WIC and Nutrition Manual 400 Policy Group Nutrition Education and Counseling

Table of Contents

Policy 400 Nutrition Education and Counseling Policy 401 Value Enhanced Nutrition Assessment (VENA) Policy 402 Certification and Mid-Certification Nutrition Education Counseling Guidelines Policy 403 Referrals Policy 404 WIC Low-Risk Secondary Nutrition Education Guidelines Policy 405 WIC High-Risk Secondary Nutrition Education Guidelines Policy 406 Nutrition Services & Regional Breastfeeding Coordinator Program Plans Policy 407 Medical Nutrition Therapy Policy 400 Appendices Nutrition Education

Policy 400 December 2024

POLICY Policy 400 Nutrition Education and Counseling All local WIC agencies shall offer nutrition education, counseling to all WIC participants, parents, and caregivers according to federal regulations, state guidelines and program goals. PURPOSE To ensure that WIC participants receive nutrition education and counseling that considers their individualized needs, strengths and developmental needs

PROCEDURES All WIC clinics shall provide nutrition education and counseling to all WIC participants using a state approved method. A. All nutrition education contacts shall include a two-way communication between staff and participants. B. Nutrition education must be made available to participants including participants who do not receive food packages such as fully breastfeeding infants < 6 months old and partially breastfeeding women whose infants are > 6 months old and receiving a full formula package. C. Any nutrition education and counseling provided to participants shall include accurate, up-to-date and evidence based information. WIC staff must use a participant centered approach and are encouraged to share personalized nutrition information to meet the individual’s health care needs. D. Each WIC agency must designate a WIC Nutrition Education Coordinator. A. The WIC Nutrition Education Coordinator must be a nutritionist or nurse. B. The WIC Nutrition Education Coordinator must obtain 4 hours of continuing education in nutrition/nutrition counseling annually. C. Refer to the Administrative Reference, Training Guidelines and Program Descriptions, WIC Program.

Page 1 Nutrition Education and Counseling

Page 1 Value Enhanced Nutrition Assessment (VENA) Policy 401 December 2024

Policy 401 Value Enhanced Nutrition Education Assessment (VENA) POLICY All local WIC agencies shall have Certifying Health Professionals to provide participant-centered nutrition assessment and counseling. Value Enhanced Nutrition Education (VENA) begins with the nutrition assessment. Beyond determining WIC eligibility, nutrition assessment, breastfeeding promotion, and support, tailoring WIC food packages and referrals are utilized to enhance the interaction between the Certifying Health Professional and WIC participant, link the collected health and diet information to the delivery of participant-centered relevant nutrition education, referrals, and food package tailoring. PURPOSE To provide client-centered nutrition education counseling and assessment. Nutrition assessment and participant-centered nutrition education and counseling include open-ended questions to determine what concerns or questions the participant has in regard to her nutrition, child’s nutrition, and/or infant’s nutrition. Individualized nutrition education counseling is then provided to address the identified questions, concerns, and goals.

RELEVANT REGULATIONS USDA, FNS, Value Enhanced Nutrition Assessment (VENA) - WIC Nutrition Assessment Policy, WIC Policy Memorandum 2006-5; March 2006. USDA, FNS, VENA Value Enhanced Nutrition Assessment in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Updated Guidance, 2020.

PROCEDURES VENA Principles A. Characteristics of the Participant-Centered approach include: 1. Collaboration- The VENA approach involves a partnership between the certifying health professional and the participant. Participant engagement and interactions are essential for effective nutrition assessment. 2. Optimism- The VENA approach recognizes that participants have hopes and desires for themselves and their families for nutrition and health. 3. Nonjudgmental environment- Participants are more likely to talk openly and honestly about their behaviors, motivations, and challenges in an accepting and nonjudgmental environment. 4. Empowerment- The VENA approach can build a participant's confidence in their own abilities. Health Professionals should affirm strengths and positive practices in order to ensure participants continue them and build additional healthy habits. B. Nutrition assessment and education shall follow the VENA model and embrace the following principles to ensure effectiveness and quality: 1. Interactive a. Nutrition education shall involve families in self-assessment and self-directed goal setting and help families move toward their desired level of wellness. b. Develop a rapport by employing active listening skills, asking open-ended questions, and identifying the participant’s stage of change. 2. Flexible a. Use multiple strategies and techniques to reach and impact participants and their families effectively. 3. Relevant a. Impart appropriate and relevant education that is reflective of the interests of the participants and/or family. b. Education offered to participants shall be in a positive and interactive manner through developmentally and culturally appropriate teaching aids.

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4. Supportive Environment a. Nutrition education shall be offered in a family-friendly environment for optimal learning. Personnel shall support the family’s needs and build a rapport with families to promote good health. 5. Trained Personnel a. Education shall be facilitated or taught by qualified, well-trained, and equipped personnel. These trainings will provide staff with the critical thinking skills, knowledge, and counseling skills to complete the nutrition and breastfeeding assessment and provide a participant-centered plan of care. b. In addition, the required training will ensure Certifying Health Professionals have the following competencies to provide WIC services: i. Understanding the Principles of Life Cycle Nutrition: Understanding normal nutritional needs during pregnancy, lactation, the postpartum period, infancy, and early childhood. ii. VENA: Understanding the steps in the VENA approach to nutrition assessment, including all the requirements related to bloodwork, anthropometric measurements, documentation, follow-up visits, etc. iii. Data Collection Techniques: Understanding the importance of precise and valid data, as well as how to collect anthropometric and hematological data accurately. iv. Communication: Knowing how to communicate effectively with participants and foster open exchanges. v. Multicultural Awareness: Understanding how sociocultural issues (race, ethnicity, religion, group affiliation, socioeconomic status, and worldview) affect nutrition and health practices and nutrition-related health problems. vi. Critical Thinking: Knowing how to analyze and synthesize information to draw appropriate conclusions. c. WIC Certifying Health Professionals must complete training as outlined in the Administrative Reference, Program Descriptions and Training Guidelines Section prior to providing WIC services. d. Required Training available through www.Train.org/ky/ include: i. WIC DPH Certifying Health Professional Training, 1109677 ii. WIC DPH Plan of Care and Goal Setting (VENA), 1109674 iii. WIC DPH Health Professional Infant Formula and WIC Nutritional Training, 1110870 iv. WIC DPH Secondary Nutrition Education for Health Professionals, 1109708 v. WIC DPH Mid-Certification Health Assessment (MCHA), 1109707 vi. WIC DPH Breast Pump Issuance and Tracking Guidelines, 1109711 vii. WIC USDA Breastfeeding Curriculum Level 1,1103549 viii. WIC USDA Breastfeeding Curriculum Level 2, 1110936 ix. WIC USDA Breastfeeding Curriculum Level 3, 1119763 e. Additional Training Coming soon: WIC USDA Breastfeeding Curriculum and 4; WIC Food Package Assignment, Tailoring, and Counseling; Completing the Annual Conducting and Documenting a Nutrition and Breastfeeding Assessment; Screening and Referrals for Lead and Immunization; Principles of Life Cycle Nutrition, and WIC Required Notifications. f. Training is available in person or via Teams upon request. g. WIC Coordinator, WIC Nutrition Education Coordinator and WIC Breastfeeding Coordinator trainings is available upon request. 6. Culturally Supportive a. Nutrition education shall acknowledge and support differences in cultures and languages and be sensitive to cultural food choices when possible.

