HRSA/MCHB 2005 FEDERAL/STATE PARTNERSHIP MEETING

PUBLIC HEALTH ACROSS THE LIFESPAN

MCH and WIC Coordination

PATRICIA DANIELS: Thank you, Michelle. When Michelle asked me to do this session, it was a bit of a challenge for me because I know that some of you are very familiar with the WIC program. And then I thought perhaps there would be some of the others attending this meeting who wouldn’t have a good idea what WIC was and then I thought, “Well, you know, even those people who think they know WIC, often miss some of the unique features of WIC.” So I’m going to bore you for just a few minutes and talk, give you a little overview of the WIC program; however at any point please interrupt me and ask questions. And then at the conclusion of my brief presentation, I’d like to have some very open free unrestrained discussion about maternal and child health and WIC coordination. I think it’s very important and one that we recognize. They are some issues, and we are here to hear your comments, your concerns and to proceed from there. I’d like to introduce Clara French who’s with me, Clara. Say, “Hello.” Clara is our policy group for the WIC program, and she knows all about privacy and confidentiality requirements, data sharing and et cetera. So she is there to keep me on the straight and narrow and to answer the real technical questions.

Okay. WIC makes a difference. The slide is there for only one reason is that is because I paid a lot of money for that poster and I decided I was going to use it in every presentation for the next year. Topics as I said, a brief overview of the WIC program. I’m going to talk a little about our WIC participant and program characteristics report, which is actually the only data collection that we do at the national level in the WIC program. And I’ve included that because several weeks ago we had a meeting with Dr. Peter van Dyke, and he was quite surprised to find that we did not have the state of the art information reporting system that you all have with. We don’t have Title V information system that state-of-the-art qualitative and quantitative performance, reporting of performance measures as well as your annual report. I’m going to tell you a little bit about what we do have. And then I’m going to talk just a bit about our state management information systems. And then about WIC data sharing and share where you a very successful coordination effort, or collaboration effort between wick and the immunization program.

Our WIC mission is basically to serve as an adjunct to good health care during critical times of growth and development. In order to prevent the occurrence of health problems including drug and other harmful substance abuse and to improve of health status of eligible infants mothers and children. I chose to put including drug and other harmful substance abuse in yellow because that was not an original mandate for the WIC program; however Congress in its infinite wisdom found that we have access to the maternal and child health population and therefore we needed to be given a mandate that would help with the referrals. That’s sometimes not a very popular component of the WIC program, but I think it’s a very important one and one that we often sometimes, I think, overlook. And when we talk about what are the WIC benefits.

We also have three primary benefits to the WIC program. We provide a supplemental food package. We provide nutrition education for the participant if it is a mother or for the caregiver if we of an infant or child in the program. And we also provide referrals to Health and Social Services.

Working together to serve our customers. I wanted to share this with you particularly because our structure is a little different from Department of Health and Human Services. The Food and Nutrition Service is an agency within the U.S. Department of Agriculture: and as a federal agency we administer the program, but we also allow a lot of flexibility in state’s administrative decisions. States have a lot of discretion. One of the reasons the states have so much discretion in administering the WIC program is because the WIC program actual authorizing legislation was written up by a federal agency, but by a task force of state and local public health nutrition advocates. And therefore the WIC legislation was written to allow minimal imposition from the federal standpoint and that has served them well over the years. Therefore when we talk about WIC programs we have to keep in mind this flexibility and understand that at the state agency level, WIC may look very different from state to state.

We also have our program cooperators who operate as sub grantees to the state agencies. And these sub grantees also have some varied ability in how they carry out the program, depending on the level of prescriptiveness that’s included in their contracts. And then ultimately we all work together to serve our consumers or the program participants who are our ultimate customers.

Where is WIC? Well, we have 50 state agencies, 50 geographic state agencies. We have trust territories, and we have 34 Indian tribal organizations. That means when we say WIC state agency, we’re talking about some very different configurations there, both in variations in size as well as capabilities and infrastructure. Our 34 Indian tribal organizations may be a two-person office that functions as a state agency, or it may be a 30-person office that serves the Navajo Nation out of seven different clinics. We have 90 state agencies and ITO’s, in total, more than 2,000 local agencies. And more than 10,000 clinics. And 46,000 authorized grocers. And the authorized grocers have a relationship with those state agencies. That’s just to give you a little sense of the WIC program and also to say that the WIC program is very data heavy. Operating the way we do, there is a lot of information generated between those grocers and those local agencies with the actual awarding of those checks and vouchers, the cashing and the redemption of those vouchers and the reconciliation. There is a lot of information exchanged in the WIC program.

So how does one become eligible for WIC? Well, we have categorical eligibility that’s based on whether you’re a pregnant woman, postpartum woman, an infant, child. Also we have income eligibility at 185 percent of poverty. There is also some flexibility for states to set the income eligibility a little lower. I believe most of our states operate at 185 percent, Clara; is that correct?

