1) Established in 1936, Florida Department of Health in Pinellas County (DOH-Pinellas) is the only public health agency with jurisdiction for Pinellas County and reports directly to the Florida Department of Health (FDOH) and to Pinellas County Government (State/County Contract). Pinellas County is the most densely populated county in Florida with 916,542 residents. Demographically, the county is comprised of 82.41% White and 10.34% Black or African American residents, and the remaining identified as other races including Asian, Native American and South Pacific Islander. DOH-Pinellas maintains a budget of $46.5 million and administers $13.7 million in (federal, state, local) grant funds. As one of Florida’s largest county health departments, the agency employs 600+ employees and provided 1,172,616 units of health services in six main health centers to 82,279 clients in FY 13/14. Health Department staff provide personal health services, community outreach and family support, Maternal and Child Health home visiting services and family planning, immunization, chronic disease prevention services, school health, nursing, nutrition and WIC, dental, communicable disease control services, public health preparedness, and environmental services-all supported by state of the art fiscal, purchasing and information technology (IT) systems.
2) Public Health Issue: The Special Supplemental Food Program for Women Infants and Children (WIC) is a federally funded program administered at the local level by the County Health Department, which seeks to address the substantial numbers of pregnant, postpartum and breastfeeding women, infants and young children from families with inadequate income who are at special risk with respect to their physical and mental health because of inadequate nutrition, health care, or both. More specific to Pinellas County WIC and Nutrition (Pinellas-WIC) was to address the percentage of clients eligible for WIC benefits, but not participating in the WIC Program.
3) Goals and Objectives: The primary goal is to increase participation in the WIC Program by providing greater access to services and to decrease the average client wait time for benefit issuance. The objective was to provide Drive-Thru window services that would be a faster and more convenient option that clients could use to receive some types of WIC benefits; thereby reducing non-participation. Offering clients a convenient Drive-Thru option for benefit issuance achieves both.
4) How was the Practice Implemented?: During construction of the recently opened DOH-Pinellas Mid County Health Department in Largo, Claude Dharamraj, MD, MPH and Director of DOH-Pinellas approved a prototype Drive-Thru window for the WIC clinic. The window consists of a drawer similar to that of a bank teller. One Senior Clerk is dedicated to the Drive-Thru Window. Clients can drive up to the window, and while remaining in their vehicle conduct express services including reloading of benefits, nutrition education newsletter contact, resolving a temporary certification and even picking up small quantities of special infant formula. Important milestones include: February 2012, the Drive-Thru opened for business and usage tracking began immediately; October 2013 the Florida State WIC office conducted a site visit and were impressed with the ability to provide nutrition education contacts as well as to issue benefits via the Drive-Thru Window; February 2014 the Drive-Thru closed temporarily for 3 months due to conversion to Florida Wise; April 2014 Drive-Thru services resumed using upgraded Florida Wise/EBT system. Duration of a Drive-Thru service ranges from 5 to 10 minutes. In addition, extended hours of operation are also offered due to the nature of the services, and as an added convenience for clients.
5) Results: The results of the newly implemented Drive-Thru Window include improved ability to serve clients in a more efficient manner. The average wait time for clients obtaining services via the Drive-Thru is approximately 5 minutes as compared to approximately 20 minutes for clients receiving similar types of services inside the clinic. The addition of a point of service increases capacity to serve clients by approximately 20 per day. The increased efficiency of the Drive-Thru Window also allows for staffing overhead to be reduced by 0.5 FTE. The new EBT process allows for even more convenient client transactions because benefits are easier and quicker to load onto an EBT card as compared with the prior paper voucher system. It is also possible to quickly and easily transfer clients between the 6 WIC Pinellas offices. This is a significant benefit because it allows any client to receive benefits through the Drive-Thru, regardless of their assigned clinic.
6) Public Health Impact: The public health impact is an increase in client participation in the Mid-County WIC Center as evidenced by the increasing numbers of clients utilizing the Drive-Thru option. Client participation at the Mid-County WIC Center also increased, up by 35% in August 2014 as compared to August 2013 (3,625 August 2014 participants versus 2,683 August 2013).