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Complete the WIC Nutrition Assessment A. Certifying Health Professionals will use a standardized process to collect nutrition information for all participants. B. A comprehensive nutrition assessment is required to identify nutrition risks, assign an appropriate food package, and guide WIC participant-centered nutrition services after the assessment is complete. 1. Beyond determining WIC eligibility, nutrition assessment, breastfeeding promotion, and support, tailoring WIC food packages and referrals are utilized to enhance the interaction between the Certifying Health Professional and WIC participant, link the collected health and diet information to the delivery of participant-centered relevant nutrition education, referrals, and food package tailoring. 2. Collect all relevant information and required information (e.g., anthropometric, biochemical, and clinical data; dietary assessment, environmental, cultural, and family information; nutrition practices; breastfeeding beliefs and practices; and health information) for each participant category. See Policies 215 Certification Risk Assessment, 216 Anthropometric Screening, 217 Hemoglobin and Hematocrit Screening in WIC, 218 Risk Criteria Codes and Descriptions, and 221 ARPA Waiver Remote Services. C. The following components must be used in completing a nutrition assessment: 1. Observe the participant and review the participant’s medical record. 2. Reduce participant anxiety by clarifying the other services WIC provides as well as the purpose of the assessment. 3. Create a power-sharing dynamic by telling participants in advance what will be taking place, showing respect, and setting up a framework for honest and open communication. 4. Be open about the intent of the assessment will help build interest and encourage participation in both the assessment and nutrition counseling to increase participant buy- in. 5. Ask pertinent questions to clarify, probe for additional information, or follow up on information the participant or parent/caretaker has written or verbalized. 6. Listen to and affirm the participant/parent/caretaker. 7. Use critical thinking to determine nutritional risk, assignment and tailoring of food package, understanding of health and readiness for change, etc. 8. Document services provided in the participant’s medical record.

Plan of Care A. Certifying Health Professionals must develop a plan of care for all participants. 1. The plan of care must include: a. Individualized goals are clearly stated and documented. i. Goals shall be related to the participant’s nutritional risk, reasonable, and measurable with a timeframe for completion. b. Documentation of progress toward that goal at follow-up visits c. Appropriate referrals with follow-up documentation. 2. Certifying Health Professionals shall assist the participants in setting goals.

Counseling Methods A. Motivational Interviewing 1. Designed to explore and enhance an individual's internal motivation to change by resolving ambivalence, eliciting the importance of change, and increasing confidence to make change. B. Appreciative Inquiry

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1. Focus on building confidence by drawing out positive feelings related to what went well in the past, what is going well in the present or what the family would like to have happen in the future. C. Emotional-Based Counseling 1. Taps into how an individual feels about a given topic. Recognizes that while information and facts are important, emotions are more frequently the driver behind change. D. Three-Step Counseling 1. Designed to promote positive practices by asking open-ended questions to reveal barriers and concerns, affirming and normalizing feelings, and sharing targeted information. 2. Certifying Health Professionals shall use three-step counseling to provide nutrition and assessment and participant-centered nutrition education. 3. Step 1 – Ask open-ended questions a. Begin the question with “what”, “how”, or “tell me”. b. Open-ended questions shall build rapport. c. Ask “probing” follow-up questions to help get a bigger picture of what the mother means. i. Extending Probe-ask for more information ii. Clarifying Probe-helps to understand what the participant has told you iii. Reflecting Probe-repeats the participant’s words back to them iv. Redirecting Probe-helps change the subject and steer the conversation in a different direction. 4. Step 2 – Affirm a. Affirmation is a short, simple statement that lets the participant know their feelings are okay. b. Affirmations acknowledge the feeling behind what the participant is telling you. c. There are five ways to affirm the participant: i. Agree with the participant. ii. Assure them they are not alone. iii. Read between the lines to discover what they are worried about. iv. Shine the spotlight on what they are doing well. v. Show they are a good parent/caretaker. 5. Step 3 – Educate a. Education shall be done only after asking open-ended questions and providing affirmation. b. Education shall be: i. Kept simple ii. Target their concerns iii. Reinforce the message iv. Provide options. v. Share resources.

Stages of Change A. Certifying Health Professionals shall determine the participant/parent/caretaker stage of change. 1. Precontemplation-do not intend to start healthy behavior within the next six months. 2. Contemplation -intended to start healthy behavior within the next six months. 3. Preparation-intend to start healthy behavior within the next 30 days 4. Action-currently performing healthy behavior for less than six months. 5. Maintenance-currently performing healthy behavior for more than six months. Setting Goals A. Certifying Health Professionals shall assist participants in setting goals to facilitate change. 1. Participants are the best judge of what will work for their family. 2. Goal setting needs to be participant-driven. The Certifying Health Professionals is to help participants succeed at their goals.

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3. Work with participants to set realistic, measurable goals. Suggesting small, reachable goals – taking baby steps – is a way to help your participants change behaviors and feel successful with those goals. 4. Meet a participant or parent/caretaker where they are. Any movement toward change has the potential to provide this participant with a better health outcome. Certifying Health Professionals are to help the participant/caretaker where they are in the change process. 5. Discuss and problem-solve participant or parent/caretaker’s concerns and barriers to achieving the goal(s).

