In order for the program to get off the ground, someone in the community has to see a need for oral health services for young children and their families, be driven to do something about it, and then translate that drive into action. This champion can originate from a WIC site or grantee; state, county or city health program; local dental professionals; community-based organizations; or Federally Qualified Health Centers (FQHCs). However, while finding a champion is crucial, one person alone cannot create a successful program—collaboration and support from multiple individuals and organizations is needed. Collaboration can begin on a local level first, and then expand if successful. The potential partners can be convened together to introduce the idea of an oral health/WIC collaboration, or the lead group can meet with each potential partner separately to get support and then convene the whole group to discuss the specifics of collaboration.

Making the First Contact

The first contact provides an opportunity to “sell” the oral health program and determine if it is feasible to conduct it at one or more WIC sites. Discuss the problem and the extent of Early Childhood Caries (ECC) in young children and how oral health is an integral part of overall health and nutrition. Describe how oral health / WIC collaborative programs are structured in other communities and highlight some of their successes (see Section 5 of this manual for program models.) Discuss ways in which the goals of the Early Entry into Dental Care Program and those of WIC overlap and how they might also fit with the goals of other partner groups. Ask each group to explain explicit and implied mandates, staffing patterns and staff skills, site capacity for adding oral health services, and what procedures are used when working with families. The following questions provide some guidance.

What knowledge do key WIC staff have about oral health?

• Have WIC staff received previous oral health training? If so, who provided the training, what was covered, and how was it incorporated into their interactions with families?
• Do WIC staff currently assess the oral health status and risk factors of their participants’ children? If so, how?
• What is the best way to schedule additional oral health training for WIC staff?

How can the oral health program fit into WIC’s general programming?

• What days and times are the WIC sites open and which days might be best for integrating oral health services?
• How many participants are seen per month and how often are they seen per year?
• How is participant information collected and verified? How can this process be used to efficiently share information with the dental team?
• How does WIC keep track of Medicaid information? Is there any way to provide the dental team with Medicaid numbers with the participants’ permission, especially since participants may not bring their Medicaid cards to the WIC visit?
• Who helps caregivers complete permission forms and other paperwork?
• Some WIC sites provide educational classes. How often are they scheduled? Should oral health be part of the curriculum WIC currently provides or should it be separate?
• What space(s) could be made available to the dental team? Is there are any storage space for supplies?
• Would WIC provide any materials or supplies?
• Do WIC staff schedule appointments with families, or do they have a walk-in policy? How can families be routed for a dental visit? Should dental visits use appointments?
• What languages do most families speak and which WIC staff speak those languages? Who provides translation services for families who need them? Will these individuals be available for the dental visits if needed?
• Would WIC staff assist with case management or administrative duties?
• What are the best ways to market the program to families?
• What does WIC liability insurance cover and what insurance will the dental team need?
• If dental services were initiated, how might they be sustained financially?

What relationships do WIC staff members currently have with dental professionals or clinics in the community?

• Is the WIC site part of an organization that provides dental services in another branch or location? What types of services are provided and how are they arranged?
• Does WIC currently provide families with dental referrals to dental offices or clinics in the community? If so:
  • How was the list of dental offices/clinics developed, and do all the providers participate in Medicaid or CHIP (Healthy Families, in California)?
  • Does the WIC staff track the results of the referrals to see what care was provided and if the family will be receiving care on a regular basis?
  • How much contact does the WIC staff have with dental providers in the community?
  • Have these providers ever received an orientation to WIC and how to work with WIC families?
  • Are families satisfied with the care they receive from providers?

Answers to these questions will help determine how supportive WIC staff will be of an oral health program at the site and how much effort and time will be needed to set up and maintain the program. Some WIC sites may simply be too small or otherwise unable to incorporate oral health services on-site. Relationship-building takes time but is an important first step in program development. Clear establishment of roles, responsibilities, policies, and procedures prior to the program debut is crucial. Agreed-upon goals and objectives, along with methods of measuring progress and determining what constitutes success, are key elements for any oral health program.

The WIC staff, dental team, and any other community partners should convene additional planning meetings to work out the details of the oral health program. This provides an opportunity to share objectives and gain a better understanding of how everyone will contribute to the overall vision of the oral health program. Such meetings help to foster credibility, a shared knowledge base, mutual respect, and trust. Discussions should cover best times for scheduling, use of space, participant flow, paperwork, facilitating referrals, and shared responsibilities. Enthusiasm for the program will grow if all staff (not just administrators) buy into the program early and if families value and take advantage of the services. Creating a written Memorandum of Understanding (MOU) that covers the basics of the program and outlines responsibilities of all partners will help keep the program on track and accountable. See Section 6 for more information about MOUs and a sample MOU.