We have a residential requirement that says you must live in your service area; however, we do not have a citizenship requirement in the WIC program. And we also have nutritional risk as an eligibility. Now let’s talk a little bit more about what nutritional risk is. The WIC nutritional risk may be medically based such as anemia, underweight, history of poor pregnancy outcome, or it may be dietary based such as inappropriate dietary patterns or it may be due to some predisposing factor. What is a predisposing factor? Well, say we had an infant who was nutritionally at-risk because of their low hematocrit and during the six-month certification period, the hematocrit reading was now normal. But because of some conditions within that family or some situation, the nutritionist felt that that child was at risk of in how having his hematocrit again be undesirable levels if he were not left on the program. That’s a predisposing factor. We don’t have that used a lot anymore in the program. Part of that is because the program, at this point we’re serving such a large proportion of our WIC eligibles that oftentimes the caseloads are at maximum capacity.

So what is a WIC certification? The WIC certification is actually a screening to determine the applicant eligible and it’s provided at no cost to the applicant. And at a minimum it should include a blood workup and height and weight measurements and also it frequently includes a health history and a dietary assessment. The data collected from this certification is entered into the state‘s management information system. The certification periods for WIC are short. WIC is really a short–term program. A participant can graduate in as sort as six months as a pregnant woman if they come in just before they deliver. Or be there for a period of a year. A WIC certification program is generally six months to a year, depending on the categorical eligibility. A pregnant woman is allowed to stay on the program for one year after delivery if she is breast-feeding. If she is not breast feeding postpartum it’s only six months. For an infant, they are eligible up to age five, infants and children.

The WIC priority system is a way that we manage our caseload. The WIC program is a discretionary program as opposed to say the food stamp program which is an entitlement. Thank you. It just went like that. Senior moment, thank you. It’s an entitlement program. And because WIC is a discretionary program, we have to manage within the grant that’s provided. And the way that we have developed to do that is that local agencies have established priority systems so that when we cannot serve we serve the highest priority first. When we cannot serve all eligibles. About 75 percent of all participants are class identified in the priorities one through three. The WIC priority system includes for priority one, medical nutritional risk which may be for pregnant women, breast feeding women or infants; priority two, predisposing factors for infants of WIC moms, and priority three; would be medical nutritional risk for children. Priority four would be inadequate dietary pattern for infants, pregnant women or for breast-feeding women. Priority four inadequate dietary patterns for children and then priority six, all nutritional risk for postpartum women and priority seven which is optional for state agencies and that’s the fear much regression or homelessness and vibrancy.

We have seven WIC food packages. There’s a package for the infant; 0-3 months; one for the 4 to 12 month old infant; and then food package three which is children and women of special dietary needs where there is special medical foods or some other special requirements. And then there’s food package four for children one through five, the pregnant breastfeeding woman’s basic package. And then there’s the no breastfeeding postpartum women’s package for, that’s six. And then number seven is the breastfeeding woman’s enhanced package. And that enhancement amounts to carrots and tuna being in the pregnant woman’s package.

Well, the WIC food package is certainly the topic of conversation over the last couple of years, primarily because the food package has not had a major change in its over 30 years of the WIC program. And for the last six years we have been working to revise the WIC food package and I’ll tell you a little bit more about those revisions. The current food package was selected to provide the target nutrients of protein, calcium, iron, vitamin A and vitamin C because during the 1960’s the nutritional status data for the nation, particularly the low–income citizens showed that these were the nutrients of primary concern. And the food selected in that WIC food package were selected solely to be good sources of these target nutrients. And also we wanted to find foods that were easily consumed that were acceptable to the clients and fairly inexpensive. So we ended up with our current foods in the food packages. We provide infant formula, infant cereal, infant and adult cereals, and we have juices, eggs, milk and cheese, peanut butter, dry beans or peas, carrots and canned tuna.

However, in April of this year the WIC food packages were in for a wonderful remake. The Institute of Medicine issued a report. We had asked the Institute of Medicine to review the current food packages, and also to review them on the basis first looking at the nutritional requirements of our target population, then to look at the supplemental nutritional needs of that population, and then based on practical recommendations for changes based on current nutrition science. And also to take into consideration the comments that were provided from the general public. We did publish in the federal register an advance notice of public rule making and in response to that we received many, many comments. And these comments were provided to the Institute of Medicine committee for their considerations and their deliberations. We also had a document from the National WIC association with their recommendations that were provided to the IOM committee. And we also issue with recommendations that had come from many years of accumulation of comments, concerns, and issues raised by participants and WIC staff alike across the country.

