maternal and
    infant clinics are collocated with Grady Hospital. The pediatric WIC clinic
    is located in the children's hospital (see fig. 5), two blocks from Grady
    Hospital. Another clinic, Lindbergh, is collocated with a health clinic in a
    shopping center, about 6 miles from Grady Hospital. It is Grady WIC's
    largest clinic, serving 1,403 participants in January 2000. Another clinic
    is located at a facility dedicated to HIV patients, and one clinic, Boat
    Rock, was in a health center in a low-income residential building, about 15
    miles from Grady Hospital. In January 2000, the clinics served between 116
    and 1,403 participants. The Boat Rock clinic was closed in April 2000
    because the health center closed.

    At the time of our study, five of the satellite clinics were open Monday
    through Friday, with hours of operation starting between 8 a.m. and 9 a.m.
    and closing between 4 p.m. and 5 p.m. The Boat Rock clinic was only open on
    Tuesdays and Thursdays. On Wednesdays, the Lindbergh clinic operated from 10
    a.m. to 6:30 p.m.

    Staffing

    At the time of our study, Grady WIC had 16 staff: seven worked full-time for
    WIC, and 9 worked part-time for WIC and part-time for other hospital
    programs. This equated to 12.8 full-time equivalent staff. The WIC Director
    at the time of our study had been with the program for about 7 years and was
    a registered dietitian who had coauthored several research papers on
    nutrition education and breastfeeding. The 10 CPAs on staff consisted of 8
    registered dietitians and 2 nutritionists. A CPA was in charge of each of
    the six clinics. The CPAs conducted eligibility certifications, obtained
    health measurements, provided nutrition education and breastfeeding
    promotion and support, maintained logs of nutrition education, and monitored
    participants' nutrition education statistics. Two of the five clerks at the
    agency also provided informal breastfeeding counseling and support. Five of
    the staff were bilingual.

    Number of Participants Served

    In fiscal year 1999, Grady WIC's average monthly caseload was 4,852. Table
    18 shows the number of participants by category served in January 2000. The
    WIC Director estimated that 90 to 95 percent of the participants served were
    from the metropolitan Atlanta area. Approximately 79 percent of the
    participants served in November 1999 were considered to be high-risk.

    From April 1999 to October 1999, according to the WIC Director, the caseload
    dropped significantly, by almost 400 participants. The Director attributed
    this decrease to a new requirement that applicants document their family
    income and residency.17

                                           Number of participants
     Participant category                  September 1998  November 2000
     Pregnant women                        1,473           1,052
     Breastfeeding women                   256             207
     Postpartum women not breastfeeding    415             392
     Infants                               1,457           1,360
     Children                              1,398           1,323
     Total                                 4,999           4,334

    Administration

    Participant Services

    During certification or recertification sessions, Grady CPAs will most often
    measure the participant's height and weight and test blood for anemia,
    according to the WIC Director. However, if a new participant had recently
    been admitted to the hospital or if a participant had just delivered a baby
    in the hospital, WIC staff will have access to the participant's hospital
    chart, which will have the needed information. Grady's computer system can
    also access the hospital's laboratory results database; if a patient has
    recently been seen, staff can get blood test results from the database
    instead of doing another blood test. While staff could occasionally save
    time in assessing participants, the Director indicated recent program
    changes had increased the time and the number of forms required to certify
    participants.

    For the initial assessment, both the dietitians and nutritionists saw
    participants considered to be at high-risk. An individual care
    plan--developed for all high-risk participants--was used to record the
    physical information obtained during assessment. For example, in the case of
    a child participant, this information would include whether the child had
    been immunized, the nutrition topics discussed, the handouts provided, and
    the notations regarding follow-up activities. The care plan was kept in the
    participant's WIC record, and some information on the participant was
    entered into the automated system.

    All participants were typically issued vouchers on a bimonthly basis. The
    Grady WIC clinics made appointments and accepted walk-ins for voucher
    pick-up, and certification and recertification sessions. All of the
    satellite clinics attempted to coordinate the WIC recertification
    appointments with the participants' other medical appointments. At the time
    of our study, Grady WIC was short-staffed, and therefore the clerks did not
    have time to contact participants who missed appointments. When the clerks
    had time, they made follow-up calls or sent post-cards to such participants.
    In February 2000, the WIC Director estimated that about 10 percent of
    participants missed their appointments.

    In accordance with state guidelines, during certification and
    recertification sessions, Grady WIC staff asked if child participants were
    current on immunizations and recorded the information provided by the
    caregiver. However, staff were not required to ask for documentation of
    immunization status. In making referrals to other service providers, staff
    typically provided the participant with the telephone number of the provider
    or a booklet describing Atlanta area service providers. However, when making
    referrals for health service within the hospital, staff reported that,
    depending on the seriousness of the situation, they sometimes escorted
    participants to service providers. Typically, Grady WIC staff did not refer
    participants to non-WIC staff to address any nutrition education or
    breastfeeding issues. Staff recorded some referral information in the
    participant data system and attempted to follow up with participants at the
    next scheduled appointment regarding the outcome of the referral.

    Regarding voter registration, according to the WIC Director, staff will
    inquire if adult participants are registered to vote. If not, staff will
    provide participants with the registration paperwork and help them fill it
    out if necessary. The program does not track whether participants have been
    asked about voter registration.

    Nutrition Education

    According to the WIC Director, although the agency used several different
    methods to provide nutrition education, the primary method was one-on-one
    counseling during certification, recertification, and voucher pick-up
    appointments. The certification and recertification appointments that we
    observed lasted from 10 to 40 minutes. Grady WIC staff did not differentiate
    between nutrition education and counseling but provided little extensive
    counseling. The topics discussed during a nutrition education or counseling
    sessions depended on a participant's particular needs. For instance, we
    observed a one-on-one session in which staff explained to a father who
    reported giving his obese 6-month-old baby soft drinks that plain water was
    a better choice.

    High-risk participants are typically allotted 10 minutes for a nutrition
    education session, according to the WIC Director. Because of a staff
    shortage, the nutrition education for low-risk participants typically
    consisted of providing a nutrition brochure or having them watch a video.
    The Director indicated that although a daily nutrition education class was
    scheduled at the maternal WIC clinic, it was often not held because
    participants would not come in at the designated class times.

    Grady WIC also provided nutrition education via brochures, videotapes, group
    sessions or a touch screen computer kiosk. The touch screen computer kiosk,
    which the state provided, was located at the maternal clinic. It offered a
    self-paced narrated program to educate the participant on how the WIC
    program works and to discuss various nutrition education and breastfeeding
    issues. Grady WIC also displayed a few posters illustrating general
    nutrition information at some of the clinics.

    To serve its multilingual population, Grady WIC offered materials and
    classes in English and Spanish and some written materials in other
    languages. However, the WIC Director said that the program did not have
    funding for enough nutrition education materials translated into other
    languages. She also said that Grady did not have nutrition education classes
    geared toward the child participants because it did not have sufficient
    space or staff.

    In response to the need of some WIC participants for more nutrition
    education than could be provided by the WIC program, GHS' Maternal and Child
    Health Nutrition Department received federal funding from two other programs
    providing nutrition services that benefited many WIC participants. The
    Department's support to the prenatal, obstetric, and HIV clinics is funded
    by two Department of Health and Human Services (HHS) grants. Since so many
    of the high-risk maternity and infant patients are eligible for WIC
    services, the WIC dietitians and the HHS-funded dietitians closely
    coordinated their efforts to provide this supplemental education. The Grady
    WIC Director indicated that the loss of these complementary services would
    significantly affect the demands placed on WIC staff and thus the quality of
    WIC's nutritional services.

    Breastfeeding Promotion and Support

    Grady WIC promotes breastfeeding through classes, support groups, telephone
    contacts and on-call services. All pregnant participants received
    breastfeeding information at certification. The WIC breastfeeding
    coordinator was a focal point and resource for breastfeeding information in
    Grady Hospital. For instance, she provided in-service training to the
    hospital's health professionals. The coordinator and two CPAs, were also
    certified lactation consultants. The coordinator spent the largest portion
    of her time providing one-on-one breastfeeding assistance to WIC
    participants who were in the hospital. One of the lactation consultants
    taught a breastfeeding class in Spanish twice a month and in English twice a
    week, as well as a teen breastfeeding class once or twice a month. In
    addition to visits conducted by the coordinator, a WIC nutritionist visited
    the maternity ward daily. The program also trained and utilized volunteer
    breastfeeding peer counselors, who conducted the telephone contacts and met
    with participants in the WIC clinics.

    Grady had one of the highest breastfeeding initiation rates in the Georgia
    WIC program, about 57 percent for fiscal year 1998. However, because of
    funding constraints, Grady had fewer staff to provide individual
    breastfeeding counseling and follow-up than it had in the past.
    Consequently, the breastfeeding coordinator had observed a decrease in the
    initiation rate; in January 2000, the rate was 50 percent.

    Administration

    Maintaining participants' records. Grady WIC used a local database system
    that created a participant record and tracked participant data. The local
    system printed the first set of vouchers at certification. Grady's
    participant data were uploaded daily to the state's third party data
    processor and a state printing contractor. The state's printing contractor
    sent preprinted vouchers to Grady for issuance to participants at subsequent
    appointments. The staff documented information such as the participant's
    diet, nutrition risk factors, and physical measurements on paper. Because
    they rely on preprinted vouchers rather than printing vouchers on demand,
    Grady staff need time to enter and download participant data to a state
    contractor, and they had to void and reconcile preprinted vouchers when
    participants did not pick them up. Although Grady's participant data system
    generated various reports, staff often took data off the system and
    generated reports using off-the-shelf software because the system did not
    perform the kind of data analysis needed.

    Managing vendors. Unlike the other local WIC agencies in Georgia, Grady
    played little role in vendor management activities because it was located at
    a hospital. Instead, vendor activities were typically limited to referring
    any problems that came to the staff's attention to the state WIC agency.

    Outreach. According to the WIC Director, Grady WIC conducted minimal
    outreach because it did not have a defined service area and did not want to
    take participants from neighboring WIC agencies. Outreach activities were
    confined to the WIC caseload, hospital-based patients, and
    hospital-sponsored events, such as an open house meant to inform expectant
    mothers about available hospital services. Grady WIC had recently
    experienced a decrease in caseload. The WIC Director attributed this
    decrease to recent program changes, which she believed made qualifying for
    the WIC program more difficult. Given the decrease in caseload, the
    short-term outreach goal was to maintain and increase caseload.

    Travel. The staff normally did not travel from site to site to provide
    services. Travel expenses were provided for attending conferences and
    training.

    Retaining and recruiting personnel. Because of level funding over the last 3
    years, the WIC Director reported that Grady had recently eliminated two
    positions, a part-time nutritionist and a lactation assistant, and had three
    unfilled positions, for one nutritionist and two support staff. She
    indicated that hiring personnel takes 5 to 6 months because the hospital
    human resources office is short-staffed and procedures are slow. The
    eliminated nutritionist position provided on-call support to participants,
    while the lactation assistant supported breastfeeding promotion. Because the
    program was short one nutritionist, the Director had pulled the designated
    lactation consultant from her breastfeeding promotion and support duties in
    order certify eligible participants. The reassignment of the consultant and
    the elimination of the lactation assistant position had resulted in Grady's
    reducing its breastfeeding promotion and support efforts. In addition, the
    Director reported that management and nutritionists had to spend more time
    in clinics performing clerical duties, leaving little time for professional
    development, consultations, and chart notations. To cover vacancies in the
    clerical positions, the remaining clerks were working overtime on a regular
    basis.

    Table 19 shows the fiscal years 1998 and 1999 program expenditures the
    agency made by category. In fiscal year 1999, the expenditure per
    participant per month was $8.37. Ninety-six percent of Grady's expenditures
    were for personnel. In fiscal years 1998 and 1999, Grady expended no program
    funds for space or indirect costs.

                                   Fiscal year 1998       Fiscal year 1999

     Category                      Amount   Percent of    Amount    Percent of
                                            total                   total
     Personnel and benefits
     excluding expenditures for    $453,365 92%           $467,205  96%
     contracted personnel
     Equipment and supplies        31,530   6%            17,993    4%
     Facilities and related
     expenses including utilities,
     maintenance, rent and         0        0%            0         0%
     telephone
     Indirect costs                0        0%            0         0%
     All other                     5,393    1%            1,989     <1%
     Total                         $490,288 100%          $487,187  100%

    Note: Percents do not total to 100 due to rounding.

    The major nonprogram resources used by the program were in-kind
    contributions to cover all of the indirect costs incurred to operate the
    program, some nutrition and clerical staff support, and to subsidize a
    portion of the costs to provide benefits to WIC staff. According to
    information provided by a sponsoring agency official, the indirect costs GHS
    incurs to operate the program--including the space provided at no
    charge--would be about 18 percent of program expenditures, or about $88,000
    in fiscal year 1999. The WIC Director reported that the value of the
    GHS-provided nutrition and clerical staff support to be about $7,000. In
    addition, the sponsoring organization subsidized WIC employee benefits in
    1999 for a total of about $4,000. Taken together, these contributions
    (amounting to about $99,000) represented about 20 percent of program
    expenditures, or about 20 cents for every dollar in costs covered with
    program funds.

    In addition to the nonprogram resources provided by the sponsoring
    organization, Grady received a small grant ($2,000) from the March of Dimes
    in fiscal year 1998 for breastfeeding supplies and educational materials,
    and WIC dietitians received free continuing education via monthly
    teleconferences on nutrition issues provided by the Centers for Disease
    Control.