The DOH-Pinellas Website is http://www.pinellashealth.com/
1) Brief Description of LHD – Location, Jurisdiction, Size, Type of Population Served: DOH-Pinellas is the only public health agency with jurisdiction for Pinellas County and reports directly to the Florida Department of Health (FDOH) and to Pinellas County Government (State/County Contract). Pinellas County is the most densely populated county in Florida with 916,542 residents. Demographically, the county is comprised of 82.41% White and10.34% Black or African American residents, and the remaining identified as other races including Asian, Native American and South Pacific Islander.
2) Statement of the Problem/Public Health Issue: The Special Supplemental Food Program for Women Infants and Children (WIC) is a federally funded program administered at the local level by the County Health Department, which seeks to address the substantial numbers of pregnant, postpartum and breastfeeding women, infants and young children from families with inadequate income who are at special risk with respect to their physical and mental health because of inadequate nutrition, health care, or both. Poor nutrition during the formative stages of the life cycle can result in poor birth outcomes, higher incidence of anemia, obesity, and multiple other chronic health conditions later in life. The WIC Program provides supplemental nutritious food, nutrition education, and breastfeeding promotion and support to categorically and income eligible women, infants and children who are Florida residents and who are at nutritional risk and in need of supplemental foods. The program aims to improve the nutrition status of participants by providing individualized and client centered nutrition screening, education/ counseling, health care referrals, immunization referrals, community service referrals, and staple foods to clients including milk, approved breakfast cereals, 100% fruit juice, eggs, peanut butter, beans, whole grains, baby cereals, baby foods, fresh fruits and vegetables and fish. The ultimate goal of the program is to improve health outcomes for pregnant women, infants and children with a desired additional benefit of decreased health care costs associated with increased understanding of the importance of good nutrition, inadequate access to nutritious foods, and hunger. Finally, the program promotes and supports breastfeeding as the preferred normative method of infant feeding.
The public health issue is the percentage of clients eligible for benefits, but not participating in the WIC Program. Non-participation is the number of people who have been certified and have not received benefits during a given month. Over the past several years, non-participation rates have steadily increased at both the county and state level. In 2011, Pinellas-WIC had an average non-participation rate of 17% as compared to 22% for 2013, and mirrors an overall statewide trend. In February 2013, Pinellas-WIC had a non-participation rate of 24% versus the state average of 20%. The objective of the program is to decrease the non-participation rate to that of the state average or below. Pinellas-WIC serves a caseload of approximately 20,400 clients at 6 locations throughout the county. Categorically eligible clients include pregnant, postpartum and breastfeeding women, infants and children until to the age of five. Clients must meet income eligibility, which is 185% of the poverty level or be Medicaid eligible. According to State WIC reports, September 2014 data shows Pinellas-WIC had reached 82.5% of all eligible clients, which was slightly higher than the overall state average of 82.0%.
The drive-thru option seeks to specifically address barriers to participation by providing a convenient option for clients. There are both internal and external factors that can potentially affect client non-participation rates. Externally, these factors can include economic trends, birth rates, and the age demographics of the community. Internally, long client wait times, program guidelines that require the client to return frequently for benefits and inconvenient hours have all been identified as potential barriers to service. The target population for this project is all categorically and income eligible women, infants and children up to 5 years of age who reside within Pinellas County. Table 1 shows that enrollment in the Pinellas-WIC is down significantly over the past 5 years, while Table 2 shows non-participation in the Pinellas-WIC program up significantly. The goal for Pinellas-WIC was to reduce non-participation to that of the state average and consequently, increase the percentage of eligible WIC clients served. September 2014 data for Pinellas County shows 19,593 participants eligible to receive WIC benefits with 82.5%, which is equal to 16,971. Over the past several years non-participation rates have steadily increased at both the county and state level.
Table 1 Pinellas WIC Enrollment Data *Source Florida Wise
Year Annual Total Enrollment2009 2784312010 2721342011 2554152012 2553422013 251982
*An enrollee is a client who is certified and is still in current status during a given reporting month.