The recommendations that the Institute of Medicine provided in their report released in April were kind of exciting for those of us who are been in WIC for a while. One of the things, and I’ll go over some of the major changes. They deleted infant juices. This is under the infant package. They also added fruit and vegetable choices for infants six to twelve months and that’s baby foods. They also added baby meats for the breast-feeding infants of six to twelve months. They reduced infant formula by about 23 percent for infants of six to twelve months. And they replaced that formula reduction with infant foods. They also recommended that mothers who initiate breast-feeding would not routinely receive formula in the first month after birth. This means that a wick mother when she delivers will have to make a choice. That she will either be a breast-feeding mother or a formula feeding mother. If she's a breast-feeding mother, she will receive no formula. Currently breast-feeding mothers are issued formula, or can be issued formula in the WIC program. For the women and children’s package, milk was reduced by 21 to 33 percent. And only low–fat milk will be allowed for the one–year olds, reduced fat yogurt and calcium–set tofu can be a partial substitute for milk. Calcium and vitamin D fortified soy beverages can also be a partial or full substitute. These proposals were made in consideration of the cultural requests that we’ve had for cultural accommodations over the years. And cheese substitution was reduced by two-thirds in most packages. Whole grain bread or other whole grain options such as whole grain cereal were recommended. We currently have cereal, but we don’t have breads provided, and the whole grain products is certainly a new addition.

The definition that the Institute of Medicine gave for whole grain products was 51 percent of the product must be whole grain. They made that distinction because at this point FDA requires all food items that carry the whole grain label to have a minimum of 51 percent whole grain cereals. That means a lot of the cereals currently available or currently authorized for purchase in the WIC program will no longer be available. IOM, when I asked why did they make that decision to go to 51 percent, they said because of the FDA labeling requirement they thought it would be easier for the participants because they could go in and look at a package and see that it said whole grain. And they can only label it whole grain if it’s 51 percent. Well, with that in mind, I went shopping the other day and reached for a pack ever cereal, and it says, “Good source of whole grain.” I don’t know how many people are going to distinguish between whole grain and good source of whole grains but that’s what they’re faced with out there. But we shall see.

We also have canned beans that may be substituted for our dried beans. And that’s a convenience item I’m sure that many of our working moms will be happy about that. Not necessarily working moms. One of the things we’re finding is that our younger moms don’t know what to do with the dried beans and peas available in the WIC program. They never learned to cook. If they can’t cook it in the microwave, that’s it.

We also have canned fish that is an alternative for this tuna, maybe offered in the breast-feeding woman’s package. Other changes included reduction of eggs by 50 percent down to one dozen. And the reduction of the quantities of juice by 50 percent. And this is the big change- and that is the addition of fresh fruits and vegetables may be purchased with a cash voucher of $8.00 to $10.00 per month. And states may allow fresh, frozen, or canned as substitutes. However, under this provision there is one caveat and that is potatoes are the only major vegetable that will be excluded from purchase under fruits and vegetables. And that decision was made by IOM because the food consumption data is showing that 50 percent of all the vegetables consumed in this country are potatoes and over 50 percent of those potatoes are consumed as french fries. And the sense was that there is an over consumption of potatoes, potatoes, while they provide some vitamin C that there is really not a lot that we could do with potatoes that we need to be spending money for. So they opted to say, “No.” Now remember that this program is administered in the U.S. Department of Agriculture whose job is to promote the consumption of American commodities and the potato board is a big commodity group. So we’ll see where that goes.

Our implementation plan for these new recommendations will be very short because by law we must develop an issue, a final rule within 18 months of the report’s release date, which was as I said April 2005.

We were planning to develop a propose rule for public comment that will incorporate all of the recommendations from the Institute of Medicine report. And we anticipate publishing this proposed rule for comment in January. I ask you all as members of the public health community to please, when this is published in the federal register, please take the time to review the recommendations and make your comments. Believe me, every commodity group, every food group that has seen a reduction in the quantities in the food package or did not get included in the food package will be submitting there comments. And what we are trying to put forward here is a food package that’s based on the science that’s not based on every commodity group’s felt need to be included for revenue purposes. So we need comments from the public health community, from the nutrition community, from the medical community, everyone who can look at these recommendations, objectively and think about the outcomes and what does it mean for maternal and child health population and the current knew nutritional issues that we face.

So after the publication of the proposed rule, which will include all of the recommendations that the Institute of Medicine has proposed, what we’ve done with those recommendations is only to make tweaks to them and add the administrivia. How do you handle this recommendation? How do you implement it? But we have in fact included all.

The interim final report, or final rule, that must be issued within 18 months, and that would be by October 20, 2006, will take into consideration all of the comments that have been received. And I doubt if it’s going to be as easy to get out the interim rule, as it has been to get this proposed rule out. But we shall see.

The WIC Nutrition Education goals, oh, I forgot this was being taped. I shouldn’t have given by spell then. Okay, The WIC Nutrition Ed goals. It doesn’t take much for me to get in trouble.