    Kanabec County's WIC program is one of 70 local agencies providing WIC
    services in Minnesota. In fiscal year 1999, the average monthly
    participation at these agencies was 90,200. According to our 1999 national
    survey of local WIC agencies, these local agencies averaged between 35 to
    18,309 participants monthly in fiscal year 1998. Over half of the Minnesota
    local agencies responding to our survey were operated by single county
    health agencies, and over three-quarters operated in rural areas.

    In fiscal year 1999, the state WIC program expended federal NSA grant funds
    totaling $13,064,382, or about $12.07 per participant per month. Since 1987,
    the state has also provided funding of about $3.7 million per year. In
    fiscal years 1998 and 1999 all the state funds were used for grants to local
    agencies. In fiscal year 1999, the amount of state funds expended for
    nutrition services and administration was $3,999,906, bringing the total
    expended (federal and state funds) for nutrition services and administration
    to $17,064,287. (Statewide, state funds covered about 31 cents in NSA costs
    for every dollar in costs covered with federal funds). About 39 percent of
    the total NSA expenditures, or $6,681,038, was made at the state level. The
    remaining 61 percent, or $10,343,249, in expenditures was made by the local
    WIC agencies. Minnesota distributes WIC program funds to local agencies on
    the basis of a cost per participant that is the same for all local agencies.
    In fiscal year 1999, the rate was $8.74 per participant. The state agency
    has a mechanism to recover and reallocate unspent funds on a quarterly
    basis. The state Director noted that another source of funding for some
    local agencies are the local tax revenues that the sponsoring agencies
    allocate to the program to cover NSA costs not covered by state or federal
    funding. She estimated that in 1999 local sponsoring agencies, statewide,
    contributed about $300,000 to local WIC agencies.

    Minnesota's WIC participant database system was fully automated in 1998. It
    is used to record and track participant information, generate predefined
    reports, and issue vouchers on demand. The state uploads the participant
    certification data from the local agencies' computers. At the time of our
    study, the state's ability to print reports was limited because the system
    could not search by specific data fields and run reports, such as a report
    on all participants by birth date. The state anticipates the system will
    have that capability in the future. Local agency program staff can obtain
    assistance with equipment maintenance, reports, and other questions via the
    state-funded WIC help desk.

    The state WIC program provides most of the training for local agency
    employees, including introductory sessions on basic WIC operations and
    conferences on nutrition education and breastfeeding promotion and support,
    and other program functions. The state WIC program provides one basic
    training class for new local agency staff. This training focuses on basic
    WIC program operations, such as certification and the use of the computer
    system, and nutrition education. In addition, the state WIC program holds an
    annual conference on nutrition education and breastfeeding promotion and
    administration; the conference offers training on issues such as working
    with the computer system, voucher issuance, and policy changes. The state
    WIC agency also funds operational and nutrition consultants to provide
    technical assistance to local agencies in the consultants' assigned
    geographic areas. Other types of support the state agency provides to local
    agencies include nutrition and breastfeeding materials, voucher stock, and
    statewide multimedia campaigns.

    Program

    The Kanabec County WIC program is located in Mora, Minnesota, and serves
    residents of Kanabec County, which had a population of about 14,000 in 1999.
    Mora is a small rural town with a population of about 3,100 in 1999, located
    approximately 60 miles north of Minneapolis. The area's terrain is flat and
    forested and contains several lakes. Snowfall during December and January
    averages about 10 inches a month, which can sometimes make travel difficult.

    Although the county's unemployment rate is low, a significant portion of its
    residents are poor. Kanabec County is the fifth poorest county in the state.
    In 1997, about 19 percent of its children were estimated to live in poverty,
    and the estimated average annual unemployment rate was 7.7 percent. In
    addition, between 1995 and 1997, Kanabec County's birthrate for teenagers
    ages 18 and 19 was over twice that of the rest of Minnesota. The county's
    population is predominantly white, with an estimated minority population of
    1.3 percent (African-Americans, American Indians, Eskimos and Aleuts, and
    Asian/Pacific Islanders).

    Sponsoring Organization

    The Kanabec County WIC program is sponsored by a single county health
    agency--the Kanabec County Public Health Department. Established in 1976,
    the WIC program operates in conjunction with other health department
    programs, such as those providing health check-ups, family planning, meals,
    and other community services. Agency officials consider the WIC program part
    of an integrated care management approach to public health. For example, WIC
    participants often stop to see the public health nurse and obtain their
    immunizations before going to the WIC office.

    The department charges the WIC program for indirect costs, such as services
    provided by the sponsoring organization's auditor and treasurer. In fiscal
    year 1999, the indirect costs charged the program were based on a cost
    allocation plan. The Department provides WIC with in-kind contributions,
    including dedicated space for the WIC office; the use of equipment; and
    support from health care staff, who provided some nutrition education, in
    conjunction with pre-natal care, to WIC participants.

    WIC Clinics

    The program provided all WIC services at one location, the Kanabec County
    Health Department building in Mora. Normal hours of operation were Tuesday
    through Thursday, 8:00 a.m. to 4:00 p.m. The clinic was open during lunch
    hours and stayed open later than normal hours, if needed. Mondays were
    reserved for other WIC duties. All of the WIC operations are conducted in
    the coordinator's office. (See fig. 6.) Participants typically waited in the
    hallway outside of the office for their appointment. On occasion,
    participants could view videotapes in the adjoining team room. Although
    Kanabec did not have satellite clinics, it did offer, on request, free or
    reduced-cost transportation to WIC participants.

    Staffing

    At the time of our study, the program employed one part-time staff member--a
    registered nurse--who serves as the WIC coordinator and is the CPA. (This is
    equivalent to a staff of .7 full time employees.) The WIC Coordinator was
    responsible for daily nutrition services and administration activities.
    Staff of the sponsoring organization provide minimal administrative or
    management support. (Another county nurse was certified to issue vouchers if
    the WIC Coordinator was unavailable.) The WIC Coordinator has been a
    registered nurse for 28 years and has been with the program for 5 years. She
    is paid on an hourly basis.

    Number of Participants Served

    The Kanabec WIC is one of the smallest local agencies in the state. In
    fiscal year 1998, it served a monthly average of 300 participants, and in
    fiscal year 1999, a monthly average of 313 participants. Table 20 shows the
    number of participants by category served in September 1998 and September
    1999. According to data from the state WIC agency, approximately 54 percent
    of the Kanabec participants in October 1999 were considered high-risk.

                                           Number of participants in:
     Participant category                  September 1998  September 1999
     Pregnant women                        6               20
     Breastfeeding women                   11              16
     Postpartum women not breastfeeding    50              30
     Infants                               24              73
     Children                              253             187
     Total                                 344             326

    Administration

    Participant Services

    During the certification or recertification session, the Coordinator
    routinely measured participants' height and weight and tested blood for
    anemia. If a participant was pregnant, she was asked to prospectively fill
    out the infant feeding survey indicating whether or not she planned to
    breastfeed. The WIC coordinator typically developed individual care plans
    for both low- and high-risk participants. The care plan specified
    behavior-related goals, the nutrition education provided, and documentation
    of follow-up visits.

    Potential participants were typically scheduled for a certification session
    after pre-screening for eligibility. If the Coordinator determined that the
    applicant was eligible for WIC benefits, she scheduled the applicant for an
    appointment and either sent or gave the forms to the applicant. Kanabec had
    a policy of scheduling separate appointments for certification and voucher
    pick-ups to manage the daily flow of participants and keep waiting times to
    5 to 10 minutes. It was not common for participants to be seen on a walk-in
    basis. Because only the Coordinator handles certifications and other
    appointments, she scheduled 6 to 8 days per month for certification and 8
    days a month for voucher pick-up. For other days, she scheduled appointments
    with participants who required more of her time, such as those with more
    in-depth nutritional needs. She attempted to schedule WIC appointments for
    participants who also participated in the Maternal Child and Health Program
    to coincide with appointments for that program. The Coordinator routinely
    called participants to remind them of upcoming appointments.

    In response to the loss of clerical support, the Coordinator decided to
    change the monthly flow of participants by changing voucher issuance for
    low-risk participants to every 3 months. According to the WIC coordinator,
    tri-monthly issuance of vouchers provided some benefits to participants by
    reducing the amount of travel to the clinic, which is especially important
    during bad winter weather. This, in turn, has decreased the number of broken
    appointments. Vouchers were issued to high-risk participants monthly or
    bimonthly. The Coordinator typically did not call participants to follow up
    on missed appointments.

    Kanabec WIC made referrals on an as-needed basis. As required by the state,
    the Coordinator fills out forms when making health care referrals. The
    referrals to the county maternal child and health nurse were also tracked
    manually. Every 6 months the Coordinator asked whether the child participant
    had received the proper immunizations. If the child needed immunizations,
    she referred the child to the public health nurse and coordinated the WIC
    appointment with the immunization appointment. Kanabec did not use a form
    when referring participants to other providers, such as social services, but
    rather provided a listing of providers with the necessary contact
    information. If applicants were not eligible for the WIC program, the
    coordinator referred them to a community food program. Although the
    community food program did not offer nutrition education, it did provide
    children and mothers with extra food for up to 1 year. The WIC Coordinator
    will typically follow up on the outcome of a referral to the county public
    health nurse. With regard to voter registration, the Coordinator had the
    voter registration cards visible in the office, but did not ask the
    participants whether they had registered.

    Nutrition Education

    Nutrition education was typically provided during 15- to 20-minute
    one-on-one sessions during certification, recertification, and voucher
    pick-up appointments. The certification appointment that we observed lasted
    about 30 minutes. The Coordinator reported, and we observed, that some
    nutrition education and breastfeeding promotion and support were also
    provided during the nutrition assessment process when the Coordinator
    provided feedback on the participant's reported diet. The contents of
    individual nutrition education sessions were tailored in response to such
    information as diet, weight, and height. For instance, she explained to the
    mother of a formula-fed newborn that the baby did not need to be given
    water, juice or any other food. The Coordinator assessed the participant's
    diet and weekly food intake record to determine the areas for focus during
    counseling. She referred participants needing medical nutrition counseling
    to the registered dietitian at local hospital. She also provided brochures
    to supplement the nutrition education discussions, and the agency displayed
    posters illustrating general nutrition information. In addition, nutrition
    education was delivered via promotional displays, newsletters, and
    videotapes. The WIC Coordinator generally directed the discussion to the
    caregiver, although she would sometimes ask children what they ate.

    Since the staff of the sponsoring public health agency carries out most
    program management responsibilities, the WIC Coordinator could spend more
    time providing nutrition services. However, she indicated that the agency
    did not have sufficient resources to carry out the program's nutrition
    education requirements. For instance, she had not provided group counseling
    sessions since she assumed additional administrative tasks following the
    loss of a part-time clerk and had to spend time automating the certification
    process.

    Breastfeeding Promotion and Support

    The WIC Coordinator, who is also the breastfeeding coordinator, provides
    breastfeeding promotion and support services, usually in one-on-one
    counseling, to both pre-natal and postpartum mothers, during certification,
    recertification, or voucher pick-up appointments. In addition, the
    Coordinator distributes breastfeeding promotional materials and provides
    space at the clinic for breastfeeding, if needed. Although the Coordinator
    has received breastfeeding training, she is not a certified lactation
    consultant. The nearest consultant, who works for another local WIC agency,
    is approximately 30 miles away. The content of breastfeeding counseling
    includes the advantages, myths about, and barriers to breastfeeding, such as
    the barriers mothers face when returning to work. In particular, the
    coordinator will review the survey that she gives to all of the prenatal
    mothers and use the responses as a basis for discussion. In order to sustain
    the mother's breastfeeding, the Kanabec Coordinator followed up on the
    status of the mother's breastfeeding during the next appointment or, if she
    had time, called.

    In August 1999, Kanabec WIC had a breastfeeding initiation rate of 35.1
    percent and 8.5 percent for infants about 3 to 6 months old. The sponsoring
    agency official noted that this percentage can vary greatly from month to
    month because of the small number of participants overall. In December 1999,
    Minnesota WIC reported a breastfeeding initiation rate of over 57 percent
    statewide.

    Program Administration

    Maintaining participants' records. Until a computer system was installed in
    May 1998, the WIC Coordinator collected and maintained all of the
    participant information by hand. Kanabec WIC now maintains participant
    information in both the computer and in paper files. At the time of our
    study, the computer system collected all the information to certify and
    recertify participants, evaluated the information to determine eligibility,
    set the nutritional risk level for the participants, and printed vouchers.
    Information still maintained in paper records included participants'
    responses to standard questions regarding infant feeding and participants'
    diet, and notations of the nutrition education provided. The Coordinator
    could also use the system to generate a few simple reports. More
    sophisticated reports required the help of skilled state employees.

    Managing vendors. Kanabec reported having little or no role in vendor
    management. The WIC Coordinator tried to resolve the few vendor or
    participant complaints that she received each year.

    Outreach. The Kanabec WIC coordinator conducted outreach by distributing WIC
    brochures at the hospital and annual county fairs, as well as to local
    organizations that serve the homeless and to local community groups.
    Participants also typically heard about the WIC program through friends and
    family, from other social service programs, and from the local family
    planning clinic collocated with the WIC agency.

    Travel. The Coordinator did not have to travel to provide nutrition services
    to participants. Travel expenditures were made for trips to state
    conferences or training.

    Retaining and recruiting personnel. The WIC coordinator reported having some
    problems maintaining an adequate staffing level. As a result of a cut in
    funding, Kanabec reduced the scheduled hours for its clerk, who subsequently
    resigned in May 1999, in part, because of the reduction in hours. After this
    resignation, the WIC Coordinator took on some of the clerical duties,
    leaving less time for nutrition education and counseling.

    Table 21 shows the agency's fiscal years 1998 and 1999 program expenditures
    by category.

