Revised Feb 2025 Connecticut WIC Program Manual

WIC 200-08 SECTION: Certification

SUBJECT: Nutrition Assessment and Risk Determination Federal Regulations: § 246.7 (e)(1)-(3); WIC Policy Memorandum 2011-05 WIC Nutrition Risk Criteria (electronic version) Nutrition Services Standard: 7 VENA Guidance Document: Value Enhanced Nutrition Assessment in WIC (VENA) | WIC Works Resource System https://wicworks.fns.usda.gov/topic/vena/value-enhanced-nutrition-assessment-wic-vena POLICY A WIC nutrition assessment is the process of obtaining and synthesizing relevant and accurate information to:

• Assess an applicant’s/participant’s nutrition status and risk • Design appropriate nutrition education and counseling • Tailor the food package to address nutritional needs and • Make appropriate referrals

A Value Enhanced WIC Nutrition Assessment (VENA) is accomplished by systematically completing a series of five steps:

• Collect relevant information • Clarify and synthesize the information that has been collected • Identify the pertinent and appropriate risk(s) and other related issues • Document the assessment and • Follow up on previous assessments, as appropriate

These steps are sequential and cyclical in nature so that previous information collected builds on future assessment and education.

The Connecticut WIC program has adopted the Health Outcome Based Nutrition Assessment as the model for its nutrition assessment process. At the core is the focus on desired health outcomes to collect relevant information. See the VENA guidance document for an explanation of the desired health outcomes, specific health determinants and relevant information to be collected for the five categories of WIC clients. Each health determinant is associated with WIC Nutrition Risk Criteria and additional information not associated with risk criteria but needed to individualize nutrition services based on participant needs.

Revised Feb 2025

Using this approach, the nutrition assessment process allows staff to:

• Emphasize strengths and healthy practices of the client and family. • Highlight accomplishments and/or developmental progress • Reinforce the increasing competence of caregivers.

Nutrition Assessment and Risk Determination shall be conducted and documented by a local agency Competent Professional Authority (CPA) or by a CPA who has a written contract with the local agency. Nutritional Assessments and Risk Determinations that are documented by contracted staff shall be reviewed by a local agency CPA and countersigned. Local agencies may use the Sample Agreement for Professional Services to ensure WIC nutrition assessments performed by a CPA not on the staff of the local agency follows WIC procedures.

For program eligibility, a complete nutrition assessment will be performed, which shall include but not be limited to the following:

• A medical history • A clinical assessment • Anthropometric measurements • Hematological measurements • Dietary assessment and • Risk determination

Expectations for Data Collection, Documentation and Quality Assurance

Local agencies are expected to implement strategies to obtain participant data required for compliance with federal program regulations for certification and recertification appointments.

Exception reasons available in the Anthropometric Grid on the Lab Screen in CT-WIC include: • Child Not Present to Verify • Disability • Refused to Take Off Coat, Heavy Clothing • Uncooperative

We do not expect to see these used frequently as they are exceptions. The option, “Child Not Present to Verify” should be rarely, if ever used, as it pertains to when information was received from a provider, is questionable, and the child did not come to WIC clinic to verify. It is not a valid reason to be used in place of “Disaster”.

If using “Disability,” documentation in CT-WIC is required. The other two options should also be documented and consistent with the appointment method - meaning these are not valid for phone visits or when data is obtained from the provider - unless the provider documents this information on a valid certification form.

Revised Feb 2025 For the Connecticut WIC Program to remain in compliance with federal regulations, appropriate quality assurance is required. During quarterly chart reviews, management must ensure that the “By Whom” field on the Anthropometric Grid is appropriately documented in CT-WIC on the Lab Screen.

If selected in “By Whom” Field Accepted Documents/Expectations for Documentation WIC CPA Documentation of measurement conducted at the WIC clinic; Appointment type - in person visit HCP Office Valid WIC Certification Form (with signature of medical provider- MD/APRN/PA/DO) on file in CT-WIC. Any documentation received from the HCP office, including visit summaries or other printouts from the HCP. Documentation in Nutrition Education Notes about how data was obtained i.e., verbal over phone, or scanned. EM Record Measurements obtained from the electronic medical record or patient portal. Other Documentation of the source of the data obtained in Nutrition Education Notes

*The option of “MD/PA” should not be used in the “By Whom” field when WIC Certification Forms are completed and scanned with only the signature of the WIC CPA.

Verbal reports of weight/length/height by participants should not be recorded as “WIC CPA” or “Other” in the “By Whom” field. Per WIC Policy 200-10 Anthropometric Data “verbal anthropometric measurements or blood work are not acceptable from a WIC participant since this information is used to assign risks and determine eligibility”.

Additionally, staff must document appropriate exemption reasons in the Bloodwork Grid on the Lab Screen in CT-WIC. “CPA Determined Bloodwork Skipped” should not be selected as a matter of routine. If it is used, documentation as to why it was selected is required. The other “Exemption Reasons” must be substantiated and documented.

A hematological test for anemia such as a hemoglobin or hematocrit test shall be obtained for participants based on the following schedulei:

Pregnant Women

During the current pregnancy.

Postpartum/Breastfeeding Women Preferably 4-6 weeks post-delivery (An additional blood test is NOT required for breastfeeding women 6-12 months postpartum. However, if it makes sense to screen for low iron again based on the initial postpartum bloodwork results, local agency staff can use Pronto to screen.

Infants Between 9-12 months of age (A blood test done between 6-9 months can be used to meet this screening requirement).