Page 1 Certification and Mid-Certification Nutrition Education Counseling Guidelines Policy 402 December 2024

Policy 402 Certification and Mid-Certification Nutrition Education Counseling Guidelines POLICY All local WIC agencies shall have Certifying Health Professionals provide nutrition education to WIC participants during certification and mid-certification visits.

PURPOSE To ensure that WIC participants receive quality nutrition-focused counseling during certification and mid- certification visits that are participant-focused.

RELEVANT REGULATIONS 7 CFR 246.11(e)(5) – Participant Contacts 7 CFR 246.2 – Definitions 7 CFR 246.11 – Nutrition Education (a)General,(b) Goals, (c)(4) – Procedures to ensure that nutrition education is offered,(d) Local program responsibilities,(e) Participant contacts,(e)(4) – Documentation of nutrition education provided, and (e)(5) – Provision of individual care plan based on need 7 CFR 246.12 (d) – Compatibility of food delivery system,(r)(1) – Parents/caretakers and proxies 7 CFR 246.14 – Program Costs

PROCEDURES WIC Certification/Mid-Certification Nutrition Education A. WIC certification/mid-certification counseling must be offered to each participant/parent/caregiver at the time of their certification/mid-certification visit. Individual nutrition education is then provided at the WIC certification/mid-certification counseling. B. At the certification/mid-certification visit, after conducting a nutrition and health assessment, which will assess for nutrition risk criteria, provide nutrition education as follows: 1. Nutrition education counseling must include: a. WIC certification/mid-certification education counseling topics as outlined in the WIC Certification/Mid-Certification Education Topics Appendix of this section. 2. If counseling has been provided and documented through another service (i.e., Well Child, Prenatal), it does not have to be repeated for WIC if the content of the WIC certification/mid-certification nutrition education counseling protocols has been met. 3. The following nutrition education must be provided to every participant during the certification/mid-certification health assessment. a. Additional counseling must be provided based on the participant's risk code assignment. i. See WIC Certification/Mid-Certification Health Assessment Nutrition Education Counseling Protocol Appendix in this section. ii. See Policy 401 Value Enhanced Nutrition Education.

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WIC Certification/Mid-Certification Health Assessment Nutrition Education Counseling Protocol (In addition to this counseling, all WIC participants must be provided counseling on Specific Nutritional Risks) Provider: Certifying Health Professional Topic When Required WIC General Nutrition Counseling and Screening Protocol by Status Discuss WIC Program eligibility and benefits. Certification (Support staff may explain the process at registration) • Explain the purpose of the WIC Program (The Program provides nutritional support through supplemental foods, nutrition education, breastfeeding support, and referrals) • At initial certification, explain the certification process, including income eligibility assessment, nutrition assessment to provide individualized nutrition education and a tailored food package, the eligibility periods, and recertification schedule. • Discuss the importance and benefits of participating in the WIC Program and encourage ongoing participation and recertifications. The Program provides individualized and group nutrition education, breastfeeding support, referrals, and healthy foods. It helps to provide nutrition during critical growth and development periods for pregnancy, early postpartum, infancy, and early childhood. Counsel on basic diet and the importance of regular physical activity. Certification and MCHA Determine what concerns or questions the participant has in regard to her nutrition, child’s nutrition, and/or infant’s nutrition. Provide counseling to address questions/ concerns/dietary habits. Women and Children: • Review Choose My Plate Dietary Guideline Tip Sheet (s) • Review dietary concern(s) and appropriate action. • Encourage an average of 30 minutes for women and 60 minutes for children of physical activity each day. • Limit screen time to no more than 2 hours/day. • Remove the television from the child’s bedroom. • Encourage healthy foods (e.g., low-fat and reduced-fat food choices including 1% or less milk, (women/children > 2), 5 Fruits and Vegetables per day & Avoid Sugar- Sweetened Drinks) Infants: • Discuss the Kentucky Infant Feeding Guide appropriate for age and development. • Encourage caregiver(s) to promote physical activity and motor skill development in their infant (rolling over, standing, movement, play). • Review dietary concern(s) and appropriate action. Encourage to breastfeed unless contraindicated for health/lifestyle reasons. Certification and MCHA Pregnant women: • Discuss the advantages of breastfeeding. • Discuss the benefits of Kangaroo Care. • Encourage to breastfeed unless contraindicated. • Offer the opportunity to speak with a Breastfeeding Peer Counselor, where available. Breastfeeding women: • Encourage continuation and support of breastfeeding unless contraindicated. • Discuss the benefits of Kangaroo Care. • Offer the opportunity to speak with a Breastfeeding Peer Counselor, where available. Refer to Policy 501 Breastfeeding Promotion and Support Standards.

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Lead Screening Certification • Explain the impact of elevated blood lead levels on growth and development and the importance of a blood lead level screening. • Provide a referral to primary care provider or local Lead Program in the following situations: o The infant/child has never received a lead test. o The child had an elevated BLL 12 months prior and has had no interim follow-up screening. o The infant/child is suspected by a parent or a health care provider to be at risk for lead exposure. o The infant/child has a sibling or frequent playmate with an elevated BLL. o The participant is a recent immigrant, refugee, or foreign adoptee. o The breastfeeding or lactating woman, parent, or child’s principal caregiver works professionally or recreationally with lead. o The family has a household member who uses traditional, folk, or ethnic remedies and cosmetics or who routinely eats unregulated/uninspected food imported from abroad. The family has been identified at increased risk for lead exposure by the health department because the family has local risk factors for lead exposure. Immunization Screening Certification • Advise the parents or caregivers that immunization records are requested as part of the WIC health screening process. • WIC staff are required to screen all WIC participants aged 3 to four years of age at each certification visit and refer those who are under-immunized. • Immunization status/providing immunization records will not impact the availability of WIC services. • Refer under-immunized to their healthcare provider for immunizations. Document the referral. • Refer to Policy 215 Certification Risk Assessment. Discuss the effects of drug and other harmful substance use (tobacco, alcohol, drugs). Certification and MCHA • Discuss how tobacco and/or alcohol can affect the woman, fetus, infant, and child. This should include information about smoking cessation if appropriate, and the effects of secondhand smoke. • Discuss recommendations not to use tobacco products. Refer to 1-800-QUIT NOW (1- 800-784-8669) if the client smokes. • Discuss recommendations not to take any medications, over the counter or otherwise, unless specifically ordered by a physician. • Discuss recommendations not to use drugs (marijuana, cocaine, etc.). • Discuss recommendations not to drink alcohol. • Refer as appropriate for substance abuse. Discuss Safe Sleep Environment for Infants Certification and MCHA Infants: • Discuss American Academy of Pediatrics (AAP) Safe Sleep Policy. • Refer to Policy 404. Collection of Anthropometric and Hematological Data Certification, if available at MCHA • Notify applicants of the collection of height, weight, and hematological data to determine eligibility. • For remote certifications, if data is unavailable at the time of certification, notify participants of the need to have height and weight data within 60 days of certification. Refer to Policy 216 Anthropometric Screening, Policy 217 Hematological Screening, and Policy 221 ARPA Waver Remote Services. For participants being recertificated and at MCHA • Review and discuss previously set goals.