                                 Fiscal year 1998        Fiscal year 1999

     Category                    Amount      Percent     Amount      Percent of
                                             of total                total
     Personnel and benefits
     excluding expenditures      $35,279.07  89%         $27,006.30  89%
     for contracted personnel
     Contracted personnel        0           0%          0           0%
     Equipment and supplies      500.28      1%          601.35      2%
     Facilities and related
     expenses including
     utilities, maintenance,     970.11      2%          568.27      2%
     rent and telephone
     Indirect costs              2,211.99    6%          1,866.15    6%
     All other                   762.09      2%          346.82      1%
     Total                       $39,723.54  100%        $30,388.89  100%

    Kanabec's program expenditures include both federal and state WIC program
    funds. Its expenditure per participant per month in fiscal year 1999 was
    $8.09.

    The program's major nonprogram resources were in-kind contributions from the
    sponsoring organization of dedicated space for the WIC office, the use of
    equipment, and support from health care staff. The county health official
    estimated the value of these contributions to be $3,000 for fiscal year
    1999. This represented about 6 percent of program expenditures, or about 6
    cents for every dollar in costs covered by program funds.

    In addition, staff from the sponsoring organization spent up to several
    hours a month providing general administrative support to Kanabec WIC. Other
    minor support from the sponsoring organization, not covered by indirect
    costs, were supplies and materials. In addition, a national medical supply
    company donated infant feeding supplies. No estimate was available of the
    value of these additional nonprogram resources.

    Long Beach WIC is one of 83 local agencies providing WIC services in
    California. In fiscal year 1999, the average monthly number of participants
    served by these local agencies was 1,229,495. According to our 1999 national
    survey of local WIC agencies, the local WIC agencies in California range in
    size from about 400 to 307,000 average monthly participants. Of the 67
    California local WIC agencies that responded to our survey, 25 operated in
    urban settings, 20 in rural settings, 10 in suburban settings, and 12 in
    mixed geographic settings.

    In fiscal year 1999, the California WIC program expended about $170,805,225
    in federal NSA grant funds, or about $11.58 per participant per month.
    California provided no state funds for nutrition services and
    administration. About 25 percent of NSA expenditures, or $43,101,972, were
    made at the state level. Of this amount, about three-quarters was used for
    state-level operations and about one-quarter was used for costs associated
    with providing state support to local agencies, primarily for operating the
    state's case management information system and for purchasing the nutrition
    education materials provided to local agencies. The remaining $127,703,253,
    or 75 percent, of California's WIC expenditures was made by the local WIC
    agencies. California distributes funds to local agencies using a formula
    that results in smaller agencies receiving more per participant per month
    than larger agencies. The formula has two elements: (1) a base allocation
    that depends on an agency's caseload and (2) a per participant per month
    cost rate.

    The California WIC program implemented its statewide integrated automated
    participant and vendor information system in 1995. The computer system is an
    on-line real-time system. Once local agency employees log onto it, they have
    immediate access to all information, restricted only by their level of
    clearance. Local agency staff enter information obtained from participants
    during certification and follow-up meetings. They use the system to
    calculate income eligibility, determine nutritional risk priority, recommend
    a food package tailored to participants' needs and preferences, schedule
    appointments, and interface with Medi-Cal, California's Medicaid system. The
    system also assists staff with referrals to other public assistance programs
    for which the applicant may be eligible. An advantage to an on-line,
    real-time system is that if someone attempts to enroll at one agency while
    actively enrolled at another agency elsewhere in the state, the system
    recognizes this attempt and alerts the WIC staff.

    The state-level agency provides hardware and software, computer support,
    technical assistance, and the training necessary for the local agencies to
    use the system. It also provides local agencies with nutrition education and
    breastfeeding promotion materials, training, and assistance in fraud and
    abuse prevention efforts, and conducts statewide outreach campaigns.

    Program

    The Long Beach WIC program serves the city of Long Beach, which is located
    on the southern California coast in Los Angeles County, with a 1997
    estimated population of about 437,800.

    According to 1990 Census data, 17 percent of all Long Beach residents lived
    below the poverty level. The data indicated that Long Beach was ethnically
    diverse, with 24 percent of the population Hispanic, 13 percent
    African-American, and 13 percent Asian/Pacific Islander. In March 2000, the
    WIC Director reported that approximately 78 percent of Long Beach WIC
    participants do not speak English as a primary language.

    Sponsoring Organization

    Long Beach WIC, which has operated in the city for more than 23 years, is
    sponsored by the city's Department of Health and Human Services, one of only
    three independent city-operated health jurisdictions in California. The WIC
    Director described the WIC program as a gateway to the Department's other
    programs such as lead poisoning prevention, child health and disability,
    immunization, and the prenatal clinic.

    The Department charges the WIC program for indirect costs, such as
    personnel, accounting, and postage. However, because of a state limit on the
    amount of indirect costs that can be charged to the program, only a portion
    of the indirect costs the Department incurs are charged to the WIC
    program.18 The Department also provides WIC with in-kind contributions of
    space for two sites. Other in-kind contributions from the sponsoring agency
    included utilities for two sites, equipment, furniture and translation
    services.

    WIC Sites

    In California, WIC clinics are referred to as WIC sites. This was done to
    distinguish the role of the California WIC program from the health care
    system. The main Long Beach WIC site is collocated with the Department of
    Health and Human Services and serves an average of 9,300 participants each
    month. To make services more convenient to participants with limited
    transportation, Long Beach has four other sites--on a hospital campus, in a
    stand-alone building, in a city-owned health facility, and in a strip mall.
    The number of participants being served at three of the four additional
    sites ranges from a monthly average of about 4,000 to 8,000. The fourth site
    opened in February 2000 and at that time was serving about 257 participants.
    The WIC Director expected that site to serve a monthly average of about
    5,000 participants after 3 months of operation.

    The sites operated Monday through Friday. Two of the sites operated from
    7:30 a.m. to 6:00 p.m.; two from 7:30 a.m. to 5:30 p.m.; and one, the
    newest, from 8:00 a.m. to 5:00 p.m. On Monday and Tuesday, the main site had
    extended hours to 7:00 p.m., as well as every Saturday from 8:00 a.m. to
    noon.

    Staffing

    At the time of our study, Long Beach WIC had 53 staff, and all but 2 worked
    full-time, for a total of 52.2 full-time equivalent staff. The WIC Director
    is a registered dietitian who has been with the program since 1984. Fifteen
    of the staff were also registered dietitians. Administrative registered
    dietitians developed local agency policy and procedures as needed to
    implement new regulations, assessed staff training needs in nutrition
    education, and developed and implemented staff training programs on
    nutrition education. Twenty-one of the staff were nutrition aids or
    assistants who were CPAs. Seventeen of the staff were clerical or support
    staff. Of the 53 staff at the agency, 28 were considered contract
    consultants who are not permanent employees of the sponsoring organization
    and therefore did not receive health or vacation benefits. The sponsoring
    organization was exploring the option of converting the contract WIC
    employees to city employees with benefits, as a means of improving staff
    retention. Converting these employees would increase personnel costs for
    Long Beach WIC, according to Department staff.

    Each of the agency's five sites had a registered dietitian as a supervisor
    and a team leader. The supervisor provided counseling to high-intervention
    participants and supervised the paraprofessional staff. The team leader was
    responsible for assisting with nutrition education by teaching classes and
    keeping education materials up-to-date.

    Number of Participants Served

    Long Beach WIC's monthly participation rate increased from 9,000 in 1992 to
    28,452 in October 1999. Table 22 shows the number of participants by
    category served in October 1999. In August 2000, according to the WIC
    Director, approximately 18 percent of the agency's participants served in an
    average month were considered high-intervention.19

                                           Number of participants
     Participant category                  September 1998  October 1999
     Pregnant women                        2,842           2,639
     Breastfeeding women                   1,699           1,725
     Postpartum women not breastfeeding    2,100           2,007
     Infants                               6,136           6,063
     Children                              17,231          16,018
     Total                                 30,008          28,452

    Administration

    Participant Services

    Long Beach WIC, in accordance with California WIC policies, strongly
    encouraged participants to obtain their physical measurements (such as
    height and weight) and the results of blood tests from their Medi-Cal
    provider, the state's Medicaid program, or private physician, thus
    decreasing the amount of time WIC staff need for this activity. In
    California, WIC staff do not do blood work to assess medical conditions such
    as anemia. Requiring this information from a medical provider has several
    advantages: it encourages the applicant to visit a medical provider,
    requires less staff time, and eliminates the need for specialized staff. If
    an applicant does not have all of the information needed to determine
    eligibility, the applicant is typically approved for 1 month's participation
    and must bring the needed information at the next visit. Initially, all
    participants are seen by a CPA. Participants determined to be
    high-intervention are typically seen the following month by a registered
    dietitian. In some instances, a registered dietitian would see
    high-intervention participants the same day. Long Beach, in accordance with
    state requirements, required that a nutritionist or a registered dietitian
    develop an individual care plan for all high-intervention participants.

    Since Long Beach schedules appointments in blocks of time, staff report that
    participants are seen on a "first-come, first-served" basis, contributing to
    a typical 30-minute waiting time. One site reported about 25 percent of its
    appointments were walk-ins, and another reported that as much as 40 percent
    were walk-ins. Long Beach uses an automated telephone calling system to make
    recorded calls reminding participants of upcoming appointments and to
    reschedule missed appointments. According to the WIC Director, the missed
    appointment rate at the end of any given month is less than 10 percent.

    The frequency of voucher issuance varies by participant type and risk
    category as shown in Table 23.

     Type of participant    Frequency of voucher issuance
     Pregnant woman         Monthly
     Infant, first 2 months Monthly
     Infant, 3 to 12 months Monthly/bimonthly
     Child                  Monthly/bimonthly
     High-intervention      Monthly/bimonthly

    Long Beach WIC typically refers its participants to other service providers
    by giving them access to a listing of providers. Two of Long Beach's sites
    have a binder of referral information available at the reception desk for
    use by applicants and participants. Staff note the immunization status of
    child participants in their case record and refer participants to
    immunization services as necessary. In addition, they offer a class on the
    benefits of immunizations. Long Beach also distributes a referral guide to
    participants that lists services such as low-cost health clinics. WIC does
    not provide the names of, or recommendations to, specific doctors. In
    addition to counselors, receptionists answer questions and provide brochures
    and pamphlets as requested on a variety of topics, including child care and
    parenting. Long Beach staff are not expected to note in the participant data
    system to whom the participant was referred. The staff indicated that they
    did not always follow-up with the participant on referrals.

    Regarding voter registration, staff asked participants whether they were
    registered to vote during the enrollment appointment and noted the answer on
    the back of the participant's file folder. The program also has voter
    registration forms available.

    Nutrition Education

    Long Beach WIC presented some type or level of nutrition education at almost
    every participant contact. One-on-one nutrition education discussions began
    during the nutrition assessment phase of the certification process, when the
    dietitian provided feedback on the participant's reported diet. The
    certification appointment that we observed lasted about 45 minutes. Staff
    typically discussed aspects of nutrition information and diet informally
    during the certification or recertification process or during any other
    contact with a participant and handed out brochures to supplement the
    discussion. The registered dietitians provided nutrition education to
    high-intervention participants during one-on-one counseling sessions. They
    also referred participants who needed medical nutritional counseling to
    registered dietitians in medical settings. Long Beach WIC also provided
    nutrition education, particularly to low-intervention participants, through
    15-minute classes that addressed nearly 40 different topics. These classes
    were offered both to individuals and to groups of between 5 and 20
    participants. For instance, during an individual class given to the mother
    of a 2-month old infant, the CPA advised the mother to avoid the
    ready-to-feed formula that was giving the baby diarrhea and use the powdered
    formula instead. In November 1999, these short classes were being offered
    about 12 times per day at each of the sites. According to the nutrition
    education coordinator, about 55 percent of the nutrition education is
    provided in one-on-one sessions, and the remaining 45 percent is provided in
    group sessions. She indicated that there was inadequate time to develop new
    classes.

    Long Beach WIC also provided nutrition education through brochures and
    pamphlets, educational displays relating to nutrition such as posters
    illustrating general nutrition information such as the Food Pyramid, and
    videos. Pamphlet and booklet topics included nutrition during pregnancy and
    infant feeding. Nutrition education was also provided by playing WIC or
    nutrition-related videotapes in the waiting rooms. (See fig. 7). Video
    topics observed at one site in Long Beach included cooking with beans and
    infant safety.

    To serve its multilingual population, Long Beach WIC hired bilingual staff
    to provide nutrition education to non-English-speaking participants. Classes
    were taught in several languages, including Spanish, Khmer, Laotian,
    Vietnamese, and Hmong. Generally, classes were geared toward the adult
    participants. Long Beach staff indicated that they recently taught a pilot
    class on nutrition geared to children 1 to 5 that was well-received by
    participants and caregivers. However, according to the nutrition education
    coordinator, the program lacked the staff to continue to teach this type of
    class.

    Breastfeeding Promotion and Support

    All of the Long Beach WIC staff were trained to promote breastfeeding.
    Breastfeeding information and education is provided to all pregnant
    participants at the first appointment and staff distributed promotional
    materials to the participant at that time. The state agency requires local
    agencies to provide breastfeeding education and to make at least two
    contacts with the new mother after delivery to encourage breastfeeding. Long
    Beach WIC staff visited two hospitals in the city once a week to provide
    breastfeeding support to all new mothers. Long Beach WIC also used its own
    staff to develop breastfeeding and nutrition education brochures for its
    Cambodian participants.