Nutrition Ed. is one of the important benefits of the WIC program, and we have been doing some work in this area for the last 6 years. We believe that nutrition education is a very important benefit for our WIC participants and primarily nutrition education is how we must address the prevention of overweight for children. We must begin to relate our nutrition education messages in ways that our clients can begin to understand and take action and be motivated to make behavior changes. And we can achieve that by doing what we call “WICening” which is to say, “Here’s a pamphlet. Read it.” That kind of information doesn’t get it as the discussion in this morning’s session about the need for very well designed nutrition education interventions in repetition and focus on motivating changes in behavior, not only in the clients themselves but also within the family context. So we’re doing a lot of work in the nutrition education area.

We’re also doing quite a bit in expanding WIC breast-feeding promotion and support. Certainly the breast feeding participants are eligible to participate in the WIC program for up to a year while eye postpartum woman who is not breast-feeding is eligible only for six months. But is really not a lot of incentive. We haven’t seen that a real incentive to increase initiation beyond a point. And the breast feeding participants receive a greater variety and quantity of foods than the nonbreastfeeding postpartum women. That also was intended as an incentive, but it serves to increase our rates very slightly.

What we have looked at though is expanding our WIC promotion and support. And one of the things that we’ve gone is to expand our efforts under our national WIC breast-feeding campaign, which is called “Loving Support Makes Breastfeeding Work.” And this campaign has been around now for almost ten years. And we have expanded it by added components that deal well the community. We have added a component called “Using Love and Support to Build a Breastfeeding Friendly Community.” And we have included in that training effort a collaboration between the food nutrition service Best Start social marketing and the Mississippi State Department of Health. And the intent was to provide training and technical assistance for WIC staff and for community partners in their targeted communities for their increased breast-feeding promotion efforts. And they were asked to bring in all of there maternal and child health partners, hospital, partners, private providers, nurses, actually churches a lot of other community groups and groups interested in breast feeding support and they were part of the community–based training to take WIC breast feeding promotion efforts out of the WIC clinic and make it part of the community effort and to better educate the community folks about what WIC was doing and these have been extremely successful. We have had over 22 states that have participated in these training efforts and CDC has had a strong partnership with us.

The physical activity and nutrition of CDC had their staff to attend each of our trainings. Someone from there staff participated. They also paid for additional training in two states and then they made a requirement that each of their community obesity grant recipients must have this training conducted as a part of their community activity. And that’s been very successful. We’ve also expanded our breast-feeding peer counseling component. And we’ve done that by increasing the funding available to the WIC program and also by increasing the training available and this funding is earmarked specifically for expanding peer counseling. The research has shown that peer counseling makes a definitive division in the initiation rate and the duration rate for breast-feeding.

WIC referrals, we’ve been doing this. We’ve continued to do this. I’m running short of time so let me get on so we can do the discussion. The average monthly participation witching the WIC program is 7.9 million participants a month.

The WIC funding has remained fairly stable with an inflation factor for 2006. We expect to be around 5.26 billion. And that’s fairly consistent. However, that’s a lot of money. And often when we talk with other programs within the maternal and child health arena, they say WIC has so much money but they’re stingy. They won’t share it with us. Well, there are restrictions on how WIC spends its money. The WIC formula that’s used for the state grants is a set formula and it provides appropriately 74 percent of all of WIC dollars as food dollars. Food dollars can only be spent to purchase food. Food dollars do not cover administrative costs, it doesn’t cover salaries. It doesn’t cover breast-feeding promotion. It doesn’t cover nutrition education. We have another small part of the grant, which is called Nutrition Services and Administration, which includes what we would normally find in administrative and operations or overhead cost which is only 9 percent. And then we have Client Services, which probably covers the personnel cost for the nutritionists, the clerks, et cetera. And then we have the nutrition education and breast-feeding promotion, which comes to about 6 percent of that grant.

State agencies have a lot of flexibility in how they run their programs. One of the things they don’t have flexibility in is how they spend WIC money. And remember the WIC program is administered through the Department of Agriculture. We have 14 nutrition assistance programs. The Food and Nutrition Services’ sole duty is to administer those federal grants. Our relationship with those state agencies is very different from the relationship that Health and Human Services has with their state level grantees, particularly HRSA where the role is to support the building of infrastructure for the delivery of public health programs and other things. All the Food Nutrition Services’ has been over the years is accountability for the money.

WIC is one of the younger programs within the food nutrition service. One of the things that we’ve learned from our big brothers like Food Stamps is how to stay out of the General Accounting Office’s reports on mismanagement and how not have to go before congressional inquiry committees about fraud, waste, abuse and other things. So we have in fact earned that reputation of being stingy.