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• For participants who completed the online nutrition education lesson, review and discuss the lesson completion certificate, participant goal set during the lesson, and links visited. Discuss specific nutritional risks for which the participant qualifies. Certification and MCHA • Review specific nutrition risk codes identified during the assessment. • Advise the participant/caretaker of all identified nutrition risk codes that qualify the participant for the Program. • See the WIC Certification/MCHA Counseling for Specific Nutritional Risk Protocol Table below in this policy for a full list of nutrition codes and required nutrition education. Referrals based on Participant Needs identified during the Nutrition Assessment Certification and MCHA • Notify the participant of any referrals recommended based on assessment. • Document the referrals in the medical record. • Document acceptance or decline of the referral in the medical record. • For agencies with the Breastfeeding Peer Program, offer all Pregnant and Breastfeeding Women the opportunity to speak with a Peer Counselor. Document acceptance/ referral or denial. • Refer to Policy 403 Referrals. Food Package Assignment Certification and MCHA • WIC Health Professional will assign and tailor the food package to meet the specific needs of the participant. • Explain the WIC Shopping List, WIC approved list, and how and where to use the eWIC card. • For food package changes or WIC Program Status changes that impact the food package, review the food package to ensure the participant has an understanding of the benefits. • Review the eWIC-1 handout as appropriate. • See WIC and Nutrition Manual, Section 600 Food Package Assignment. • For in-clinic services, advise participants/caretakers to swipe their eWIC card at the Card Reader to test their PIN and to ensure benefits have been loaded on their card. 4. Establish participant-centered goals and plan of care for follow-up visits. Refer to Policy 401. a. These goals shall be: i. Related to the participant's identified nutritional risks and the participant/family nutrition-related interests. ii. Be actionable with a measurable timeframe for completion. iii. Be reasonable and achievable. 5. Make and document referrals for other programs or services (when appropriate). 6. Document as appropriate in the participant’s medical record. Documentation must include: a. Goals established/progress of goals. b. Referrals for other programs or services (when appropriate), including if the referral was accepted or declined. c. Nutrition education provided per protocol” or the acronym “NEPP” or “Mid- Certification Health Assessment nutrition education per protocol” or the acronym “MC-NEPP” when the information provided to the participant covers all topics outlined in the counseling protocols. If the protocol is not followed, then documentation must be made of the counseling that is provided and any supporting materials/handouts that were provided. d. Additional nutrition education information or pamphlets that are provided that are not listed in the counseling protocols must be documented. 7. Code the service on the Patient Encounter Forms. Nutrition Education and Breastfeeding Counseling a. W9401 WIC Nutrition Education Counseling (7.5 minutes) when following the certification counseling protocols. a. 2699 – is used for nutrition counseling

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b. W9401 WIC Nutrition Education Counseling (7.5 minutes) when following the mid-certification counseling protocols. a. 2699 – is used for nutrition counseling c. W9401BF for Breastfeeding Counseling above and beyond WIC Nutrition Counseling. a. v241- is used for breastfeeding services d. If additional information is provided above and beyond the WIC Certification/Mid- Certification protocols listed in the appendix tables must be documented in the participant’s medical record and is coded on the PEF as W9402 (15 minutes), W9403 (22.5 minutes) or W9404 (30 minutes) as appropriate. Certification Assessment a. W0200 is used to code certification and enrollment b. W0204 is used for screened but does not have a qualifying nutrition risk Mid-Certification Health Assessment (MCHA) a. W0205 is used to code the MCHA assessment

WIC Certification/MCHA Counseling for Specific Nutritional Risk Code Assignment Protocol WIC participants must be provided WIC Certification Nutrition Education Counseling based on their individual risk Code Assignment *Status Code: P= any Pregnant Status, BF= any Breastfeeding Woman Status, PP= Postpartum Status, C= Child Status, I= any Infant Status Provider: Certifying Health Professional Risk/Status*/ Reference Materials** Counseling/Education Referral Guidance Low Hematocrit/Low Hemoglobin Status: P, PP, BF, C, I ● Define low hematocrit/low hemoglobin. ● Discuss iron-rich foods. Refer for Medical Evaluation:  All status Hematocrit < 27% Hemoglobin < 9 gm./dL. Elevated Blood Lead Status: P, PP, BF, C, I • Discuss the importance of adequate calories, calcium, iron, vitamin C and low-fat foods (for children after age 2), which decrease the absorption of lead. • Discuss the importance of regular meals and snacks. • Discuss CDC recommendations regarding mothers' lead levels and breastfeeding (Breastfeeding Woman). See Blood Lead Levels & Breastfeeding in Policy 501. Refer for Medical Evaluation.  See Lead Guidelines in Core Clinical Services Guide (CCSG). Schedule for High-Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement Low Head Circumference • Discuss the impact of prematurity on growth and development if age-adjusted.