    In fiscal year 1999, about 7 percent of Long Beach's infant participants
    were exclusively breastfed and about 20 percent were partially breastfed. In
    March 1999, California WIC staff reported that the statewide average rates
    for exclusively and partially breastfed WIC infants were 10 and 24 percent,
    respectively.

    Program Administration

    Maintaining participants' records. Long Beach WIC tracks participant data on
    a real-time basis and issues food vouchers using the state system. Because
    of the system, the agency needs to maintain only minimal paper records.
    During a participant's initial visit, staff enter all participant
    information into their computer system to establish a participant record.
    The system automatically identifies the participants' level of nutritional
    need (intervention level) on the basis of this information. According to the
    WIC Director and staff, the state system has significantly improved the
    workflow at the sites and reduced participants' waiting times. However, on
    occasion, the system goes down. When this happens, participants return to
    the site later to pick up their food vouchers or wait at the site for
    vouchers to be issued by hand or for the computer to come back on line. To
    minimize the time participants spend at the site during a return visit,
    staff issued participants a special pass that allows them to get served
    immediately.

    Managing vendors. Local agencies in California have no role in vendor
    management. Long Beach staff will send participant complaints about vendors
    to the state and to the individual vendors.

    Outreach. In fiscal year 1998, staff contacted local school officials, other
    social service providers, officials at local hospitals or medical centers,
    area physicians, local community groups, and local health associations or
    professional groups. They also used display booths or tables at community
    fairs, mailed program literature to interested persons, and encouraged
    referrals by participants. Long Beach WIC also had written agreements, in
    1999, with six other Department of Health and Human Services programs and
    other organizations. These agreements included provisions for the mutual
    referral of participants, inclusion of medical data when appropriate in
    referrals, and regular planned reviews of referral outcomes.

    Travel. WIC staff are typically assigned to work at one site location and do
    not travel among the sites to deliver program services. However, staff do on
    occasion travel to other sites to attend training.

    Retaining and recruiting personnel. The WIC Director indicated that the
    program had several unfilled positions and had difficulty identifying
    candidates for the positions because it was unable to offer competitive
    salaries. Salaries for registered dietitians and nutritionists at the Long
    Beach WIC are not competitive with salaries offered by private sector,
    according to the Director. In order to stretch the funds available for
    personnel, Long Beach WIC began, over 20 years ago, to employ contract
    employees, who do not receive health or vacation benefits. As mentioned
    above, 28 of the staff were contract employees. The WIC Director also
    reported having some problems maintaining an adequate staffing level and a
    staff turnover rate of about 15 percent. According to sponsoring
    organization officials, the WIC program has become a training ground for
    nutritionists, who then leave for higher-paying jobs. To improve staff
    retention, the sponsoring agency was exploring the option of converting the
    contract employees to city employees with benefits.

    Table 24 shows the fiscal years 1998 and 1999 program expenditures made by
    Long Beach WIC by category. The program expenditure per participant per
    month in fiscal year 1999 was $8.43.

                                 Fiscal year 1998        Fiscal year 1999

     Category                    Amount     Percent of   Amount      Percent of
                                            total                    total
     Personnel and benefits,
     excluding contracted        $1,362,422 47%          $1,470,586  50%
     personnel
     Contracted personnel        942,968    33%          770,045     26%
     Equipment and supplies      31,086     1%           69,240      2%
     Facilities rental,
     including utilities,
     maintenance, and            147,466    5%           200,726     7%
     telephone
     Indirect costs              142,500    5%           147,500     5%
     All other                   272,003    9%           286,817     10%
     Total                       $2,898,444 100%         $2,944,914  100%

    Note: Totals may not add to 100% due to rounding.

    During fiscal years 1998 and 1999, Long Beach WIC also received a grant of
    about $238,000 from the California WIC program for a 2-year smoking
    cessation program.

    The program's major nonprogram resources were in-kind contributions from the
    sponsoring organization, a portion of the indirect costs incurred to operate
    the program, and space. Regarding the indirect costs, according to the
    sponsoring organization's cost allocation plan for 1998, the indirect cost
    rate for WIC was 15 percent of total direct operating expenses, or $415,504.
    In accordance with state WIC regulations, which limit indirect costs to 10
    percent of expenditures for personnel excluding benefits, Long Beach WIC
    paid $142,500 in indirect costs in fiscal year 1998. The Department of
    Health and Human Services covered the balance of the indirect costs the Long
    Beach WIC incurred to operate the program--$273,004. Regarding the space
    contribution, the sponsoring organization's in-kind contributions of space
    at two sites were valued at $60,000. The total of these two contributions,
    approximately $333,000, represented about 11 percent of program expenditures
    in fiscal year 1998, or about 11 cents in nonprogram resources for every
    dollar in costs covered with program funds.

    We did not obtain estimates of the value of other nonprogram resources, such
    as equipment, furniture, and translation services.

    York WIC is one of 25 local agencies providing WIC services in Pennsylvania.
    In fiscal year 1999, the average monthly number of participants served by
    these agencies was 238,203. That year, the agencies ranged in size from
    about 1,400 to 48,000 participants, on average, each month. Of the 24
    Pennsylvania local agencies that responded to our 1999 nationwide survey of
    local WIC agencies, 14 were operated by county or community health agencies,
    5 by community action agencies, 2 by hospitals, and 3 by other types of
    organizations. Ten of the agencies responding to the survey operated in
    rural settings, 4 in urban, 2 in suburban, and 8 in mixed geographic
    settings.

    In fiscal year 1999, Pennsylvania expended federal NSA grant funds totaling
    $35,315,599, or about $12.35 per participant per month. Pennsylvania
    provided no state funds for WIC nutrition services and administration. About
    24 percent, or $8,571,993, of NSA expenditures were made at the state level.
    The remaining 76 percent, or $26,743,606, was made by the local WIC
    agencies.

    Pennsylvania distributes WIC program funds to local agencies each year
    largely on the basis of a formula that uses three per participant per month
    rates. The first and highest rate is for the first 15,000 participants
    served by an agency. Successively lower rates are used for the next 10,000
    participants and for over 25,000 participants, respectively. Such a formula
    provides somewhat lower per participant per year funding to agencies with
    caseloads over 15,000. In fiscal year 2000, only 3 of the state's 25 local
    agencies had caseloads over 15,000. Some program funds are distributed to
    local agencies to cover special needs, such as migrant programs or clinic
    relocations.

    The Pennsylvania WIC participant database system was first automated in 1983
    and upgraded in 1991. The statewide-automated system is used, among other
    things, to record and track participant information, assign nutritional risk
    codes to participants, track immunization status, track referrals, run
    reports, create custom food packages and print food instruments. The state
    conducts nightly batch processing of the participant information uploaded
    from the local agencies' computers. Local agency program staff can obtain
    system technical assistance and support from the state WIC agency, such as
    assistance with managing reports and system development.

    The types of support the state agency provides to local agencies include
    guidance on state policies and procedures; forms; brochures in several
    languages; technical assistance, such as handling participant abuses (e.g.,
    dual participation); and nutrition and breastfeeding guidance. The state
    program also provides training to local agency directors through statewide
    meetings held three times a year.

    Program

    York WIC serves the county of York, which is located in south-central
    Pennsylvania. The topography of York County consists primarily of rolling
    hills, bordered on the east by the Susquehanna River. The county is a
    combination of urban and rural communities. Its estimated population in 1997
    was 370,518, while the estimated population for the City of York was 40,087.
    The average unemployment rate for York County was 3.7 percent in 1998, while
    the rate for the City of York was reported in 1999 to be about 2 percent
    higher than the county rate.

    In 1995, about 6.5 percent of the county population was living below the
    poverty level. The per capita income for York County in 1996 was $23,610,
    while the City of York's per capita income was $10,485. In 1996, an
    estimated 16.4 percent of the families and 31.2 percent of the children in
    the City of York lived in poverty. According to 1997 estimates, about 72
    percent of City of York residents were white, about 21 percent
    African-American, and about 8 percent Hispanic. In April 1999, approximately
    70 percent of York's WIC participants were white, about 14 percent were
    African-American and about 15 percent were Hispanic.

    Sponsoring Organization

    The York WIC program is administered by the Community Progress Council
    (CPC), a community action agency. Chartered in 1965, CPC is governed by a
    board of Directors representing low-income, business sector, and elected
    community members. In addition to the WIC program, which it has operated
    since 1975, CPC operates Head Start of York County; the Foster Grandparents
    program, a Welfare-to-Work program, a Case Management program, a Department
    of Community Centers, and the Senior Community Services Employment Program.
    (The Case Management program provides homeless and low-income families and
    individuals with assessment, referral, and follow-up services aimed at
    building self-sufficiency and increasing community involvement.)

    CPC charges the WIC program for some of its indirect operational costs,
    including costs related to management and administrative personnel,
    auditing, and postage. In fiscal year 1999, the indirect costs the
    sponsoring organization charged the program were based on a rate of 6.3
    percent of program expenditures for personnel, excluding benefits. According
    to the Executive Director of CPC, the amount charged to the program
    represented only part of the indirect costs incurred to operate it. The
    remaining indirect costs were covered by CPC's Community Services Block
    Grant. CPC also provided WIC with in-kind contributions in the form of one
    part-time administrative support staff whose pay was covered by stipends
    from a Department of Labor grant. The sponsoring organization also provided
    some miscellaneous contributions, such as office furniture and supplies.

    WIC Clinics

    To provide WIC services throughout York county, York WIC operated nine
    clinics. The main clinic is collocated with CPC's Case Management program in
    downtown City of York. In addition to the main clinic, the York County WIC
    program operated eight satellite clinic sites. One, referred to as Noell, is
    located in the City of York, and seven are located in the boroughs of Delta,
    Dillsburg, Dover, Hanover, Lewisberry, New Freedom, and Red Lion. Normal
    hours of operation for the main clinic were 8:00 a.m. to 5:00 p.m., 5 days a
    week. To provide extended hours for participants, the main clinic was also
    open 3 days a month until 6:30 p.m. The York Director said it was a hardship
    for one of her staff to work evening hours because the amount she paid for
    childcare during the evening was more than she earned for those hours. Most
    of the program's participants receive services at the main City of York
    site. The hours of operation at the satellite sites varied, with most
    operating 1 or 2 days a month.

    The satellite sites all share space with other health and social service
    programs, such as a local food pantry, a family health clinic, an
    immunization clinic, and a clothing bank. Staff noted that some participants
    who travel to satellite offices feel that there is a lack of privacy in
    these settings because several nutritionists are working with participants
    in the same space, at the same time, and discussions can be overhead.

    Staffing

    At the time of our study, York WIC had 20 staff: 10 full-time and 10
    part-time, for a total of 16.2 full time-equivalent staff. The WIC Director
    has worked for WIC since 1975 and has a B.S. in Nutrition. In addition to
    the Director, eight staff members, including a nutrition education
    coordinator, four nutritionists, two nurses, and one lactation consultant,
    were CPAs. Other staff included an administrative assistant, a secretary,
    four nutrition assistants, four clerks, and a janitor. The WIC Director is
    the only salaried employee; the rest of the staff are paid hourly. Staff are
    assigned to provide services at the satellite sites on a rotating basis.

    Number of Participants Served

    In fiscal year 1999, the average monthly participation was 4,859
    participants. Table 25 shows the number of participants by category served
    in September 1998 and November 1999. The WIC Director was not able to
    provide an estimate of the percent of participants considered high-risk in
    an average month in fiscal year 1999. Although participants are identified
    as high-risk in their individual paper records, the data system does not
    identify risk category.

                                           Number of participants
     Participant category                  September 1998  November 1999
     Pregnant women                        534             554
     Breastfeeding women                   133             107
     Postpartum women not breastfeeding    508             462
     Infants                               1,369           1,417
     Children                              2,320           2,297
     Total                                 4,864           4,837

    Administration

    During certification and recertification sessions, participants were seen by
    a CPA, but the nutrition assistant in some instances collected the income
    and residency information, measured height and weight, and tested blood for
    anemia. (Both CPAs and nutrition assistants were able to perform blood
    tests.) During the initial sessions, a CPA would typically assess the
    participant's medical or nutritional risk, and, if the applicant was
    eligible, prescribe a food package, explain program policies and procedures,
    and provide some nutrition education. One senior staff member indicated that
    in performing the assessment she only reviewed the participant's diet
    through a diet recall protocol if she could not find a medical reason to
    establish eligibility or if the participant had questions about her diet.
    During the initial session, either a CPA or nutrition assistant also checked
    on and recorded the immunization status of child participants and issued
    vouchers. Staff reported, and we observed, that some nutrition education and
    breastfeeding promotion and support was also provided during the nutrition
    assessment process.

    According to the nutrition education coordinator, a nutritionist was
    required to develop an individual care plan for all high-risk participants.
    These plans included information on the nutrition education topics
    addressed, the materials provided to the participant, and specific reasons
    for any change in a participant's risk status. These plans, according to the
    nutrition education coordinator, were typically communicated to the
    participant in a combination of written and/or oral suggestions. The care
    plan is kept in hard copy in the participant's file.

    Vouchers were typically issued to all participants on a bimonthly basis. The
    CPAs manually created the first set of vouchers for new participants.
    Subsequent vouchers were printed in advance of the next scheduled pick-up
    appointment by the participant data system.

    The staff typically scheduled appointments for certification and
    recertification sessions. Walk-ins were typically scheduled for a
    certification session at a later date because applicants may not have all
    the required documentation needed for certification. The main clinic
    frequently got walk-ins for voucher pick-up, but staff discouraged the
    practice. Staff indicated that waiting times ranged from 10 minutes to an
    hour, depending on the number of staff working on a given day. When time was
    available, staff called new participants to remind them of upcoming
    appointments and sent reminder postcards to participants who missed
    appointments. York WIC, as required by the state, tracked the "no-show" rate
    for recertification and voucher pick-up appointments. Recent no-show rates
    for recertification and voucher pick-ups were about 8 percent and 10 percent
    in November 1999 and May 2000, respectively.