Table 2 Pinellas Non-Participation Data *Source Florida Wise
Year % of Non-Participation2009 14%2010 17%2011 17%2012 20%2013 22%
*Non-Participation is the number of people who have been certified and have not received benefits during a given month.
3) What Has Been Done in the Past to Address the Problem: In the past, to increase participation, Pinellas County has: offered extended hours, offered a WIC Express inside the clinic, issued up to 3 (maximum) months of benefits to low risk clients, eliminated all unnecessary low risk nutrition education contacts, initiated a mid-certification service to extend income eligibility period to one year for infants, children and breastfeeding women, added community outreach events requirement of 4 events annually for every staff member’s performance objective and partnered with Pinellas Healthy Consortium and the local Cooperative Extension to offer cooking demonstration in the clinic using WIC approved foods.
4) Why is Current/Proposed Practice Better: This practice is better than the previous practices because it provides clients a more convenient method for obtaining their WIC benefits. The Drive-Thru at the Mid-County location opened in February 2012 and has proven to be a popular option for clients. The WIC Drive-Thru impacts public health by improving access to WIC services, improving customer service and timeliness of services while decreasing program costs. The added convenience of the service helps to increase participation because the client does not need to get out of the car to receive some WIC services. The location of Drive-Thru is another benefit; it is centrally located within the county making it easily accessible to all residents. Table 3 below shows the monthly Drive-Thru usage since opening, which serves an average of 194 clients per month. Since offering this service, the WIC clinic in Mid-County has experienced improved clinic flow by reducing client traffic through the waiting areas and parking creating more parking spaces for clients that need to enter the building.
Table 3 WIC Drive-Thru Totals
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2013 0 166 123 177 201 163 210 241 193 210 223 223
2014 414 1 3 24 95 194 249 170 229
*Due to implementation of a new computer system and EBT card conversion, the drive-thru was closed February – March 2014
6) Is Current Practice Innovative: As a new and innovative option, the Pinellas-WIC Drive-Thru offers a convenient service to our busy clients by removing one of the barriers to participation in the program. The Pinellas-WIC Mid-County Drive-Thru is the first and only drive-up service offered in the State of Florida. This innovative option has already been duplicated by the Mobile County, Alabama WIC Office, which unveiled a new Drive-Thru option in mid-October 2014.
Nutrition, Physical Activity, and Obesity
1) Goals and Objectives: The ultimate goal was to increase client participation in the WIC and Nutrition Program by adding a service that would improve efficiency and reduce client wait times. The objective of the project was to include a Drive-Thru Window in the Mid-County WIC Clinic, which would offer clients a convenient drive-thru option for some WIC services. The Drive-Thru option reduces wait time because clients’ do not need to get out of the car to receive services. It’s healthy “fast food”.
2) What did you do to achieve the goals and objectives: Pinellas-WIC program staff was involved with the initial design phase of the Mid-County Goal: to increase participation rate.. A vision quickly developed to add a drive-thru window option to the new site location. The Pinellas-WIC team worked on the logistics of the clinic flow and how to incorporate a drive-thru option that would be seamless to the client yet maximize efficiency. The Drive-Thru Window was located on an outside wall adjacent to the inside front check-in area. Clients were able to pull their vehicle alongside the Drive-Thru Window to receive services. The clerical staff responsible for the drive-thru operation is located inside the check-in area with other clerical staff. This utilizes staff to their fullest potential because only 2.5 clerical staff are necessary instead of the typical 3 clerks needed for WIC clinics that offer an inside WIC Express option.
3) Any Criteria for who was Selected to Receive the Practice (if applicable)? The drive-thru option is open to all WIC eligible participants enrolled in the program; regardless of their clinic assignment. It is important to note that not all WIC services can be provided via the Drive-Thru Window. Eligibility, certification, and mid-certifications all require the client to come into the clinic for service.
4) The timeframe for the practice: The timeframe for this project was lengthy (2009-2011) because an entirely new health department facility was being constructed. In early 2009 planning began for new a new facility to be centrally located within the county. The cost and timeframe can vary significantly, and will depend on the particular modifications necessary to accommodate a drive-thru facility for a particular location. Additional items needed for this project included a slide out drawer similar to what is used by the banking industry and a microphone system to communicate with clients. An employee work station must also be located in close proximity to the Drive-Thru Window that allows for computer access.