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Status: I, C (up to age 2) • Discuss the importance of nutrition on growth and development Refer for Medical Evaluation. Preterm Birth/Early Term Birth Status: I, C (up to age 2) • Discuss the impact of prematurity on growth and development. • Discuss the importance of good nutrition for proper growth and development. Low Birth Weight/Very Low Birth Weight Status: I, C (up to age 2) • Discuss the impact of birth weight to growth and development. • Discuss the importance of good nutrition for proper growth and development. Schedule for High-Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement At Risk for Overweight Status: I, C • Discuss the importance of prevention of overweight. • Discuss the importance of physical activity. • Reduce sedentary activity such as computer games and watching television. • Discuss the appropriate quantity of food. • Discuss healthy foods (e.g., low-fat and reduced-fat food choices). (children >age 2) • Discuss the importance of good nutrition for proper growth and development. (infants) Overweight, Obese, High Weight for Length Status: P, PP, BF, C, I • Review the growth chart. (children) • Discuss the importance of physical activity. • Reduce sedentary activity such as computer games and watching television. • Discuss the appropriate quantity of food. • Discuss healthy foods (e.g., low-fat and reduced-fat food choices). (women/children >age 2) Schedule for High-Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement At Risk for Underweight Status: I, C • Review the growth chart. • Discuss the importance of frequent feeding. • Discuss healthy foods in relation to growth and development. Underweight Status: P, PP, BF, I, C • Review the growth chart. (Infants and children) • Discuss the importance of frequent feeding. • Discuss healthy foods in relation to growth, development, and appropriate weight gain. Schedule for High-Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement At Risk for Short Stature Status: I, C • Discuss growth for age and stature/size of parents. • Discuss healthy foods in relation to growth and development. Short Stature Status: I, C • Discuss growth for age and stature/size of parents. • Discuss healthy foods in relation to growth and development. Growth Problems Status: I, C • Discuss growth for age and stature/size of parents. • Discuss healthy foods in relation to growth and development.

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Inappropriate Weight Gain Pattern Status: P, PP, BF, I, C Pregnant woman • Discuss the importance of appropriate weight on the developing fetus. Postpartum or breastfeeding woman • Discuss the importance of an adequate diet to promote lactation and/or attaining standard weight. Infant • Discuss the importance of frequent feeding in relation to weight gain. Children • Discuss healthy foods in relation to growth and development. Alcohol and Substance Use Status: P, PP, BF • Discuss the importance of discontinuing the identified substance use (tobacco, alcohol, drugs) (S-A-D). • Discuss the importance of discontinuing smoked tobacco, electronic nicotine delivery systems (ENDS), smokeless tobacco (chewing tobacco, snuff, dissolvable,) hookahs, cigars, pipes, and nicotine replacement therapies (gums, patches). Refer to counseling and/or treatment as appropriate. Environmental Tobacco Smoke Exposure Status: P, PP, BF, I, C • Discuss the importance of consuming foods high in vitamin C. • Discuss the importance of fruits and vegetables in the diet. • Discuss the risk of thirdhand smoke. BF Infant/BF Woman at Nutritional Risk Status: I, P, BF Breastfed infant • Discuss adequate diet for lactation and health. Breastfeeding mother • Discuss the impact of the mother’s health on the growth and development of the infant. Breastfeeding Complications Status: BF, P, I • Discuss the impact of an adequate diet. • Discuss the importance of frequent feeding. • Discuss specific conditions/problems. Refer to IBCLC/Designated Breastfeeding Expert (DBE)/Nutritionist/Dietitian Refer for Medical Evaluation:  Mastitis or Severe nipple pain Infant of a WIC Mother/ Mother at Risk Status: I • Discuss the impact of the mother’s nutritional risk during pregnancy to the infant’s health. • Discuss an adequate diet for the infant. • Discuss specific conditions/problems. Infant of a Mother with Complications that Impair Nutrition Status: I • Discuss an adequate diet at an appropriate level of comprehension for the client.

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Pregnancy Induced Conditions Status: P, PP, BF • Discuss specific conditions/problems. • Discuss the additional demand on nutrient stores. Schedule for High-Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement Delivery of Preterm /Early Term/ Low Birth Weight Infant Status: P, PP, BF Pregnant • Discuss the problems identified and the effect on current health. • Stress the importance of appropriate weight gain. Breastfeeding/Postpartum • Discuss the problems identified and the effect on current health. Fetal or Neonatal Death Status: P, PP, BF • Discuss the problems identified and the effect on current health. General Obstetrical Risk Status: P, PP, BF Pregnant • Discuss the importance of appropriate weight gain for the developing fetus. • Discuss the additional demand on nutrient stores. Breastfeeding/Postpartum • Discuss the additional demand on nutrient stores. Nutrition/Metabolic Conditions/Infectious Disease Acute or Chronic Status: P, PP, BF, I, C Pregnant/Breastfeeding/Postpartum • Discuss the relationship of the specific condition/problem to nutritional status and its potential impact on a woman’s current status. • Discuss the impact of over-the-counter medications and nutrient interactions. Infant/Child • Discuss the relationship of the specific condition/problem to nutritional status and its importance to growth and development. • Discuss the impact of over-the-counter medications and nutrient interactions. Schedule for High-Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement except:  Lactose Intolerance  Short Term Antibiotic Use – Drug Nutrient Interaction  Asthma – persistent asthma that requires daily medication  Food allergies – per patient request and/or professional discretion Impaired Ability to Prepare Food Status: P, PP, BF, I, C • Discuss an adequate diet at an appropriate level of comprehension for the client. • Discuss the specific condition/problem. Refer to Social Programs. Complications which Impair Nutrition Status: P, PP, BF, I, C Pregnant/Breastfeeding/Postpartum • Discuss an adequate diet at an appropriate level of comprehension for the client. • Discuss the relationship of the specific condition/ problem to nutritional status and its potential impact on a woman’s current status. Schedule for High-Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement For complications/