    According to the WIC Director, at initial certification participants
    received a brochure that provided information on a number of local service
    providers. She indicated that referrals were commonly made to the state's
    medical assistance program (Medicaid), CPC's case management program, Food
    Stamps, cash assistance, medical providers, food pantries, and shelters.
    Typically, the participant was given the brochure and the phone number for a
    specific service provider. Staff normally entered information about
    referrals in the participants' files as well as information related to
    eligibility for medical assistance, cash assistance, and food stamps.
    Information in the participant database could be used to track the number of
    referrals made to the different types of service providers. Staff reported
    that they did not always follow-up with the participant on the outcome of
    referrals that had been made.

    Regarding voter registration, in accordance with state policy, York staff
    ask each adult participant if she is registered to vote, note the response
    in the participant's file, record the response on a data collection form,
    enter the response into the data system, give the voter registration form to
    the participant, and assist the participant in completing it. York staff
    also deliver completed forms to the voter registration office.

    Nutrition Education

    Nutrition education was typically provided in one-on-one sessions with both
    low- and high-risk participants during certification, recertification, and
    voucher pick-up appointments. The certification and recertification
    appointments that we observed lasted from 20 minutes to over an hour.
    One-on-one nutrition education discussions began during the nutrition
    assessment phase of the certification process, when the CPA provided
    feedback on the participant's reported diet. At many of the appointments
    that we observed, the content and the duration of the nutrition education
    provided were minimal. For example, participants were asked brief
    nutrition-related questions; however, there was little, if any, discussion
    of a participant's specific nutrition situation or of general nutrition
    education issues. One nutritionist told us that because staff try to adhere
    to the allotted time of 30 minutes per certification and recertification
    appointment, not much time was available to provide education after dealing
    with eligibility, assessment, and voucher issuance issues.

    York participants also received general nutrition education from the
    brochures that staff distributed to supplement their nutrition education
    discussions. Brochures on numerous nutrition topics and display posters were
    also available in the main clinic's waiting area. (See fig. 8.) The WIC
    Director told us that the clinics normally played WIC orientation,
    nutrition-related, or food demonstration videos in the waiting room, but, at
    the time of our study, the videotape machine was out of order. The WIC
    Director told us that the program does not offer group classes because space
    is not available at the clinics.

    To serve non-English-speaking participants, York hired bilingual staff to
    provide nutrition education to Hispanic participants. The local hospital's
    lactation consultants referred Hispanic patients to York WIC for
    breastfeeding services because the hospital does not have employees who can
    speak or translate Spanish. York WIC had nutrition and breastfeeding
    materials available in Spanish, Vietnamese, Laotian, and Cambodian. York WIC
    staff did not provide nutrition education directly to child participants.
    They did distribute sipper cups and toothbrushes to the children to promote
    good dental health.

    Breastfeeding Promotion and Support

    Breastfeeding at York WIC was typically promoted through one-on-one
    counseling and/or handouts. The breastfeeding coordinator reported that all
    of the staff--including the clerks--had been trained to promote and
    encourage breastfeeding. However, we observed that during the certification
    appointments for two pregnant women, breastfeeding education or counseling
    was minimal or did not occur at all. One of the women was only asked about
    her breastfeeding intentions while no mention of breastfeeding was made to
    the other woman. The breastfeeding coordinator, who is also a lactation
    consultant, spent much of her time certifying and recertifying participants.
    She indicated that if more staff were available she would be able to devote
    more of her time promoting breastfeeding.

    According to the breastfeeding coordinator, breastfeeding classes were not
    offered because of low attendance in the past. The breastfeeding coordinator
    did not conduct telephone follow-up calls to encourage and support
    breastfeeding because of the difficulty she had previously encountered in
    trying to reach participants. The breastfeeding video was not being shown to
    participants during our visit because the only videotape machine was out of
    order. Breastfeeding support groups were not offered because of lack of
    staff time and facilities. York WIC provided breast pumps for rent and for
    distribution to WIC breastfeeding mothers for a minimal fee.

    In November 1999, about 4 percent of York WIC infant participants were
    exclusively breastfed. In December 1999, the percentage of infant
    participants at York who were partially breastfed was about 46 percent,
    compared with about 51 percent for WIC participants statewide.

    Program Administration

    Maintaining participants' records. Although York WIC tracked participant
    data and issued food vouchers using the state data system, it relied heavily
    on paper records. CPAs or nutritionists first recorded participant's
    certification and other appointment-related information on paper forms, then
    a clerk entered the data into the computer system. Staff had access to the
    statewide system through two of its computers. They were able to use the
    state system to generate a few standardized reports, such as breastfeeding
    rates or vendor lists. According to the WIC Director, staff would use
    computers more if more were available. At the time of our study, four
    computers were available for staff use.

    Managing vendors. In accordance with state guidelines, York WIC had
    significant vendor management responsibilities. At the time of our study, it
    managed 40 vendors. One staff member, the administrative assistant, devoted
    part of her time to vendor management. Her responsibilities included
    training vendors, monitoring their adherence to program rules, performing
    inventory audits, and assisting state staff in vendor selection,
    authorization, and the performance of compliance buys. The administrative
    assistant indicated that there were insufficient resources to manage 40
    vendors effectively.

    Outreach. The administrative assistant who manages York's vendors also
    coordinates all of the outreach efforts. She reported that recent outreach
    included mailings to homeless shelters, substance abuse agencies, local high
    and middle schools, day care centers, health care groups and individual
    physicians. She served as member of two coalition groups that focused on
    community health issues. She actively coordinated with CPC's Head Start
    program and the county's foster care agency.

    Travel. Thirteen York staff traveled to the satellite clinics to provide
    services. York reimbursed staff for travel to the satellite clinics and
    state WIC meetings.

    Retaining and recruiting personnel. The WIC Director reported significant
    difficulty in recruiting and retaining WIC staff because she is not able to
    offer nutritionists and registered nurses salaries comparable to those that
    the county health department, local family planning organizations and
    hospitals can offer. The CPC Executive Director indicated that the salaries
    that the program is able to offer to WIC staff are "shameful." The WIC
    Director reported that the agency offers a nutritionist or dietitian half of
    the hourly rate offered for a comparable position at the local hospital. She
    can only offer the clerical staff an hourly rate of $5.70, about
    three-quarters of the hourly rate being offered at the local fast food and
    retail stores. According to the WIC Director, one staff member pays more for
    babysitting than she makes on those evenings when she works extended hours.

    The expenditure per participant per month in 1999 was $9.47. Table 26 shows
    the fiscal years 1998 and 1999 program expenditures for York WIC, by
    category.

                                    Fiscal year 1998       Fiscal year 1999

                                             Percent of              Percent of
     Category                       Amount   total         Amount    total
     Personnel and benefits
     excluding expenditures for     $488,050 82%           $464,554  84%
     contracted personnel
     Contracted personnel           0        0%            0         0%
     Equipment and supplies         13,567   2%            6,623     1%
     Facilities and related
     expenses including
     utilities, maintenance, rent   47,845   8%            42,443    8%
     and telephone
     Indirect costs                 24,668   4%            23,353    4%
     All other                      24,460   4%            15,360    3%
     Total                          $598,590 100%          $552,333  100%

    Note: Percents may not total to 100% due to rounding.

    The major nonprogram resources used by the program were in-kind
    contributions made by the sponsoring organization and the landlord who
    leased the space for the main clinic. The in-kind contributions from the
    sponsoring organization were in the form of payment of some of the indirect
    costs incurred to operate the program and one part-time administrative
    support staff provided to the program at no cost. According to information
    provided by the sponsoring organization, in fiscal year 1999, about $31,000
    of the indirect costs it incurred to operate the WIC program were covered by
    its Community Service Block Grant. Additionally, about $5,400 in Department
    of Labor grant funds were used to cover the costs of one administrative
    support staff assigned to WIC. The landlord's in-kind contribution was in
    the form of a charge for the space of the main WIC clinic that was below the
    market rate. Using information provided by the WIC Director, we estimate
    that in fiscal year 1999, the value of the discount on the rent would be
    about $20,000.20 In fiscal year 1999 York WIC also used $2,000 in grant
    funds from the city of York to educate mothers on baby bottle tooth decay.
    The total value of these nonprogram resources obtained from the sponsoring
    organization, the landlord, and the city of York in fiscal year 1999 was
    about $58,400. This represented approximately 11 percent of program
    expenditures in fiscal year 1999 or about 11 cents for every dollar in costs
    covered with program funds.

    York WIC also made use of other miscellaneous nonprogram resources,
    including shared space used at its satellite locations, waiting room
    furniture in the main clinic that was donated by a local pediatric practice,
    and some office furniture donated by a local bank. We did not obtain or
    develop an estimate of the value of theses miscellaneous in-kind
    contributions.

    The Zuni WIC program is operated by the Pueblo of Zuni, a federally
    recognized Indian Tribe. It is one of 33 Indian Tribal Organizations (ITO)
    operating WIC programs nationwide that are considered to be state-level
    agencies by the U.S. Department of Agriculture (USDA). Since 1979, the Zuni
    WIC program has operated under the auspices of the Zuni Tribal Council, a
    six-member Council headed by an elected governor and lieutenant governor.
    The Governor and the Council are elected to 4-year terms and governed by the
    tribe's own constitution. According to the WIC Director, the WIC program is
    one of the largest Zuni-run programs. In fiscal year 1999, Zuni provided WIC
    services to a monthly average of 857 participants. According to the
    Governor, WIC is a major program in the tribe's effort to improve community
    health, and the program closely coordinates its efforts with the Zuni
    Pueblo's only medical facility--a U.S. Indian Health Service hospital.

    In fiscal year 1999, Zuni WIC, as a state-level agency, expended federal NSA
    grant funds totaling $264,372, or about $25.71 per participant per month.
    According to information Zuni reported to USDA, about 23 percent of NSA
    expenditures, or $60,530, was made for state-level program management costs.
    The remaining 77 percent, or $203,842, was expended for costs typically
    incurred by local agencies in providing nutrition services and administering
    the program.

    Zuni WIC's participant database system was first automated in 1996. The
    current system was developed by the Inter-Tribal Council of Arizona (ITCA)
    and implemented at Zuni in October 1999. Its capabilities include
    maintaining participant records, generating reports, and printing food
    vouchers. The system processes participant certification data as they are
    entered. The WIC Director described the system as user-friendly, flexible,
    and fast. She found the printed forms had a quality assurance problem and
    was working with ITCA on programming. ITCA provides technical assistance for
    the database, via telephone, and the agency has a contract for hardware and
    other software support.

    The Tribal Council charges the WIC program for indirect costs, such as
    procurement, accounting, and personnel. The indirect rate for fiscal years
    1998 and 1999 was 16.7 percent of total direct costs, less capital
    expenditures, pass-through funds, and other exclusions. The Pueblo applied
    the indirect rate only to WIC administrative expenditures. The ITO also
    provides WIC with in-kind contributions of the land for the WIC trailer
    facility.

    Program

    Zuni Pueblo is a rural community in New Mexico with a total population of
    about 10,895 in July 1999. The main reservation is situated in a semiarid
    valley surrounded by mesas, about 150 miles southwest of Albuquerque. The
    Zuni WIC program provides service to residents within Zuni tribal boundaries
    and some Navajo tribal areas. Since only 16 of the 560 miles of roads
    maintained by the county are paved, bad weather conditions along rural dirt
    roads can make travel almost impossible and further isolate large portions
    of the population.

    In 1997, an estimated 47 percent of Zuni's labor force was unemployed.
    According to the Governor, the Zuni population has elevated rates for
    diabetes, hypertension, and heart disease, and these need to be reduced. In
    1998, according to a report from the local Indian Health Service (IHS)
    hospital, between 35 and 60 percent of Zuni adult patients over the age of
    50 have diabetes, and about 28 percent of Zuni patients between the ages of
    2 and 4 years old were obese. Approximately 87 percent of the Zuni Pueblo
    population were members of the Zuni tribe.

    WIC Clinics

    Zuni WIC provided nutrition services at four locations: the clinic in Zuni,
    a grocery store in a nearby town, and two local high schools. The Zuni
    clinic provided the full range of nutrition services (see fig. 9); its
    normal hours of operation were Monday through Friday, 8:00 a.m. to 4:30 p.m.
    This clinic offered limited services during extended evening hours, which
    were held several days a month. Most of the program's participants received
    services at the main clinic.

    The grocery store site--located in Ramah, New Mexico--was approximately 17
    miles from Zuni. Staff set up a card table near the front of the store.
    Activities at the site were limited to issuing vouchers to low-risk
    participants. Staff were at this site every other month, from 9:00 a.m. to
    3:00 p.m. This site served from 20 to 25 participants, most of whom were
    Navajo.

    The two high schools are located in the Zuni Pueblo. WIC staff used space in
    the day care centers at the high schools. Activities at these sites were
    also limited to issuing vouchers to low-risk participants. Vouchers were
    issued at these sites twice a month. Each high school site served from 10 to
    20 teenage participants.

    Number of Participants Served

    In fiscal year 1999, Zuni WIC served a monthly average of 857 participants.
    Approximately 33 percent of the agency's participants served in an average
    month during that year were considered high-risk. Table 27 shows the number
    of participants by category served in September 1998 and 1999.

