P2.089: WIC Screening and Referral Using the Electronic Health Record: A Cross Institutional Implementation Study

Background: The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) reduces food insecurity and improves health outcomes for children. Yet, just over half of WIC-eligible children are enrolled nationally. Pediatricians are well-positioned to identify WIC-eligible children and facilitate referrals to WIC, but few programs exist. Two academic medical centers in North Carolina (NC) collaborated to develop and implement an electronic health record (EHR) referral to WIC to increase enrollment. The aim of this study was to explore the effectiveness of implementation of these approaches using the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework.

Methods: Screening for WIC eligibility occurred in the Atrium Health Wake Forest Baptist (AHWFB) health system, in Winston-Salem, NC from July 2020-October 2023 and subsequently expanded in February 2024 to the Duke University Health System (DUHS) in Durham, NC. A referral was created in the EHR to local WIC providers that allowed for read-only access to medical charts in both health systems. The implementation processes within each health system are displayed in Figure 1. DUHS used a similar process as AHWFB, but, once a referral was placed, WIC had access to a limited EHR view until the child’s 5th birthday.

WIC screening and referral data were extracted from the EHR. At DUHS, screening changed from patient-based to encounter-based during implementation. Forsyth and Durham County WIC tracked referral and outcome data from November 2021-October 2022 and May 2024-February 2025, respectively. The i-PARIHS framework was leveraged to assess the success of implementation, with an outcome of WIC enrollment. The components of the model that were measured quantitatively included facilitation (WIC screening and referral rate) and context (WIC screening and referral across health systems).

Results: For facilitation outcomes, at AHWFB, 5497 unique children were screened >1 time, with 3606 (67%) already enrolled and 1691 (33%) not enrolled. Among those not enrolled, 866 (70%) were offered a WIC referral and 470 (54%) accepted (Figure 1). At DUHS, 1367 children were screened with an additional 2356 screens completed since changing to encounter-based screening. Among children screened, 1189 (77%) were already enrolled/not eligible, 111 (7%) had a referral placed, and 67 (4%) declined referral.

Measuring the success of implementation, for AHWFB, 363 referrals were tracked and 212 (58%) ultimately enrolled. For DUHS, 469 referrals were tracked with 218 (46%) completing enrollment (Figure 2). For both, most referrals were lost due to inability to contact the family or because the family did not show to the appointment (AHWFB 32%, DUHS 39%).

Conclusion: Through this cross-institutional collaboration, we found that EHR-based WIC referrals have the potential to increase enrollment for WIC-eligible, but not yet enrolled children, even despite unique clinical contexts and differing geographic locations.