Let me just hurry on here. Our participant characteristic study is the only data that we get from the WIC program and it’s collected only every two years in April. It’s a snap shop in the month of April, collected every two years. We have what we call the minimum data set. We do not have a fancy Title V information system type of reporting. We have a very basic inefficient reporting. The data that we get is gleaned from the state management information systems. But state management information systems run the gamut from state-of-the-art to being ten years out of date. We actually have a state operating on a cobalt management information system if you can believe it. So they run the gamut. Some of them are still very paper intensive. But they struggle and they can get that data in. Now there are states that collect a lot of data that we don’t even collect. They’re much more advanced than we are. The challenges that state management information systems has is, first of all as I said they’re aging and many of them lack some basic automated functions. We’ve identified 19 core functions for basic automation that we think every WIC program should have. And actually they all aren’t automated. And then funding for management information systems is extremely limited because we do not have designated funding for information systems. All of our technology funds come out of the nutrition services administration grant.

62 percent of the systems have exceeded their life cycle. 38 percent have about four years left. Our system functionality, we only had about 44 percent that can actually perform all of those 19 core functions. We also have some WIC confidentiality requirements that impact the disclosure of participant information. And I no that at this point there are some questions, or there may be some questions around the whole issue of data sharing and so why don’t I stop here and see if there are questions or comments. And then we can deal with the rest of the information. I don’t want to run out of time before we have time to deal with any questions if we have some or concerns.

UNKNOWN SPEAKER: Is nutrition network money where they do five–day advertising. Where does that money come from or how does that get generated through the USDA, and what is the purpose of that money? I wish I was a little more specific but I –

PATRICIA DANIELS: I know. Okay. What you’re talking about in California, what they call the California Nutrition Network and all of that comes out of several offices there in California. But basically what they’re using in California, they received a network grant that was funded back when the Food Nutrition Service finally woke up and recognized that nutrition education needed to be a part of Food Stamps. One of the first things they did was to award some grants, discretionary grants. And one of them went to California. And these grants were for establishing in networks and trying to pilot different ways to do nutrition education to support the Food Stamp office. And California got one of those.

Subsequent to that the Food Stamp state grants were put into place where states submit a grant request or grant proposal and for whatever funds, for state funds, I’m sorry, Federal Nutrition Education funds and the state puts in a matching grant. That’s where that 200 million of federal funds is spent for Nutrition Ed. in support of the Food Stamp program and that’s matched by another 200 million from state agencies. So there is a 50/50 match.

California ’s money is being used--some of California ’s money is being used to support the network and some of the activities that they’re doing. How well coordinated is it? Well, SNAP was put in place, one of the projects I talked about there briefly this morning. That’s called the state nutrition action plan. SNAP was put in place to try to get a handle on some of the states like California that just was all over the place with there Food Stamp monies. And believe me the Food Stamp people aren’t real happy about it. So they’re beginning to real them in in terms of how they’re directing they’re funds and making it more prescriptive and directive. But they also have monies that are coming in for fruit and vegetable promotion. There is a lot of, I think, a number of funding streams that go into their activities and are fairly broad. But it’s not WIC; I’ll tell you that.

UNKNOWN SPEAKER: The reason I was asking is it says MCH and WIC coordination and neither one of those programs in California control how that money is spent.

PATRICIA DANIELS: That’s Food Stamp monies and I don’t know what office Sue Forrester works for?

UNKNOWN SPEAKER: Prevention Services.

PATRICIA DANIELS: Okay, and the extension service. That office and extension service would probably be –

UNKNOWN SPEAKER: So, when they’re looking at it will they then come up with different approaches or a it’s working or that it’s doing what they are intending or?

PATRICIA DANIELS: It’s up to the state. It’s up to the state agency. Again, there is some discretion in how the state manages they’re Nutrition Ed. grants within the Food Stamp program. But the guidelines are becoming more prescriptive.

Are there other questions?

UNKNOWN SPEAKER: A data-sharing question. I’m with the state of Maryland and I work with our SSID program, Title V has asked us to look at linking WIC and Vital Statistics data, and about 25 percent of the states do that. We were always told in Maryland that we can’t because USDA requirements prohibit it.

PATRICIA DANIELS: Yes we do have confidentiality requirements. However they done prohibit data sharing. There are some restrictions on that, on how it must be done. And data can be shared with persons who are directly connected with the administration or the enforcement of WIC or representatives of public organizations designated by the achieve state health officer which administers health or welfare programs that serve persons categorically eligible for WIC. So that means that in fact you can have data sharing with them MCH programs. There is also a requirement that sharing data with public organizations that don’t intend to publish this data to a third party or make it available to a third party. One of the things you have to do is have a memorandum of understanding. That memorandum of understanding must be between the organization and the WIC program.

So your specific MCH program in that program. There may be one memorandum of understanding coming from the health department, state health department, that has the signature for five different programs on there but each of those programs must have a signee with the WIC program. So you don’t have to have five different MOU’s, but you can do it all in one, and are ways to do that and also understanding that we must have written consent of the WIC applicant. Well that’s usually taken care of when they sign up for the WIC program they do sign a consent for sharing of there data for limited purposes. If your doing a third party data sharing, and that’s if the information has identifiers on it. There is a third--if the information is to be shared with the third party, there needs to be a separate written consent from the WIC applicant specifically for that data and how it will be used. That’s over simplification of the process. That’s if you are sharing data with identifiers.