                                           Number of participants
     Participant category                  September 1998  September 1999
     Pregnant women                        62              53
     Breastfeeding women                   66              66
     Postpartum women not breastfeeding    29              36
     Infants                               160             166
     Children                              544             517
     Total                                 861             838

    Staffing

    At the time of our study, the program employed six full-time and one
    part-time staff, for a total of 6.4 full-time equivalent staff. The WIC
    Director had been with the program for 20 years and is an active member of
    the community. She was the former department head of the Department of Human
    Services and the current president of the board of education. The part-time
    staff member was a registered dietitian, and the only lactation consultant
    in the county. Two of the other five full-time staff and the WIC Director
    were designated as CPAs--having passed a competency-based test developed by
    registered dietitians from the New Mexico ITOs and approved by USDA. One of
    the full-time staff members was a breastfeeding peer counselor, and two were
    administrative support staff. All of the staff were paid on an hourly basis.

    Administration

    Participant Services

    During the certification and recertification sessions, the Zuni WIC staff
    routinely measured participants' height and weight and tested blood for
    anemia. Zuni WIC also received a health summary from the IHS hospital prior
    to each participant's certification or recertification visit. This summary
    typically included the latest information that the hospital had on the
    participant's height, weight and immunization status. At each visit
    participants completed a form to identify the foods they were eating. Staff
    reported, and we observed, that some nutrition education and breastfeeding
    promotion and support was also provided during the nutrition assessment
    process. CPAs see the low-risk participants, while participants considered
    to be high-risk were seen by the staff dietitian as well as a CPA. An
    individual care plan is typically developed for high-risk Zuni participants.
    The Zuni WIC Director believed that the required proof of income is a
    barrier to Zuni residents applying for WIC services because they find it
    humiliating to have to prove how poor they are.

    The Zuni WIC clinic schedule dedicated Mondays and Tuesdays of each week to
    updating files, preparing participant folders for those who are scheduled to
    be seen later in the week, and scheduling participants for upcoming
    appointments. Participants were scheduled for visits on Wednesdays and
    Thursdays of each week. Walk-ins were seen on Thursdays. Fridays were
    dedicated to completing any work left over from earlier in the week. Staff
    sent letters to participants who missed more than four appointments. If they
    could not reach the participants by letter, then they visited them at home.
    During the certification process, as described by the staff, participants
    returned to the waiting area at least twice while their case information is
    updated. Regarding the flow of participants through the main clinic, no
    recent information was available about the amount of time participants spent
    waiting for services.

    All staff members were responsible for issuing the food vouchers, and the
    agency tracks voucher issuance on the computer system. Food instruments
    could be printed on demand at the main clinic and were printed beforehand
    for issuance at Ramah and the local high schools. Vouchers were typically
    issued to participants every 2 months. Zuni WIC staff sometimes made
    preappointment calls, but routinely made follow-up telephone calls or sent
    postcards to participants who missed an appointment.

    In making referrals to the IHS health care providers, Zuni WIC staff
    completed a hospital referral form, recording the reason for the referral.
    Copies of the form went to IHS, the participant, and the participant's WIC
    file. After completing the form, the WIC staff called the IHS health care
    provider and scheduled an appointment for the participant. This was done to
    help ensure that participants followed through on the referral. After seeing
    the referred WIC participant, the IHS provider returned the referral form to
    Zuni WIC, indicating the services provided. If the referred agency did not
    return the form to WIC, staff followed-up with the participant during the
    next recertification and, if necessary, telephoned the IHS provider to
    obtain the completed form. In referring participants to other types of
    providers, such as social services, staff sent a memo notifying the agency
    that a referral has been made. For such referrals, the nature of referral
    and the date it was made was noted in the participant's WIC record. With
    regard to voter registration, staff provided participants with registration
    forms and referred them to the county to register. The referral was noted in
    the computer system.

    Nutrition Education

    The CPAs and the dietitian normally provide nutrition education through
    one-on-one sessions, during certification, recertification and voucher
    pick-up appointments, because group education is less accepted culturally in
    the Zuni community. Nutrition education sessions typically involved
    reviewing the participant's diet and addressing any identified nutrition
    deficiencies, such as low iron levels, by suggesting foods to eat. The
    recertification appointments that we observed lasted between 45 and 60
    minutes. These sessions were often supplemented with brochures dealing with
    good nutrition, such as the Food Pyramid. The WIC registered dietitian
    referred participants who needed medical nutritional counseling to the
    registered dietitian at the local IHS hospital. In order to facilitate the
    delivery of nutrition education, the program employed bilingual staff who
    spoke Zuni during all or part of the appointment. Zuni WIC staff offered
    regular nutrition education to child participants, through individual
    discussions in English and Zuni, and coordinated activities with Head Start
    and the IHS-sponsored diabetes prevention program.

    Most of the participants came to the WIC clinic for their bimonthly voucher
    pick-up, enabling staff to use this opportunity to offer classes, such as
    15-minute cooking demonstrations in the clinic's kitchen. Furthermore, Zuni
    WIC had some interactive displays depicting general nutrition information
    that required participants to study the presentation and answer review
    questions, such as a display on juices that depicted the relative amount of
    fruit juice in locally purchased juice drinks. In addition, Zuni WIC had
    created over a dozen nutrition education brochures using graphics depicting
    Native American women and children and culturally appropriate foods, such as
    the Pueblo Food Pyramid.

    Breastfeeding Promotion and Support

    Zuni WIC offered many breastfeeding promotion and support activities, such
    as one-on-one counseling, quarterly group classes, home and hospital visits,
    breastfeeding pumps and aids, videos, promotional materials, and scheduled
    follow up. On a daily basis, the breastfeeding peer counselor tracked new
    births at the local hospital, conducted hospital visits at the maternity
    ward in the morning and home visits in the afternoon and made follow-up
    telephone calls at regular intervals to check on a breastfeeding mother's
    progress and provide assistance. To make breastfeeding convenient while
    mothers were visiting WIC offices, Zuni WIC dedicated private space for this
    purpose. In addition, Zuni WIC invested local resources to create and
    distribute a video that depicted Zuni and other Native American women and
    their experiences with breastfeeding. Zuni WIC shared this breastfeeding
    video and its brochures with other ITOs.

    To support their efforts in this area, all of the Zuni WIC staff are trained
    to promote breastfeeding. In addition, the agency staff includes a certified
    lactation consultant, the only one in the area, and a full- time peer
    counselor. As a result of the long-term team effort, the program had, in
    fiscal year 1999, a breastfeeding initiation rate of 77 percent and a
    breastfeeding rate of 43 percent for infants 6 months and older.

    Program Administration

    Maintaining participants' records. While a substantial amount of participant
    and program data are maintained on the automated system, individual
    hard-copy participant records are also maintained to verify the accuracy of
    information on the new database system.

    Managing vendors. Since Zuni WIC is a state-level agency, the staff are
    heavily involved in all aspects of vendor management, including selection,
    authorization, training, routine monitoring, compliance buys, inventory
    audits at participating vendors, enforcement, and payment of redeemed
    vouchers. One staff member was dedicated to vendor management and was
    supported by other staff. At the time of our study, Zuni WIC had nine
    vendors, five in the Zuni area and four in the Gallup area. Several of the
    small Zuni vendors raised concerns that their cash flow was being affected
    because of the length of time it took to get reimbursed for redeemed WIC
    vouchers, even though the program was reimbursing them within the contracted
    timeframes. The Pueblo of Zuni staff were aware of the issue and were
    attempting to speed up reimbursements.

    Outreach. The program employs an outreach specialist who coordinates all
    such efforts. The specialist reported that she had conducted outreach at
    Head Start, the local health center, the hospital, high schools, and health
    fairs. In response to recent declines in caseload, WIC staff encouraged
    participants to inform friends of WIC benefits and opened the clinic for
    extended hours to serve working WIC mothers. The outreach staff mailed
    letters to potentially eligible participants by using Head Start's address
    list. Posters and flyers were made to recruit participants and displayed at
    the offices of the local television station.

    Travel. Zuni WIC staff traveled to three satellite sites to provide
    services. The WIC program purchased a vehicle for the staff for such
    purposes as visiting satellite sites, attending area training sessions, and
    responding to emergencies.

    Retaining and recruiting personnel. There were no unfilled positions at the
    time of our study. The WIC Director did not describe any difficulties in
    hiring or retaining staff.

    Table 28 shows the fiscal years 1998 and 1999 program expenditures the
    agency made by category.

                                Fiscal Year 1998         Fiscal Year 1999

     Category                   Amount      Percent      Amount      Percent of
                                            of total                 total
     Personnel and benefits,
     excluding expenditures     $171,587.22 67%          $179,918.92 68%
     for contracted personnel
     Equipment and supplies     21,148.77   8%           11,270.00   4%
     Facilities and related
     expenses, including
     utilities, maintenance,    4,888.72    2%           5,483.71    2%
     rent and telephone
     Indirect costs             36,833.94   14%          36,187.68   14%
     All other: motor vehicle
     operation, postage,        22,937.84   9%           31,511.69   12%
     printing
     Total                      $257,396.49 100%         264,372.00  100%

    According to the WIC Director, the current funding level for nutrition
    services and administration is insufficient because nothing is factored into
    their funding to reflect the added costs of conducting their operation out
    of their own building.

    The major nonprogram resource used by Zuni WIC in fiscal year 1999 was the
    sponsoring organization's in-kind contribution of rent-free land and a grant
    from the IHS diabetes prevention program, Healthy Lifestyles, to distribute
    toys to encourage children's' physical activity. A Zuni tribal official
    estimated the value of the ITO's in-kind contribution of the land for the
    WIC trailer facility at $5,000 per year. The IHS grant amount was $500. The
    total of these nonprogram resources, $5,500, represented about 2 percent of
    program expenditures in fiscal year 1999, or about 2 cents for every dollar
    in costs covered by program funds.

    Zuni WIC also received some minor nonprogram resources from other
    organizations. The two public high schools in Zuni provided shared space for
    WIC staff to deliver vouchers to teenage WIC mothers and a grocer in the
    neighboring town of Ramah also provided shared space for the delivery of
    vouchers. We did not obtain an estimated value of these nonprogram
    resources.

    Time Study Results − Percent of Staff time and Staff Time Costs Spent
    on Activities

    This appendix presents information on the results of the time studies
    conducted at each of the six agencies. For each agency, information is
    provided on the percent of staff time as well as the percent of staff time
    costs spent on specific activity subcategories in the four broader
    categories of participant services, nutrition education, breastfeeding
    promotion and support, and administration. Information on the time span of
    each time study and the calculation of percent of staff time costs are
    presented in appendix 1.

    (Continued From Previous Page)

                                                     Percent of
                                                           Staff    Staff time
          Category/subcategory         Staff  Staff time    time     costs in
                                       time   in category
                                                           costs    category
                          Participant services activities
     Scheduling participants          13.6   25.7         13.4    26.3
     Determining participants'
     eligibility                      8.8    16.6         8.2     16.1
     Assessing participants'
     nutritional risk                 13.2   24.9         12.7    24.9
     Making referrals and
     conducting follow-up             1.0    1.9          1.0     1.9
     Explaining benefits and
     procedures to participants       1.2    2.3          1.3     2.6
     Issuing checks                   5.1    9.6          4.8     9.5
     Providing or receiving
     training or other professional   4.8    9.1          4.4     8.7
     development
     Making record notations          5.2    9.9          5.1     10.0
     Total--all participant
     services activities              52.8   100.0        50.9    100.0
     Nutrition education activities
     Providing one-on-one nutrition
     education or counseling          9.5    69.9         8.9     65.1
     Providing group nutrition
     education                        .6     4.4          .7      5.2
     Developing materials and
     activities                       .9     6.4          1.1     7.9
     Consulting with medical
     providers regarding nutrition
     education of individual          .2     1.4          .2      1.5
     participants
     Providing or receiving
     training or other professional   .8     6.0          .8      5.5
     development
     Monitoring and evaluating
     nutrition education activities   1.6    11.9         2.0     14.7
     Total--all nutrition education
     activities                       13.6   100.0        13.7    100.0
     Breastfeeding promotion and support
     Providing one-on-one
     breastfeeding                    4.6    91.2         4.3     89.8
     instruction/counseling
     Providing group breastfeeding
     instruction/counseling           .1     2.2          .1      2.8
     Developing materials and
     activities                       .1     2.1          .1      2.8
     Consulting with medical
     providers regarding              .1     1.6          .1      1.9
     breastfeeding issues
     Providing or receiving
     training or other professional   .1     2.7          .1      2.5
     development
     Monitoring and evaluating
     breastfeeding promotion          <.1    .2           <.1     .2
     activities
     Total--all breastfeeding
     promotion and support            5.0    100.0        4.7     100.0
     activities
     Administration
     Outreach to potential
     participants                     .8     2.6          .8      2.4
     Outreach to health care
     providers and other              2.4    8.5          2.9     9.6
     organizations
     Clerical tasks                   11.5   40.3         11.5    37.3
     Travel                           4.9    17.3         5.1     16.6
     Personnel tasks                  .8     2.6          .8      2.5
     Accounting and finance           1.9    6.5          2.3     7.6
     Vendor management                .1     .5           .2      .5
     General management               4.3    15.1         4.9     16.0
     Organize self/work               .1     .3           .1      .3
     Miscellaneous                    1.8    6.3          2.2     7.1
     Total--all administrative
     activities                       28.6   100.0        30.7    100.0
     Grand total                      100.0               100.0

    Note: Totals may not add due to rounding.