All infants nine months of age and older (> 9 months), who have not already had a hematological test, shall have a hematological test performed, or test results shall be obtained from outside referral sources. The

Revised Feb 2025 hematological test for infants nine months and older does not have to occur within ninety (90) days of the date of certification. A reminder can be given to the parent at the infant’s six (6) month WIC visit about the importance of screening their infant for anemia and obtaining the hemoglobin test results from the health care provider at the next well baby checkup.

Children 12-24 monthsii Between 15-18 months of age, preferably six months after the infant test. Children are required to have at least one (1) hematological test between twelve (12) and twenty-four (24) months of age, completed six (6) months after the requirement for both the infant and the 12–24- month child screening. (One blood test at or before 12 months cannot fulfill the requirement for both the infant and the 12–24 month child screening)

Children 2-5 years Annually between the ages of 2 and 5 years (If the annual blood test result is abnormal, a repeat blood test is required at six-month intervals).

The hematological test/screening for anemia should be obtained at the time of certification. However, if at least one qualifying nutritional risk factor is identified the individual shall be certified and issued benefits monthly until the blood test results are obtained.

If the blood test result is not available at the time of certification, inform the participant or parent/guardian that WIC benefits will be issued monthly until it is received. Nutrition staff should attempt to resolve such cases by contacting an individual’s health care provider (HCP), when appropriate. Make any necessary referrals to assist the participant or parent/guardian in obtaining the bloodwork at no cost in a timely manner. At the subsequent WIC appointment, nutrition staff will assess the participant or payee/guardian’s progress in obtaining the bloodwork.

The local agency staff is responsible for ensuring that the child’s blood work data is obtained according to the anemia screening schedule above and recorded in the participant’s electronic record. Every effort should be made to obtain the hemoglobin value from the health care provider. However, when this is not possible, the local WIC agency must perform the 15–18-month blood test using Pronto. See 200-34 Local agency use of non-invasive hemoglobin (HGB) testing policy.

Blood test results shall be documented in CT-WIC, Lab screen - Infant/Child Height/Weight tab, and the participant or parent/guardian shall be informed of the test results when there is a finding of anemia.

How Verified? Accepted Documents/Expectations for Documentation Form/Fax Valid WIC Certification Form (with signature of medical provider- MD/APRN/PA/DO) on file in CT-WIC and/or any documentation received from the HCP office, including visit summaries or other printouts from the HCP received in-person from the participant or by fax from the healthcare provider.

Revised Feb 2025 Phone Documentation of the bloodwork results obtained by speaking to the healthcare provider’s office or the laboratory which performed the blood test. WIC Office Documentation of the non-invasive hemoglobin testing at the WIC clinic. Appointment type – in-person visit. EM Record Bloodwork obtained from the electronic medical record or patient portal.

Upon data entry of bloodwork results, CT-WIC will automatically reassess the participant’s nutritional status and change priority assignment, when warranted.

Nutrition education, health care referrals, and the food package prescription should be reassessed and amended, as appropriate by a WIC CPA.

Bloodwork Exemptions Blood tests are not required for the following:

• Medical conditions contraindicating bloodwork. For participants with a medical condition preventing safe collection of blood. A health care provider must document ongoing medical care. • Beta-thalassemia major or Sickle Cell anemia. Every effort should be made to obtain the most recent bloodwork results from the health care provider. A recent blood test must be documented. While an annual test is required, the 6-month re-test is not required in this case. A diagnosis of Beta-Thalassemia or Sickle Cell must be documented in the participant’s file. • Autism/Sensory Processing Disorders. A health care provider must document ongoing medical care. Every effort should be made to obtain the most recent bloodwork results from the health care provider. • Delayed bloodwork-Postpartum woman only. Bloodwork must be obtained during the postpartum period. • CPA determined bloodwork skipped. Rare, if ever used as most of the acceptable exemptions accounted for and defined above. If used, documentation must be provided. Cannot be used to bypass the requirement for bloodwork. When a participant has a valid bloodwork exemption rationale, documentation must include the exemption reason, any appropriate diagnosis and information on when or if bloodwork will be obtained during the current certification period. If the health care provider has a previously collected hemoglobin or hematocrit result, contact may be necessary to obtain this and/or other pertinent information. Document any communication with the health care provider in CT-WIC and follow up as necessary to obtain bloodwork results.

i WIC Program bloodwork policy is developed based on recommendations from the Centers for Disease Control and Prevention (CDC) MMWR https://www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm. Two key recommendations that specifically target the WIC population.

• In populations of infants and preschool children at high risk for iron-deficiency anemia (e.g., children from low- income families, children eligible for the Special Supplemental Nutrition Program for Women, Infants, and Children {WIC}, migrant children, or recently arrived refugee children), screen all children for anemia between ages 9 and 12 months, 6 months later, and annually from ages 2 to 5 years. Selective Screening

Revised Feb 2025

• Annually assess children aged 2-5 years for risk factors for iron-deficiency anemia (e.g., a low-iron diet, limited access to food because of poverty or neglect, or special health-care needs). Screen these children if they have any of these risk factors. ii Although bloodwork data obtained when an infant was between 9 and 12 months old may be used to certify a 12-month- old as a child, such data cannot be used to fulfill the blood test that is required between 12 and 24 months. Children who had an inadequate iron intake during infancy are at greatest risk of developing anemia between 12 and 24 months of age. Thus, for example, a child who is first certified for WIC and first tested at or before 12 months of age, must have a follow-up test by 24 months of age and preferably at 18 months of age (as recommended by CDC). See also: Bright Future Periodicity Schedule periodicity_schedule.pdf (aap.org)