There is another option and that is the data can be shared in aggregate or summary data where all identifiers are removed. And for some purposes that’s enough. If you are trying to track services to families it may not be. You may need the identifiers so you can track it back to the family unit. But for a lot of cases aggregate or summary data is sufficient.

Now, we no that there has been some problems with that and some of those problems can be addressed to the fact that maybe state WIC programs aren’t interested in sharing that data because in order to prepare that data in an aggregate form to share it, it’s a resource burden on them. They don’t have the money. First of all if they have got one of those clunking systems it takes a lot to manipulate the data to make it even useful, if they can transfer it. So that could be a limitation in some places. Other places it’s not. It may be other concerns.

What we have said in our guidance and we have data confidentialities addressed in our regulation. It’s also addressed in an instruction and we have a policy memo. And in reading those three in preparation for this meeting I realize they are very convoluted. And what we have said though on several times was that that data, I mean in developing the MOU’s, the state agencies were encouraged to work with their legal counsel. They were encouraged to work with there are legal counsel in developing the MOU’s. Now that goes back to the fact that the WIC program is designed with a lot of state flexibility. And states have options. They can share data. They also have options to decide they don’t want to share data. If they want to share data there is a way for them to do that. We have said that they need to work with there are legal counsel at the state level in writing up those MOU’s because sometimes the state has confidentiality requirements that may be more stringent than what we have at the federal level. We are, however, going to work with our regional offices and with our state WIC directors to encourage and cajole, jawbone, do whatever towards a more conciliatory he other relationship when it comes to data sharing.

Let’s talk about the coordination, what’s needed and we were going to go back and that’s one of the reasons, Clara’s here today. We’re going to go back and take a look at all of our guidance and try to come up with some simple guidance that clarifies it. This is what you need to do, very basic. And then work with our state regional directors and our agencies so that they will understand. I personally believe that data sharing from the WIC population is an important part of WIC’s role as a public health nutrition program. But you must understand that WIC has not been perceived as a public health nutrition program since it was public in the Department of Agriculture. It was conceived as a public health program when it was originally designed, when Congress passed the legislation Department of Health Education and Welfare says, “Not us. That’s a food assistance program, we don’t want it.” The Department of Agriculture said, “We don’t want it. That’s a health program, a nutrition program. We don’t want it.” But Congress forced, well actually the secretary of agriculture didn’t accept the program. It was only after the nutrition advocates sued the secretary of agriculture that the WIC program was implemented within agriculture. And in that environment the WIC program was implemented to be very restrictive. It was not a health program. Data sharing, it is the WIC program. It’s categorical funding and within the culture of FNS where the big deal is, “How are you going to account for this money? And was it spent for its intended purpose?” And that’s the environment that the WIC program has developed in. And that makes it a little bit more restrictive. And that’s why I talk about the cultural difference. What we’re working on now is presenting WIC as a public health nutrition program where our intervention is primary education and that we have a collaborative role with other maternal and child health programs. And one of those tasks under that role is the sharing of data for the purposes of monitoring, because we don’t do that kind of monitoring and tracking within the WIC program.

There is some sense that we’re working on that, “Well, how do you know the outcomes for the WIC program?” Well, the outcome of the WIC program is how many food packages you provide and how many people do you see. So our participation numbers is our outcome. “Well, how do you get to quality?” Well, we haven’t been looking too much at quality. But, if we are going to get to quality the way we would look at it is looking at our national nutrition surveillance system. To look at the trends in the pediatric nutrition surveillance and the pregnancy nutrition surveillance data, because right now the pediatric nutrition surveillance data, 80 percent of those records are WIC records, and if you want to talk about outcomes for WIC, that’s where you look in the long term. So I mean that’s kind of where we’re going and still jawboning that with our folks.

We’ve also had a change at the state levels. Those public health nutrition folks who really fought to get this program have retired, they’re gone, they have been replaced with administrative types who really don’t have a perspective of WIC and it’s greater role. So you are going to have a variation from state depending on personalities, either with the WIC director, the MCH director, with the achieve health officer even at local clinics, the local directors, the environment they are in. So all of that comes into play when you start talking about coordination.

UNKNOWN SPEAKER: I want to add from a document that I hadn’t read and that’s the MCHB nutrition strategic plan. So I don’t know anything about it. But I guess my question is more of the flexibility question. The question is what do you see as the maximum feasible participation of state level WIC folk. In a process envisioned by, a strategic plan by maternal and child health?