     (Continued From Previous Page)                  Percent of
                                                           Staff    Staff time
          Category/subcategory         Staff  Staff time    time     costs in
                                       time   in category
                                                           costs    category
     Participant services
     activities
     Scheduling participants          4.3    10.0         3.4     8.5
     Determining participants'
     eligibility                      4.9    11.4         4.9     12.4
     Assessing participants'
     nutritional risk                 10.7   24.7         11.1    27.6
     Making referrals and
     conducting follow-up             2.9    6.7          2.2     5.6
     Explaining benefits and
     procedures to participants       .5     1.2          .6      1.4
     Issuing vouchers                 9.7    22.5         7.0     17.3
     Providing or receiving
     training or other professional   1.0    2.2          1.0     2.6
     development
     Making record notations          9.2    21.3         9.9     24.6
     Total--all participant
     services activities              43.2   100.0        40.1    100.0
     Nutrition education activities
     Providing one-on-one nutrition
     education or counseling          4.5    51.4         4.7     49.2
     Providing group nutrition
     education                        <.1    .4           <.1     .4
     Developing materials and
     activities                       .8     9.5          1.1     11.3
     Consulting with medical
     providers regarding nutrition
     education of individual          .3     3.3          .4      4.1
     participants
     Providing or receiving
     training or other professional   2.5    28.1         2.7     28.1
     development
     Monitoring and evaluating
     nutrition education activities   .6     7.3          .7      6.9
     Total--all nutrition education
     activities                       8.8    100.0        9.6     100.0
     Breastfeeding promotion and support
     Providing one-on-one
     breastfeeding                    3.0    44.0         3.4     43.9
     instruction/counseling
     Providing group breastfeeding
     instruction/counseling           .3     3.6          .3      3.6
     Developing materials and
     activities                       .9     13.1         1.0     13.1
     Consulting with medical
     providers regarding              .8     11.6         .9      11.5
     breastfeeding issues
     Providing or receiving
     training or other professional   1.6    24.3         1.9     24.6
     development
     Monitoring and evaluating
     breastfeeding promotion          .2     3.3          .3      3.3
     activities
     Total--all breastfeeding
     promotion and support            6.7    100.0        7.8     100.0
     activities
     Administration
     Outreach to potential
     participants                     .4     .8           .4      .9
     Outreach to health care
     providers and other              .1     .3           .1      .3
     organizations
     Clerical tasks                   28.3   68.4         25.8    61.0
     Travel                           3.4    8.3          3.7     8.8
     Personnel tasks                  .9     2.1          1.2     2.8
     Accounting and finance           .1     .2           .1      .3
     Vendor management                0      0            0       0
     General management               4.8    11.6         7.0     16.5
     Organize self/work               1.4    3.4          1.5     3.4
     Miscellaneous                    2.0    4.9          2.5     6.0
     Total--all administrative
     activities                       41.3   100.0        42.3    100.0
     Grand total                      100.0               100.0

    Note: Totals may not add due to rounding.

    (Continued From Previous Page)

                                                     Percent of
                                                           Staff    Staff time
          Category/subcategory         Staff  Staff time   time      costs in
                                       time  in category
                                                          costs     category
     Participant services activities
     Scheduling participants          5.1    13.5        5.5      13.5
     Determining participants'
     eligibility                      4.7    12.5        5.1      12.5
     Assessing participants'
     nutritional risk                 14.9   39.3        15.9     39.3
     Making referrals and conducting
     follow-up                        .5     1.4         .6       1.4
     Explaining benefits and
     procedures to participants       2.0    5.2         2.1      5.2
     Issuing vouchers                 3.5    9.2         3.7      9.2
     Providing or receiving training
     or other professional            <.1    .1          <.1      .1
     development
     Making record notations          7.2    18.9        7.6      18.9
     Total--all participant services
     activities                       37.9   100.0       40.5     100.0
     Nutrition education activities
     Providing one-on-one nutrition
     education or counseling          2.4    26.5        2.6      26.5
     Providing group nutrition
     education                        0      0           0        0
     Developing materials and
     activities                       1.7    18.7        1.8      18.7
     Consulting with medical
     providers regarding nutrition
     education of individual          .3     3.4         .3       3.4
     participants
     Providing or receiving training
     or other professional            4.6    51.4        5.0      51.4
     development
     Monitoring and evaluating
     nutrition education activities   0      0           0        0
     Total--all nutrition education
     activities                       9.0    100.0       9.7      100.0
     Breastfeeding promotion and
     support
     Providing one-on-one
     breastfeeding                    .7     12.0        .7       12.0
     instruction/counseling
     Providing group breastfeeding
     instruction/counseling           0      0           0        0
     Developing materials and
     activities                       .1     1.0         .1       1.0
     Consulting with medical
     providers regarding              0      0           0        0
     breastfeeding issues
     Providing or receiving training
     or other professional            4.7    87.0        5.0      87.0
     development
     Monitoring and evaluating
     breastfeeding promotion          0      0           0        0
     activities
     Total--all breastfeeding
     promotion and support            5.4    100.0       5.8      100.0
     activities
     Administration
     Outreach to potential
     participants                     .5     .9          .5       1.1
     Outreach to health care
     providers and other              <.1    .1          <.1      .1
     organizations
     Clerical tasks                   21.2   44.5        15.2     34.4
     Travel                           5.5    11.5        5.9      13.3
     Personnel tasks                  2.0    4.1         2.0      4.6
     Accounting and finance           .5     1.1         .3       .8
     Vendor management                .1     .2          .1       .2
     General management               10.7   22.4        12.3     28.0
     Organize self/work               4.2    8.8         4.5      10.1
     Miscellaneous                    3.1    6.5         3.3      7.5
     Total--all administrative
     activities                       47.7   100.0       44.1     100.0
     Grand total                      100.0              100.0

    Note: Totals may not add due to rounding.

    (Continued From Previous Page)

                                                     Percent of
                                                           Staff    Staff time
          Category/subcategory         Staff  Staff time    time     costs in
                                       time   in category
                                                           costs    category

     Participant services activities
     Scheduling participants          19.1   39.1         14.6    35.3
     Determining participants'
     eligibility                      4.3    8.9          4.1     9.9
     Assessing participants'
     nutritional risk                 9.6    19.6         9.5     22.9
     Making referrals and
     conducting follow-up             1.1    2.2          0.9     2.2
     Explaining benefits and
     procedures to participants       1.5    3.1          1.4     3.5
     Issuing vouchers                 8.6    17.7         6.5     15.6
     Providing or receiving
     training or other professional   .5     1.1          .2      .5
     development
     Making record notations          4.1    8.3          4.2     10.1
     Total--all participant
     services activities              48.8   100.0        41.4    100.0
     Nutrition education activities
     Providing one-on-one nutrition
     education or counseling          12.2   63.7         12.2    56.8
     Providing group nutrition
     education                        2.6    13.3         2.2     10.4
     Developing materials and
     activities                       2.1    10.7         3.3     15.6
     Consulting with medical
     providers regarding nutrition
     education of individual          .1     .2           .1      .3
     participants
     Providing or receiving
     training or other professional   1.0    5.4          1.6     7.6
     development
     Monitoring and evaluating
     nutrition education activities   1.3    6.7          2.0     9.4
     Total--all nutrition education
     activities                       19.2   100.0        21.4    100.0
     Breastfeeding promotion and
     support activities
     Providing one-on-one
     breastfeeding                    2.6    77.4         2.4     66.7
     instruction/counseling
     Providing group breastfeeding
     instruction/counseling           .1     3.8          .1      3.2
     Developing materials and
     activities                       .5     14.8         .8      22.1
     Consulting with medical
     providers regarding              0      0            0       0
     breastfeeding issues
     Providing or receiving
     training or other professional   .1     2.6          .2      4.9
     development
     Monitoring and evaluating
     breastfeeding promotion          <.1    1.5          .1      3.1
     activities
     Total--all breastfeeding
     promotion and support            3.4    100.0        3.6     100.0
     activities
     Administration
     Outreach to potential
     participants                     .8     2.7          .6      1.9
     Outreach to health care
     providers and other              .9     3.3          1.3     3.9
     organizations
     Clerical tasks                   9.1    32.8         8.5     25.4
     Travel                           1.6    5.6          1.7     5.2
     Personnel tasks                  .8     2.7          1.1     3.3
     Accounting and finance           1.6    5.6          2.3     6.8
     Vendor management                .1     .1           <.1     .1
     General management               8.4    29.2         11.8    35.2
     Organize self/work               3.7    13.0         4.1     12.1
     Miscellaneous                    1.7    6.0          2.0     6.0
     Total--all administrative
     activities                       28.7   100.0        33.5    100.0
     Grand total                      100.0               100.0

    Note: Totals may not add due to rounding.

    (Continued From Previous Page)

                                              Percent of
                                                           Staff    Staff time
         Category/subcategories        Staff  Staff time    time     costs in
                                       time   in category
                                                           costs    category
     Participant services
     activities
     Participant services
     activities
     Scheduling participants          8.7    22.3         7.2     17.4
     Determining participants'
     eligibility                      5.1    13.2         6.3     15.2
     Assessing participants'
     nutritional risk                 5.5    14.1         6.9     16.6
     Making referrals and
     conducting follow-up             .4     1.0          .3      .7
     Explaining benefits and
     procedures to participants       1.0    2.5          1.2     2.8
     Issuing vouchers                 7.5    19.2         7.1     17.3
     Providing or receiving
     training or other professional   3.4    8.6          4.3     10.5
     development
     Making record notations          7.5    19.2         8.1     19.5
     Total--all participant
     services activities              39.0   100.0        41.3    100.0
     Nutrition education activities
     Providing one-on-one nutrition
     education or counseling          2.6    54.5         2.6     49.2
     Providing group nutrition
     education                        0      0            0       0
     Developing materials and
     activities                       .6     13.0         .9      16.3
     Consulting with medical
     providers regarding nutrition
     education of individual          .5     11.1         .7      13.5
     participants
     Providing or receiving
     training or other professional   1.0    21.4         1.1     21.0
     development
     Monitoring and evaluating
     nutrition education activities   0      0            0       0
     Total--all nutrition education
     activities                       4.8    100.0        5.3     100.0
     Breastfeeding promotion and
     support activities
     Providing one-on-one
     breastfeeding                    .4     51.9         .5      47.0
     instruction/counseling
     Providing group breastfeeding
     instruction/counseling           0      0            0       0
     Developing materials and
     activities                       .2     19.2         .2      23.0
     Consulting with medical
     providers regarding              <.1    3.8          <.1     3.9
     breastfeeding issues
     Providing or receiving
     training or other professional   .2     25.1         .3      26.2
     development
     Monitoring and evaluating
     breastfeeding promotion          0      0            0       0
     activities
     Total--all breastfeeding
     promotion and support            .8     100.0        1.0     100.0
     activities
     Administration
     Outreach to potential
     participants                     .2     .3           .3      .6
     Outreach to health care
     providers and other              .8     1.5          1.0     1.9
     organizations
     Clerical tasks                   38.4   69.2         31.6    60.2
     Travel                           3.1    5.6          3.4     6.6
     Personnel tasks                  .4     .7           .6      1.2
     Accounting and finance           .1     .2           .2      .4
     Vendor management                2.5    4.5          3.2     6.1
     General management               5.3    9.5          7.8     14.8
     Organize self/work               .5     1.0          .7      1.3
     Miscellaneous                    4.3    7.7          3.6     6.9
     Total--all administrative
     activities                       55.5   100.0        52.4    100.0
     Grand total                      100.0               100.0

    Note: Totals may not add due to rounding.

    (Continued From Previous Page)

                                                    Percent of :
                                                           Staff    Staff time
         Category/subcategories        Staff  Staff time    time     costs in
                                       time   in category
                                                           costs    category
     Participant services activities
     Scheduling participants          3.4    14.4         2.8     12.5
     Determining participants'
     eligibility                      2.7    11.4         2.3     10.3
     Assessing participants'
     nutritional risk                 2.3    9.6          3.1     13.7
     Making referrals and
     conducting follow-up             .3     1.4          .4      1.7
     Explaining benefits and
     procedures to participants       .1     .5           .1      .5
     Issuing vouchers                 5.2    21.9         4.1     18.6
     Providing or receiving
     training or other professional   2.4    10.2         3.8     16.9
     development
     Making record notations          7.2    30.6         5.7     25.8
     Total--all participant
     services activities              23.6   100.0        22.3    100.0
     Nutrition education activities
     Providing one-on-one nutrition
     education or counseling          2.8    21.7         4.3     25.9
     Providing group nutrition
     education                        4.6    35.9         5.2     31.5
     Developing materials and
     activities                       3.5    27.3         3.5     21.4
     Consulting with medical
     providers regarding nutrition
     education of individual          .6     4.5          .9      5.7
     participants
     Providing or receiving
     training or other professional   1.4    10.5         2.5     15.2
     development
     Monitoring and evaluating
     nutrition education activities   <.1    .2           <.1     .3
     Total--all nutrition education
     activities                       12.9   100.0        16.4    100.0
     Breastfeeding promotion and
     support activities
     Providing one-on-one
     breastfeeding                    4.4    58.0         2.8     54.7
     instruction/counseling
     Providing group breastfeeding
     instruction/counseling           .1     1.7          .2      3.1
     Developing promotion materials
     and activities                   1.0    13.5         .8      15.0
     Consulting with medical
     providers regarding              .3     4.2          .2      4.1
     breastfeeding issues
     Providing or receiving
     training or other professional   .8     11.0         .8      15.3
     development
     Monitoring and evaluating
     breastfeeding promotion          .9     11.6         .4      7.9
     activities
     Total--all breastfeeding
     promotion and support            7.6    100.0        5.2     100.0
     activities
     Administration
     Outreach to potential
     participants                     1.0    1.7          1.1     1.9
     Outreach to health care
     providers and other              1.9    3.5          2.3     4.0
     organizations
     Clerical tasks                   23.7   42.5         17.7    31.6
     Travel                           5.0    9.0          5.4     9.5
     Personnel tasks                  2.9    5.2          3.7     6.5
     Accounting and finance           2.5    4.4          2.7     4.7
     Vendor management                10.2   18.2         11.5    20.5
     General management               5.4    9.7          8.0     14.2
     Organize self/work               1.4    2.6          1.6     2.9
     Miscellaneous                    1.8    3.2          2.3     4.1
     Total--all administrative
     activities                       55.8   100.0        56.2    100.0
     Grand total                      100.0               100.0

    Note: Totals may not add due to rounding

    Time Study Results: Approximate Minutes per Case-Month Spent on Nutrition
    Services and Administration Activities

    This appendix presents information on the results of the time studies
    conducted at each of the six agencies. For participant services, nutrition
    education, breastfeeding promotion, and administration, the approximate
    number of minutes per case-month spent on specific activity categories are
    presented for each of the six agencies. Information on how we calculated the
    approximate number of minutes per case-month that was available to carry out
    all nutrition services and administrative activities is presented in
    appendix 1.