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Infant/Child • Discuss an adequate diet at an appropriate level of comprehension for the client. • Discuss the relationship of the specific condition/ problem to nutritional status and its importance to growth and development. potential complications which impair nutrition/ delays/disabilities that impair chewing /swallowing/ require tube feeding. Dental Problems Status: P, PP, BF, I, C Pregnant/Breastfeeding/Postpartum/Child/Infant • Discuss the importance of proper dental care. • Drink/provide only water between meals. • Limit sugary foods/drinks. Limit juice intake to 100% juice and no more than 4-6 ounces per day. • Brush teeth twice daily. • Refer to a dentist/doctor regarding fluoride. • Follow up with your dentist as appropriate for dental problems. Infant/Child • Breastfeeding is recommended for the 1st year of life and beyond as mutually desired. • Avoid having an infant/child sleep with a bottle. • Wipe the gums of young infants with a soft washcloth or soft toothbrush, even prior to tooth eruption. Other Health Risk/Fetal Alcohol Spectrum Disorder Status: P, PP, BF, I, C • Discuss adequate diet. Presumed Dietary Risk Status: P, PP, BF, C (age 2 and older) • Counsel on an adequate diet. Feeding Practices Status: P, PP, BF, I, C • Counsel on a specific problem (s) Inappropriate Nutrient Intake Status: P, PP, BF, C • Discuss the importance of calcium and protein sources. • Counsel on an adequate diet. Eating Disorders Status: P, PP, BF • Discuss the relationship of the specific condition/ problem to nutritional status and its potential impact on a woman’s current status. • Counsel on an adequate diet. Schedule for High-Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement Refer for Medical Evaluation. Recipient of Abuse Status: P, PP, BF, I, C • Counsel on an adequate diet. • Counsel based on readiness. Refer to Social Programs. Foster Care Status: P, PP, BF, I, C • Counsel on an adequate diet. • Discuss specific problems/conditions such as chronic health problems, birth defects, short stature, and inadequate nutrition. Refer to Social Programs. Homelessness Status: P, PP, BF, I, C • Counsel on an adequate diet with emphasis on homelessness/migrancy as appropriate. Refer to Social Programs.

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Migrancy Status: P, PP, BF, I, C • Counsel on an adequate diet with emphasis on homelessness/migrancy as appropriate. Refer to Social Programs. Possibility of Regression- Priority III Status: C • Discuss the importance of a good diet in preventing the previous risk from recurring. Possibility of Regression- Priority IV Status: C • Encourage continuance of a good diet as appropriate for child’s age. Transfer of Certification Status: P, PP, BF, I, C • Provide nutrition education for condition/problem, if known.

Page 1 Referral Based on Nutrition Risk Policy 403 December 2024

Policy 403 Referrals POLICY Local WIC Agencies will make referrals when there is an identified need or upon participant request. Referrals shall be made for medical provider evaluations, Designated Breastfeeding Expert (DBE) visits, Medical Nutrition Therapy, substance abuse, Lead Program, treatment/counseling services, and social programs. In addition, local WIC Agencies must screen for alcohol, tobacco, and other drug use, refer for further assessment when needed, and provide drug and other harmful substance abuse information.

PURPOSE To improve the health and well-being of WIC participants by ensuring awareness of and referrals to available resources for assistance and information. Screening and counseling shall be conducted in a non-judgmental and compassionate setting.

RELEVANT REGULATIONS AND POLICY 7 CFR 246.4(a)(8) and (9) – State Plan 7 CFR 246.7(a)(b) and (n) – Certification of Participants 7 CFR 246.11(a)(3) and (b)(1) – Nutrition Education 7 CFR 246.149(c)(1) and (9) – Program Costs Final WIC Policy Memorandum #2001-7 Immunization Screening and Referral in WIC WIC Policy # 2001-1 Clarification of WIC’s FY 2001 Appropriations Act Provision Regarding Blood Lead Screening WIC #1993-3A WIC’s Role in Screening for Childhood Lead Poisoning, 7 CFR 246.7(b).

PROCEDURES Certification Visits A. At each certification, local WIC Agencies must provide information on referrals to participants based on identified needs or by participant request. B. At each certification, WIC support staff must provide written referral information about other health-related and public assistance programs (Medicaid, SNAP, immunizations, etc.) and, when appropriate, shall refer applicants/participants to such programs. This information is available in written form on the eWIC-1 handout. C. At each certification, all participants should be screened for potential referrals. D. Prenatal and Breastfeeding participants should be offered the opportunity to speak with peer counselors where the Breastfeeding Peer Program is available. E. Participants with identified risk codes or community needs should be offered a referral. See Referrals Based on Risk Criteria Table below in this policy. F. Documentation of the referral and acceptance or denial should be documented in the participant's medical record. G. Each certification shall include a screening for potential alcohol, tobacco, or other drug use by prenatal and postpartum participants. Documentation of the referral and acceptance or denial should be documented in the participant's medical record. 1. It is not in the scope of WIC to provide drug, alcohol, or tobacco assessment or counseling. 2. If further assessment or counseling is needed, refer the participant to their medical provider. 3. Make available a list of local resources for drug or other harmful substance abuse counseling and treatment. This list must be made available to all WIC participants: pregnant, postpartum, and breastfeeding women and parents/caretakers of infants and children.

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4. Raise awareness of all participants and caretakers about the dangers of alcohol, tobacco, and other drugs. H. Upon enrollment of an infant or child, the parent or caretaker must be asked if the child has had a blood lead test. A referral should be made and documented to a health professional/local agency lead program if: 1. The infant/child has never had a lead test. 2. The child had an elevated BLL 12 months prior and has had no interim follow-up screening. 3. The child is suspected by a parent or a health care provider to be at risk for lead exposure. 4. The child has a sibling or frequent playmate with an elevated BLL. 5. The participant is a recent immigrant, refugee, or foreign adoptee. 6. The breastfeeding or lactating woman, parent, or child’s principal caregiver works professionally or recreationally with lead. 7. The family has a household member who uses traditional, folk, or ethnic remedies and cosmetics or who routinely eats unregulated/uninspected food imported from abroad. 8. The family has been identified at increased risk for lead exposure by the health department because the family has local risk factors for lead exposure. I. Refer infants and children under age two to a medical provider for immunizations. Documentation of the referral and acceptance or denial should be documented in the participant's medical record. 1. At initial certification and all subsequent certification visits for children under the age of 4, screen the infant/child’s immunization status using a documented record. A documented record is a record (electronic or paper) in which actual vaccination dates are recorded. This includes a parent’s record provided by the medical provider, an immunization registry or an automated data system, an electronic medical record, or client chart. 2. At a minimum, screen the infant/child’s immunization status by counting the number of doses of the DTaP (diphtheria, tetanus toxoid, and acellular pertussis) vaccine they have received in relation to the age, according to the timeline below: By 3 months of age, the infant/child should have at least 1 dose of DTaP. By 5 months of age, the infant/child should have at least 2 doses of DTaP. By 7 months of age, the infant/child should have at least 3 doses of DTaP. By 19 months of age, the infant/child should have at least 4 doses of DTaP. By 4 years of age, the child should have at least 5 doses of DTaP. 3. If the infant/child is under-immunized: i. Provide information on the recommended immunization schedule appropriate for age, ii. Refer for immunization services, ideally with a healthcare provider. 4. If the documented immunization record is not provided by the parent/caretaker: iii. Provide information on the recommended immunization schedule appropriate to the current age of the infant/child iv. Refer for immunization services, ideally with a healthcare provider. v. Request and encourage the parent/caretaker to bring the immunization record to the next certification visit/ sign a release of information to have the immunization record sent to the WIC office. J. WIC Staff must refer WIC participants for appropriate resources such as social services, the Breastfeeding Peer Program, lactation counseling with the Designated Breastfeeding Expert, medical providers, Medical Nutrition Therapy, smoking cessation, etc., based on identified needs or upon request. Documentation of the referral and acceptance or denial should be documented in the participant's medical record.