PATRICIA DANIELS: Oh, that’s a loaded question. And I can’t respond to that because I don’t know what’s in the plan. I don’t know whether it’s feasible or not. I do not that what we are trying to do is to promote an environment of collaboration to sit down and jointly look at what can be done, what WIC can contribute, what’s essential.

UNKNOWN SPEAKER: So if I were to read and understand the plan and then bring in the WIC folk in and say here’s the plan, what do you think, et cetera we might have a conversation that might include the regional office about what their role might be. Is that one way to proceed?

PATRICIA DANIELS: Well, yeah. I would think so. To ask them to review that plan as you view it and then to sit down together and try to identify what the respective roles would be and then they would go and work with their regional office to be sure that they can structure a memorandum that will be acceptable and supportive. Now see one of the processes, and we will be work with our regional offices, not that we have “have confidentiality experts there,” but they know the policy and they will also have to work with their state legal counsel with that memorandum of understanding. But just understanding that the WIC state directors are always concerned about what’s going to happen under an audit. And we are noted, I mean USDA has some very restrictive requirements. Because when we as USDA employees look at how DHHS operates their grantee programs, I go like, “Whoa, we’d all be in jail in USDA.” It just doesn’t word that way. There is that flexibility. It isn’t there. And I think people are nervous about that.

UNKNOWN SPEAKER: Would it help, because we have a bureau of nutrition services. It’s not the bureau of WIC. But which don’t put any MCHB Title V money into that because, hey, they have got WIC funds. Would it help to fund 10 percent ever 10 people with Title V money?

PATRICIA DANIELS: Sure. If you are willing to put that kind of offer on the table, I’m sure they’d be willing to talk to you. But that’s what we are saying. Encouraging you to go back and have those conversations.

UNKNOWN SPEAKER: Yeah.

PATRICIA DANIELS: Yes.

UNKNOWN SPEAKER: At the state level the pediatric nutrition surveillance of areas.

PATRICIA DANIELS: It varies. We’ve had an effort here in the last three years to encourage WIC state agencies to provide data. And we have had about ten states to come on board. We provide small grants for them to tinker with these MIS systems so that they can provide data in a format that CDC can except so we have been encouraging them. But it depends. The data is not housed in any one place so there may be one person responsible for coordination of the data submission from a state, but they are pulling from many different sources. It’s my understanding. For maybe some of who work with this data at the state agency can better answer that.

UNKNOWN SPEAKER: We use Mighty Mass Index in the pediatric side and in some of the MCH data, is we get a weight and a height and the WIC participant program characteristics, is there ever going to be like body mass index or complications of obesity some other way? Because in my state WIC is the biggest service delivery of women and children and it’s not MCH services.

PATRICIA DANIELS: Some states are actually recording the BMI. And the BMI data is available in some states, not all states. I’m not sure which states. Now again that’s one of the things that we have to look at if that’s one of the data needs and you’re looking at the WIC community to sit down and talk with them about it.

MICHELLE LAWLER: I should add too that’s one of the impetus for really this meeting. if you had time to go in and look on the website at the proposed performance measures as we talked the other day, we have proposed the addition of two new performance measures. One of which centers around overweight, looking at children ages 2 to 5 receiving WIC services that are at or about the 85 percentile BMI. So one of reasons we have had our work group, we have had a lot of input into this process, and what has come up several times from Title V directors and state epidemiologists is that they have a very hard time getting data from the WIC program. So one of the reasons we really wanted to do this session is to talk about some of those issues that have you at the state level with sharing data, not to have that be an end point, really have that be sort of a starting point. But to talk about some states seem to do it very well. Other states seem to really struggle. And when we suggested using the WIC population, some of the state

Title V directors said WIC won’t give us their data. So you know just to take maybe the last few minutes and really have a frank discussion around in of those issues, not limiting coordination to just data sharing, but there does seem to be an issue in many states around the sharing of data and in considering that that is a proposed national performance measure just to maybe get your thoughts on that or if have you any questions, Pat’s the person to ask.

We did have a meeting several weeks ago with Dr. van Dyke and the NCH staff and the WIC staff, and we really are going to be trying to work at this at the federal level to move that forward to explore what the options are. As you can see from some of Pat’s slides, there are options for sharing data. But to get that information out to you all, what the parameters are what the limitations are maybe to share success stories, there are some. But it really is helpful that I’d like to have to hear from you all too. In the first session we will earlier today, a lot of issues were raised, so any thoughts on that or any comments that you all would like to make?

UNKNOWN SPEAKER: I saw that just last week or so, and I don’t recall the phrasing within the WIC population and (inaudible)

MICHELLE LAWLER: I think it says Receiving WIC Services.