Schedule

The schedule will depend on how frequently WIC services are provided at a site and how often professionals are available to perform the clinical services. Some WIC sites may operate full-time while others are only open a few days per month. Generally, the dental team will want to spend 4-5 hours at a site to maximize their time and the flow of participants. To make the program cost-effective, providers at larger sites should average 15-25 participant visits (clinical dental encounters for billing purposes) during that timeframe. In small or rural sites this volume will not be possible. The WIC director should try to schedule the visits at times that would maximize the number of participants for the dental team and be the least disruptive to core WIC services.

The team will also need to determine whether children will return for additional fluoride varnish visits if a dental home is not found, and how many visits per year would be appropriate and realistic to achieve the best oral health outcomes. This may be difficult to achieve if an appointment system is not used. Also determine how appointments are made or how “walk-ins” are approached to be offered services.

Space at the WIC site

At a minimum, WIC dental visits require:

• For each clinical provider, two conventional chairs to facilitate performing a knee-to-knee position for the oral assessment and preventive services with the caregiver and child;
• A table to place supplies and paperwork;
• A waiting area, either a separate one or easy access to a main waiting area with toys/books to keep children entertained;
• A garbage can.

When space is available, a small room or cubicle is best for privacy. A larger open space partially divided by a table that is in close proximity to the waiting area may also be used.

Be aware of infection control issues when looking for appropriate space and traffic flow. See Section 3 for more information on infection prevention and control.

Staffing

Staffing will depend on how many participants can be seen in one day, how involved the WIC staff will be with various aspects of the program, what type of dental or health professionals are available to participate in the program, the procedures that state practice acts allow dental and other health care providers to perform, and Medicaid coverage for the various procedures, including who can bill and receive reimbursement.

A typical dental team consists of one dental or health professional (who can bill for services) to provide the clinical services and one administrative person or educator to interact with families and facilitate completion of paperwork and referrals. Enough staff support should be available to minimize waiting time for families and to provide them a positive experience that promotes two-way communication. See Section 3 for more details on staffing and billing.

Process for verifying Medicaid status

Determine who on the WIC staff can access and share this information (some WIC sites may not provide this information), or if the dental team will need to verify the information directly with families. Brainstorming potential problems during the planning stage will prevent bottlenecks and possible lost opportunities for seeing children if their status cannot be readily verified. In some cases (but not all), WIC staff have been able to check their particpant information system when a participant arrives and immediately print the participant’s information. This process minimizes errors and provides reliable information to use for case management, follow-up with families, and billing.

Caregiver Education

There are many things to consider when planning a successful caregiver education program. Partners should attempt to determine in advance which topics and methods are most appropriate, but allow for flexibility as extensive evaluation and revision may be required to better suit the needs of participants and staff. See Section 5 for more information on different program models and their education strategies.

The following questions should be discussed:

• Will education be done in a class setting, or through individual counseling? This is largely determined by participant volume; classes may not be possible in small or rural WIC sites, for example, but will likely be more time-efficient than individual counseling in high-volume urban WIC sites.
• How and when will classes or counseling sessions be scheduled and how long do they last?
  • If classes will be held, the classes should be conducted on the same days as the dental visits, if possible, with the participants first attending the class and then receiving dental services.
  • Counseling sessions are generally conducted by a dental assistant, educator, or promotora as participants wait to receive the clinical services.
• If classes will be held, will they be taught in different languages? How will this be scheduled? In the Alameda County model (see Section 5 for more on this model), for example, classes are taught in English on some days and in Spanish on others.
• What curriculum or key messages will be taught? Are the oral health messages consistent with WIC health and nutrition messages? See Section 6 for the Center for Oral Health’s recommended educational materials, available electronically.
• Can the oral health education be developed to fulfill one of the WIC educational requirements for participants? This would be an additional incentive for families to attend and receive oral health services.
• Who will be providing the education? Are the educators adequately prepared to address the oral health content and answer questions in a way that meets the learning needs of the audience? If not, then a staff training session should be conducted to explain the key messages and the best strategies for delivering them.

Key points covered in either classes or individual counseling sessions should be reinforced by the clinician during the anticipatory guidance portion of the visit.