                                   Approximate minutes per case-month:
     Participant service                                    Long
     activity categorya            Gallatin  Grady Kanabec  Beach    York Zuni
     Scheduling participants       4.2       1.1   1.1      3.4      2.8  2.4
     Determining participants'
     eligibility                   2.7       1.2   1.0      .8       1.6  1.9
     Assessing participants'
     nutritional risk              4.1       2.7   3.1      1.7      1.8  1.7
     Making referrals and
     conducting follow-up          .3        .7    .1       .2       .1   .2
     Explaining benefits and
     procedures to participants    .4        .1    .4       .3       .3   .1
     Issuing vouchers              1.6       2.4   .7       1.5      2.4  3.7
     Providing or receiving
     training or other             1.5       .3    <.1      .1       1.1  1.7
     professional development
     Making record notations       1.6       2.3   1.5      .7       2.4  5.2
     Total--all participant
     services activities           16.4      10.8  8.0      8.8      12.5 17.0

    Note: Totals may not add due to rounding.

    aA description of each participant service activity category is provided in
    appendix 1.

                                       Approximate minutes per case-month:
         Nutrition education                                  Long
         activity categorya       Gallatin  Grady  Kanabec   Beach   York Zuni
     Providing one-on-one
     nutrition education or       2.9       1.1    .5       2.2      .8   2.0
     counseling
     Providing group nutrition
     education                    .2        <.1    0        .5       0    3.3
     Developing education
     materials and activities     .3        .2     .4       .4       .2   2.5
     Consulting with medical
     providers regarding
     nutrition education of       .1        .1     .1       <.1      .2   .4
     individual participants
     Providing or receiving
     training or other            .2        .6     1.0      .2       .3   1.0
     professional development
     Monitoring and evaluating
     nutrition education          .5        .2     0        .2       0    <.1
     activities
     Total--all nutrition
     education activities         4.2       2.2    1.9      3.5      1.5  9.3

    Note: Totals may not add due to rounding.

    aA description of each nutrition education activity category is provided in
    appendix 1.

                                     Approximate minutes per case-month:
     Breastfeeding promotion and                             Long
     support activity categorya      Gallatin  Grady Kanabec Beach   York Zuni
     Providing one-on-one
     breastfeeding                   1.4       .8    .1      .5      .1   3.2
     Instruction/counseling
     Providing group breastfeeding
     instruction/counseling          <.1       .1    0       <.1     0    .1
     Developing breastfeeding
     promotion materials and         <.1       .2    <.1     .1      .1   .7
     activities
     Consulting with medical
     providers regarding             <.1       .2    0       0       <.1  .2
     breastfeeding issues
     Providing or receiving
     training or other               <.1       .4    1.0     <.1     .1   .6
     professional development
     Monitoring and evaluating
     breastfeeding promotion         <.1       .1    0       <.1     0    .6
     activities
     Total--all breastfeeding
     promotion and support           1.6       1.7   1.1     .6      .3   5.5
     activities

    Note: Totals may not add due to rounding.

    aA description of each breastfeeding promotion and support activity category
    is provided in appendix 1.

                                       Approximate minutes per case-month:
       Administration activity                                Long
             categorya            Gallatin  Grady  Kanabec   Beach   York Zuni
     Outreach to potential
     participants                 .2        .1     .1       .1       .1   .7
     Outreach to health care
     providers and other          .7        <.1    <.1      .2       .3   1.4
     organizations
     Clerical tasks               3.6       7.1    4.4      1.6      12.3 17.1
     Travel                       1.5       .9     1.2      .3       1.0  3.6
     Personnel tasks              .2        .2     .4       .1       .1   2.1
     Accounting and finance       .6        <.1    .1       .3       <.1  1.8
     Vendor management            <.1       0      <.1      <.1      .8   7.3
     General management           1.3       1.2    2.2      1.5      1.7  3.9
     Organize self/work           <.1       .3     .9       .7       .2   1.0
     Miscellaneous                .6        .5     .7       .3       1.4  1.3
     Total--all administrative
     activities                   8.9       10.3   10.0     5.2      17.8 40.2

    Note: Totals may not add due to rounding.

    aA description of each program administration activity category is provided
    in appendix 1.

    GAO Contacts and Staff Acknowledgments

    Robert E. Robertson (202) 512-5138
    Thomas E. Slomba (202) 512-9910

    In addition to those named above, Kathy R. Alexander, Patricia Farrell
    Donahue, Judy K. Hoovler, Tina Kinney, Lynn Musser, and Carol Herrnstadt
    Shulman made key contributions to this report.

    (150147)

    Table 1: Nutrition Services and Administration Activities by Cost Category
    10

    Table 2: Percent of Total Staff Spent on Nutrition Services and
    Administration Activities 17

    Table 3: Approximate Minutes per Case-Month Spent on Nutrition Services and
    Administration Activities 18

    Table 4: Approximate Minutes per Case-Month Spent on Specific Nutrition
    Education Activities Involving Direct Contact With Participants and Percent
    of Total Staff Time Spent on These Activities 19

    Table 5: Percent of Total Staff Time and Approximate Minutes per Case-Month
    Spent on Activities Involving Direct Participant Contact 20

    Table 6: Categories of Nonprogram Resources Used to Cover the Costs of
    Providing Nutrition Services and Administering the Program, Fiscal Year 1999
    21

    Table 7: Major In-kind Contributions Made by Sponsoring Organizations 22

    Table 8: Description of WIC Activity Categories Used for Time Studies at Six
    Case Study Agencies 29

    Table 9: Time Span of Time Study for Each Agency 33

    Table 10: Characteristics of Case Study Agencies in Terms of Sponsoring
    Agency, Geographic Area Served, and Average Monthly Number Of Participants
    Served 35

    Table 11: Characteristics of Five Local Case Study Agencies Compared With
    Local WIC Agencies Nationwide 36

    Table 12: Selected Staffing Statistics for Each Case Study Agency 37

    Table 13: Six Agencies' Expenditures of WIC Program Funds, Fiscal Year 1999
    37

    Table 14: Six Agencies' Percent Distribution of WIC Program by Budget
    Category, Fiscal year 1999 38

    Table 15: Number of Gallatin Participants by Category, September 1998 and
    July 1999 46

    Table 16: Frequency of Check Issuance by Participant Type at Gallatin WIC 48

    Table 17: Gallatin WIC Program Expenditures by Category, Fiscal Years 1998
    and 1999 51

    Table 18: Number of Grady WIC Participants by Category, September 1998 and
    November 2000 56

    Table 19: Grady WIC Program Expenditures by Category, Fiscal Years 1998 and
    1999 61

    Table 20: Number of Kanabec County Participants by Category, September 1998
    and September 1999 66

    Table 21: Kanabec County WIC Program Expenditures by Category, Fiscal Years
    1998 and 1999 70

    Table 22: Number Participants by Category, September 1998 and October 1999,
    at Long Beach WIC 74

    Table 23: Category of Participant and Frequency of Voucher Issuance at Long
    Beach WIC 75

    Table 24: Long Beach WIC Program Expenditures by Category, Fiscal Years 1998
    and 1999 80

    Table 25: Number of Participants by Category, September 1998 and November
    1999, at York WIC 84

    Table 26: York WIC Program Expenditures by Category, Fiscal Years 1998 and
    1999 90

    Table 27: Number of Participants by Category, September 1998 and September
    1999, at Zuni WIC 94

    Table 28: Zuni WIC Program Expenditures by Category, Fiscal Years 1998 and
    1999 98

    Table 29: Percent of Staff Time and Staff Time Costs -Gallatin 100

    Table 30: Percent of Staff Time and Staff Time Costs-Grady 101

    Table 31: Percent of Staff Time and Staff Time Costs -Kanabec 103

    Table 32: Percent of Staff Time and Staff Time Costs--Long Beach 104

    Table 33: Percent of Staff Time and Staff Time Costs--York 106

    Table 34: Percent of Staff Time and Staff Time Costs -Zuni 107

    Table 35: Approximate Minutes per Case-Month Spent on Participant Services
    Activities at the Six Case Study Agencies 109

    Table 36: Approximate Minutes per Case-Month Spent on Nutrition Education
    Activities at the Six Case Study Agencies 110

    Table 37: Approximate Minutes per Case-Month Spent on Specific Breastfeeding
    Promotion and Support Activities at the Six Case Study Agencies 111

    Table 38: Approximate Minutes per Case-Month on Specific Program
    Administration Activities at the Six Case Study Agencies 112

    Figure 1: Performing a Blood Test at the York WIC Agency 12

    Figure 2: A Recertification Session at a Long Beach WIC Site 14

    Figure 3: Bar Code Scanner and Sheet Used in Time Study 32

    Figure 4: Topography of the Three County Area Served By Gallatin WIC and the
    Satellite Clinic Locations. 44

    Figure 5: Grady WIC Pediatric Clinic 55

    Figure 6: Kanabec WIC Clinic 65

    Figure 7: Use of Videotapes in the Waiting Area of a Long Beach WIC Site 77

    Figure 8: Use of Brochures in the Waiting Area of the Main York WIC Clinic
    87

    Figure 9: Waiting Area in Zuni WIC Clinic 93

    1. The Child Nutrition Act of 1966, as amended by section 123(a)(6) of P.L.
    101-147, 103 Stat. 898, Nov. 10, 1989.

    2. In this report, "in-kind" refers to something of value, such as office
    space, equipment, supplies, and services, that is donated from public or
    private sources at no cost to the WIC program.

    3. The first report in the series was Food Assistance: Financial Information
    on WIC Nutrition Services and Administrative Costs (GAO/RCED-00-66 , Mar. 6,
    2000). Subsequent reports will provide information on performance measures
    used to assess nutrition services and the impact of WIC services in the
    areas of nutrition education, breastfeeding promotion, and referrals.

    4. We conducted the survey for our report entitled Food Assistance:
    Financial Information on WIC Nutrition Services and Administrative Costs
    (GAO/RCED-00-66 , Mar. 6, 2000). That report contains a description of the
    survey methodology.

    5. Synthesis of Case Study Findings in the WIC Program. (Abt Associates,
    Dec. 1988)

    6. Program regulations give agencies discretion to determine which
    participants must have plans. However, regulations do require that plans
    must be prepared for participants requesting them.

    7. State WIC agencies use varying criteria to determine which participants
    are considered to be high-risk.

    8. In addition to examining the percent of staff time spent on each
    activity, we analyzed the percent of staff time costs that were devoted to
    each activity. We did this by using information on the amount of time that
    each individual spent on an activity as well as the individual's hourly wage
    rate. We found there was little difference between the percent of staff time
    and the percent of staff time costs for the various activities. Staff time
    and staff time costs percentages are reported in app. V.

    9. The time spent on these specific activities during our time study period
    at Kanabec was probably less than typically spent because the WIC
    coordinator attended a training course related to nutrition education,
    during the study, which reduced the time normally spent providing nutrition
    education and breastfeeding education to participants.

    10. Fiscal year 1998 was the most recent year for which information on the
    indirect costs for the WIC program was readily available.

    11. We conducted the survey for our report entitled Food Assistance:
    Financial Information on WIC Nutrition Services and Administrative Costs
    (GAO/RCED-00-66, Mar. 6, 2000). That report contains a description of the
    survey methodology.

    12. Medical nutrition counseling addresses medical nutrition issues such as
    gestational diabetes. Gallatin, Kanabec, Long Beach, and Zuni referred
    participants who needed medical nutrition counseling to non-WIC dietitians.

    13. During our visit the York videotape machine was out of order.

    14. We conducted the survey for our report entitled Food Assistance:
    Financial Information on WIC Nutrition Services and Administrative Costs
    (GAO/RCED-00-66, Mar. 6, 2000). This report describes the survey
    methodology.

    15. A competent professional authority (CPA), according to program
    regulations, is an individual on the staff of a local agency who is
    authorized to determine nutritional risk and prescribe supplemental foods.
    Individuals who can be designated as a CPA include nutritionists,
    dietitians, nurses, and medically trained health officials.

    16. The percentage of breastfed infants may be inflated because the infants
    whose style of feeding has not been identified are averaged into the
    breastfeeding average.

    17. USDA regulations require documentation of family income for individuals
    not participating in a qualifying program, such as the Food Stamp Program or
    Medicaid.

    18. In accordance with state policy, local agencies cannot charge the WIC
    program for indirect costs in excess of 10 percent of program expenditures
    for personnel minus benefits.

    19. In California, high-risk is referred to as high intervention level.

    20. According to the WIC Director, the value of the contribution was between
    $10,000 and $30,000. For our estimate we used $20,000.
    *** End of document. ***