5) Were Other Stakeholders Involved: Collaboration between many state and county partners was necessary during the design, planning, implementation, and construction phase of the project. Internally finance, purchasing, IT WIC Program staff and the Director’s office were also involved in the successful implementation of the project.
6) Any Start up or In-Kind Costs and Funding Services: Funding for the construction phase of the project was provided through a county contract. It is difficult to estimate the start-up costs associated with the drive-thru because it was built during the construction of the Mid-County Health Department. The purchase of the slide-out window, microphone and employee work station is estimated to be $5,000 to $10,000 dollars. However, once operational, there would be little to no ongoing costs associated with the drive-thru operation. Additional staffing was not necessary because existing staff were used operate the drive-thru. In fact the opening of the drive-thru reduced staffing needs by 0.5 FTEs.
1) What Did you Find Out?: The primary goal is to increase participation in the WIC Program by providing greater access to services and to decrease the average client wait time for benefit issuance. The objective was to provide Drive-Thru Window services that would be a faster and more convenient option that clients could use to receive some types of WIC benefits; thereby reducing non-participation. This objective was met in February 2012.
2) Did You Evaluate Your Practice?: Between January and July 2014, Florida Wise indicators show a 26% increase in participation at the Mid-County WIC Clinic as compared to 9.2% for the county (6 clinics) as a whole (Tables 4 and 5). In addition, the Mid-County WIC clinic was able to extend the hours of operation by 60 minutes by utilizing the drive-thru for early morning and late benefit pickup appointments without the need for additional staff. Anecdotal evidence suggests reduced client wait times by approximately 10 to 20 minutes simply by eliminating the need to park, remove the children from a vehicle, walk inside and check in at the front desk. An added benefit that was not originally considered was the increased accessibility that the drive-thru provided to clients with disabilities, which are able to use the drive-thru services more readily than having to come into the clinic. Just as with other types of business, such as banks, fast food restaurants, a drive-thru is an attractive option for consumers. A secondary goal was to increase efficiency and decrease costs by decreasing staff overhead. The Pinellas-WIC Program was also able to reduce a clerical position at the Mid-County location by 0.5 FTE equal to a savings of approximately $13,267.
Table 4 2014 Pinellas County WIC Participation
Jan Feb Mar Apr May Jun Jul 14964 15508 15350 15274 15918 16307 16487
Table 5 2014 Mid County Health Department WIC Participation
Jan Feb Mar Apr May Jun Jul
2665 2897 3198 3282 3433 3590 3603
1-2) Lessons Learned in Relation to Practice? Lessons Learned in relation to Partner Collaboration (if applicable): Success was achieved by involving state, county. local and internal partners from the initial concept stage, through all stages of planning and implementation. The team worked hard to develop a collaborative atmosphere that led to the successful opening of the Mid-County drive-thru in February 2012. Once operational the drive-thru proved to be a popular option with WIC clients. Many clients comment that the drive-thru is a great option for busy parents that would otherwise need to bring their children inside the clinic for services. One challenge encountered by this project was the number of WIC clients trying to obtain WIC services via the drive-thru that could only be performed inside the clinic. These services typically include: eligibility, certification or mid-certification, which are lengthy and require nutrition counseling, and lab procedures to be performed.
3) Did You Do a Cost Benefit Analysis: A formal cost benefit analysis was not performed; however, based on the number of clients using the Drive-Thru and increased client participation it is one that is worth the initial investment. The Drive-Thru option may be one factor that will encourages participation, and one that the will ultimately work towards attaining the WIC programs goal to improve health outcomes for pregnant women, infants and children with a desired additional benefit of decreased health care costs associated with, inadequate access to nutritious foods,.
4) Is There Sufficient Stakeholder Commitment to Sustain the Practice? The Drive-Thru feature was added during construction of the Mid-County Center and is sustainable because there are essentially no additional ongoing expenses associated with the project. The average monthly client usage has been steadily increasing and has become so popular that some clients based in other county clinics will often use the Mid-County Drive-Thru instead of going to their assigned WIC clinic.