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Referral Services A. Local WIC agencies shall maintain and make available a list of referral sources in the program’s service area. B. Local Programs are required to provide information about the dangers of using alcohol, tobacco, and other drugs to all pregnant, breastfeeding, and postpartum women and to parents and caretakers of infants and children. C. Local WIC agency staff shall keep informed about available health and social services in the community whenever possible. D. Refer to the table below for information on Required Referrals based on Nutrition Risk Code Assignment.

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Referrals Based on Risk Criteria A. All participants must be screened for all qualifying nutrition risk criteria. WIC participants will receive a referral to the indicated referral source if the risk codes below are identified.

NUTRITIONAL RISK CRITERIA CODES FOR REFERRAL Medical Evaluation referral: NRCC Code Risk Criteria Name 201 Low Hematocrit/Low Hemoglobin: Hematocrit < 27% Hemoglobin < 9 grams/dL. 211 Elevated Blood Lead 152 Low Head Circumference 602/603 Breastfeeding Complications: Mastitis and/or Severe nipple pain, Jaundice 358 Eating Disorders Designated Breastfeeding Expert (DBE) (Nurse or Dietitian with credentials of IBCLC, CLC, or CLS), Nutritionist or Dietitian referral: NRCC Code Risk Criteria Name 602/603 Breastfeeding Complications Treatment/Counseling Services referral: NRCC Code Risk Criteria Name 361 Depression 371 Substance Use 372 Alcohol and Substance Use Social Programs referral: NRCC Code Risk Criteria Name 902 Impaired Ability to Prepare Food 901 Recipient of Abuse 903 Foster Care 801 Homelessness 802 Migrancy

Referral Follow-Up A. Evaluate referral outcomes, when possible, by conducting follow-ups with participants at subsequent visits. 1. Ask participants if services were obtained. 2. Reinforce follow-through if services were accessed. 3. Identify barriers and options for overcoming barriers if services were not obtained.

Documentation A. Documentation of the referral and acceptance or denial should be documented in the participant's medical record.

Page 1 WIC Low-Risk Secondary Nutrition Education Guidelines Policy 404 December 2024

Policy 404 WIC Low-Risk Secondary Nutrition Education Guidelines

POLICY Nutrition-focused education must be provided at least quarterly to each participant/caregiver according to federal regulations, state guidelines, and program goals.

PURPOSE To ensure that appropriate nutrition-focused education is made available to all participants on a routine basis and to establish standards for nutrition education contacts.

RELEVANT REGULATIONS 7 CFR 246.6 (b) – Goals 7 CFR 246.11 (c)(4) and (7) – State agency responsibilities 7 CFR 246.11—Nutrition Education (a) General, (b) Goals, (c)(4) – Procedures to ensure that nutrition education is offered, (d) Local program responsibilities, (e) Participant contacts, (e)(4) – Documentation of nutrition education provided, and (e)(5) – Provision of individual care plan based on need.

PROCEDURES WIC Follow-Up Nutrition Education Counseling A. Nutrition Education shall follow the Value Enhanced Nutrition Assessment (VENA) model and embrace the following principles to ensure effectiveness and quality: 1. Interactive a. Nutrition education shall involve families in self-assessment and self-directed goal setting and help families move toward their desired level of wellness. b. Develop a rapport by employing active listening skills, asking open-ended questions, and identifying the participant’s stage of change. 2. Flexible a. Use multiple strategies and techniques to effectively reach and impact participants and their families. 3. Relevant a. Impart appropriate and relevant education that is reflective of the interest of the participants and/or family. b. Education offered to participants shall be in a positive and interactive manner through developmentally and culturally appropriate teaching aids. 4. Supportive Environment a. Education shall be offered in a family, friendly environment for optimal learning. Personnel shall support the family’s needs and build a rapport with families to promote good health. 5. Trained Personnel a. Education shall be facilitated or taught by qualified, well-trained and equipped personnel. 6. Culturally Supportive a. Education shall acknowledge and support differences in cultures and languages and be sensitive to cultural food choices, when possible. B. WIC secondary nutrition education counseling must be offered to each participant/caregiver by providing quarterly nutrition education contacts during the certification period. 1. The first quarterly nutrition education contact is provided with the certification visit.

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2. The second nutrition education contact, or follow-up contact, is provided approximately three (3) months from the certification date. 3. Nutrition education contacts shall be scheduled with food benefit issuance and, when possible, with other services. 4. If a participant misses their nutrition education visit or declines nutrition education, it shall be documented in the participant’s medical record. 5. Benefits cannot be withheld for declining or not completing nutrition education visits. 6. Participants must receive secondary nutrition education contacts on the following schedule: Nutrition Education (NE) Contact Schedule Status 1st NE Contact 2nd NE Contact 3rd NE Contact 4th NE Contact Provide at certification visit Provide at follow-up visit, approximately 3 months after certification visit Provide at Mid- Certification Health Assessment (if applicable) approximately 6 months after certification visit Provide at follow-up visit, approximately 3 months after Mid- Certification Health Assessment Pregnant Woman   N/A N/A Breastfeeding Woman     Postpartum Woman   N/A N/A Infant     Children    

WIC Secondary Nutrition Education Counseling A. Participants will be assigned appropriate risk codes during their certification. B. Based on the risk code assignment, participants will be scheduled for a WIC Low-Risk (Brief) Secondary Nutrition Education visit or a WIC High-Risk (In-Depth) Secondary Nutrition Education visit. 1. WIC High-Risk Counseling visits count as one of the required nutrition education visits. Participants identified for high-risk counseling, must receive a minimum of one high-risk (In-Depth) nutrition counseling session per certification period. High-Risk nutrition education may be provided at the Mid-Certification Health Assessment as part of the MCHA nutrition education. 2. For additional information about WIC High-Risk Counseling see Policy 405-Secondary Nutrition Education for High-Risk Participants.