UNKNOWN SPEAKER: Does it say WIC? It does say it. My concern is that’s simply not representative of the population and historically we look at total population. So I had a concern about that. On the other hand we invested Title V funding in doing a combined open mouth oral health survey and standardized training to get heights and weights. I represented a sample of third graders in every county in Ohio, so we are in the process of crunching data. We will have county specific measures of BMI for 8-year olds. So in a sense it would be great to have 3- to 5-year olds or whatever and then also 3- to 5- of a subset. But it’s going to confuse us, I think, to try to figure out is that truly representative or how is that not representative of a population in a way the third-grader is more represented, particular difficulty exchanging information. I think part of it is we are still gearing up in terms of thinking about obesity. We haven’t gone to other data sources. I don’t know. We have asked our WIC program to tell us what the BMI’s are of the people in the program. So the testing for us (inaudible)

MICHELLE LAWLER: And we understand your concern about how representative it is. As you know an issue in trying to decide a national performance measure is data source that all states can use. So I mean we looked a YRB as, we looked at--and that’s a little bit too old. We really would like to be a little bit more preventive in our thinking than to wait to that point and as you saw Dr. van Dyke’s slides from this morning, really that whole system’s capacity indicators setting up; what are the data sources? So we use that information. And WIC seemed to be the one that most states had some WIC data and had sample sizes large enough to provide a statewide estimate. But that’s good to hear that you really have not had that many problems with data sharing with the WIC program. Earlier we seemed to have a lot of people that had problems so it’s nice to have the other side represented too.

PATRICIA DANIELS: We don’t study. We don’t track our participants, so we don’t know what the outcomes are. We can’t compare that mom who stays on that extra six months to the mom who didn’t for those three months. Again, if we were really in the business of monitoring our health care delivery and looking at quality of services, that’s the kind of thing that we would monitor. But, we don’t have research money in the WIC program. Our research is done either through extramural research from universities or some other agency like the immunization study. It’s funded from some other source. We used to be able to do some major studies for data collection, but we don’t have the authorization anymore to do any kind of research or evaluation in the WIC program.

UNKNOWN SPEAKER: So when we thought about, was the (inaudible).

UNKNOWN SPEAKERS: Breast-feeding?

PATRICIA DANIELS: That’s the, you know, that was just the standard as an incentive, as an incentive for breast-feeding; to encourage breast-feeding, that’s the only reason, because otherwise, the postpartum mom was eligible for only six months.

UNKNOWN SPEAKER: You (inaudible) 75 percent--

UNKNOWN SPEAKER: In my state 75% of the moms are not breastfeeding, but they still have some of the issues and needing WIC. What does that mom do? I had that same conversation with my WIC colleagues. It almost seems like a penalty to the moms that don’t decide to breast-feed.

PATRICIA DANIELS: Well, if the mom is on for a nutritional risk, a medical risk and there’s fear of regression, she gets to be on for a year. I mean, if there is a medical reason for the mom to be on, but remember WIC is not solely on the basis of income. It’s designed to improve the outcome of that pregnancy for the mom and actually, the mom’s almost incidental in the way WIC is designed. She’s just the delivery of the infant that we want to get here well and keep well, because it’s the infant and the child, you know, so ---

MICHELLE LAWLER: I think that’s part of the issue too, though, is that she is breastfeeding, so invariably the infant is not getting as much formula, if any formula, so they’re looking at the mother as the primary source versus the postpartum mom that’s receiving the full complements.

UNKNOWN SPEAKER: And I understand that, but I mean, it’s sort of time that we look at the data. If we’re looking at pre-conceptual health and end conceptual health, in looking at the figures, and I can tell you about infant mortality from a state that’s not doing very well, then I think it’s very hard to support those arguments.

PATRICIA DANIELS: Yeah, if you’re looking at it in terms of pre-conceptual health, because those young WIC moms are going to be back in a year or two, you know.

UNKNOWN SPEAKER: And we want them healthy, hopefully healthy.

PATRICIA DANIELS: But again, understanding as WIC has evolved, it was an intervention for improving nutritional deficiencies and it has not evolved under the new research, in light of the new research, and where we should be in health care delivery systems.

UNKNOWN SPEAKERS: In the (inaudible)--

CLARA: I was just going to provide one clarification. Currently with regard to entering into MOU’s with other programs, the purposes right now stated in the regulations, is for eligibility in the outreach; it kind of goes to your issue. We published proposed regulations in 2002 to revise our confidentiality provisions to give states greater flexibility in the reasons to which they would share information with other programs, and one of the areas that we added in the proposal was for the purpose of assessing and evaluating states’ health systems and health care outcomes. We hope to issue regulations around February of 2006.

UNKNOWN SPEAKERS: Thank you.

MICHELLE LAWLER: I’d like to thank you all. That’s very good news Clara, and we will be continuing to work on this at the federal level, but certainly I think input is very helpful, so if you see issues or have issues, we’re really trying to promote coordination between MCH and WIC. Certainly, this is something, and it will vary from state to state, bit this is something that we are trying to take a stand to at the federal level. So, I’d like to thank you all for your attention and I’d like to particularly thank Patricia Daniels for being here.