Methods for WIC Low-Risk (Brief) Secondary Nutrition Education A. Individual WIC Secondary Nutrition Education Counseling 1. Discuss topics based upon status and nutritional risk, individual/family goals, and individual/family interests. Provide nutrition education on at least one nutrition topic, may follow-up on goal set at certification/MCHA visit. 2. If utilizing Trained WIC paraprofessional, see Training Requirements for the WIC Paraprofessional in the section. 3. Make referrals for other programs or services (when appropriate). 4. Documentation must be in participant’s medical record in accordance to standards outlines in the Administrative Reference, Medical Records Management Section. 5. Documentation must include:

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a. Document nutrition topic(s) covered. b. Document any updates to goals, if applicable. c. Referrals for other programs (when appropriate). 6. Code service on the Patient Encounter Form (PEF) as listed below: a. Certifying Health Professionals i. Code W9401 WIC Nutrition Education/Counseling (7.5 minutes) when following Individual Nutrition Counseling Protocols and 2699-. a. If providing Breastfeeding nutrition education, Code W9401BF and V241-. b. Trained Paraprofessionals i. Coding on the PEF shall be WP401 (7.5 minutes) WIC Low-Risk Follow- up Contact when following protocols below. PROVIDER: TRAINED WIC PARAPROFESSIONAL*** Topic /Status Counseling/Education (Reference Materials**) Feeding Practices Discuss the following topic as appropriate: • Food Safety • Beans • Calcium • Vitamin A/Vitamin C • Iron for Strong Blood Cells • Healthy Eating for Preschoolers Choose My Plate Tip Sheet • Add More Vegetables & Focus on Fruits Choose My Plate Tip Sheets Status: Child (age 2 and older) Presumed Dietary Risk Status: Child (age 2 and older) Possibility of Regression-Priority III Status: Child (age 2 and older) Possibility of Regression-Priority V Status: Child (age 2 and older)

7. Documentation of refusal or no-show demonstrates that nutrition education was offered.

B. Online WIC Secondary Nutrition Education 1. All statuses are eligible for online nutrition education: a. Participants assigned WIC High-Risk Counseling must have one WIC High-Risk (In-Depth) Counseling visit during the certification period. i. It is recommended that the WIC High-Risk Counseling Visit be provided during the Mid-Certification Health Assessment (MCHA). ii. Online nutrition education is not considered High-Risk Nutrition Education. iii. If high-risk (In-Depth) nutrition education is provided at the MCHA visit, the child may have up to two (2) online nutrition education sessions during the one-year certification period. 2. At the certification appointment, the Certifying Health Professional (CHP) will determine if the participant is eligible for online nutrition education and, in conjunction with the participant/caretaker, determine if it is the best option for the family. a. The participant/caretaker of the eligible participants are to be provided a choice regarding the method of follow-up nutrition education. 3. The CHP, in conjunction with the participant/caretaker, will determine if there is access to the internet for online nutrition education. Access to the internet could include use of smart phone with data plan, computer in home or computer in another location such as library or friend/relative’s home. 4. The CHP or designated staff will explain the process for completing the online nutrition education.

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5. The CHP may recommend specific topics based on the participant’s category, interest and/or risks. However, the participant’s/caretakers may choose which lesson topic best meets their family’s needs. 6. The CHP may recommend the caretaker review Health eKitchen component which is a resource for menu development or locating recipes. However, Health eKitchen does not count as a nutrition education contact. 7. Households with two (2) or more WIC participants will be required to complete a minimum of one (1) lesson. 8. Each completed online lesson must be documented in the participant’s medical record. The system will print a label listing the nutrition education courses the participant/caretaker has completed. 9. Participants/caretakers who complete online nutrition education are not required to be physically present for food benefit issuance. If the participant/caretaker is not physically present: a. Upload eWIC (EBT) benefits to the participant’s account after verification of completion of the online nutrition lesson. b. The reason for mailing the food instruments or uploading the EBT benefits, the month(s) of issuance and the date the food instruments were mailed, or benefits were uploaded must be documented in the participant’s medical record. i. Proof of identity is coded as “other,” code 50. ii. The Household WIC Shopping List will be mailed. To protect privacy, the WIC Benefit List shall not be mailed. 10. Participants/caretakers who still need to complete the online nutrition lesson must be offered an individual or group nutrition education contact and must return to the clinic for food benefit issuance. 11. At the subsequent certification appointment, the CHP will follow up with the participant regarding the lessons and online courses' goals. 12. Caretakers who indicate an interest in online nutrition education but later choose not to participate in online option shall be offered individual or group nutrition education. 13. Participants with a current plan to do online nutrition education as their nutrition education contact are considered as having been offered one nutrition education contact.

C. Phone WIC Secondary (Brief) Nutrition Education 1. Certifying Health Professionals may provide nutrition and breastfeeding education by phone. 2. Local WIC agencies may not utilize phone contacts to provide nutrition education at certification or mid-certification health assessments (MCHA). 3. During the phone contact: a. Have the participant confirm their identify by asking them to identify their name and at least one of the following: current mailing address, date of birth, WIC card number or other verifiable information in the participant’s medical record. b. If the participant’s identity cannot be confirmed, education cannot be provided over the phone. 4. The education provided shall follow the same policies as the Individual Follow-Up Nutrition Education Counseling Protocols. 5. Offer the participant the opportunity to ask questions during and after the nutrition education contact. 6. Make appropriate referrals. 7. Document the phone contact in the participant’s medical record, including that the contact was via the phone. 8. Code the phone contact on the Patient Encounter Form (PEF).

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a. Code W9401 WIC Nutrition Education/Counseling (7.5 minutes) when following Individual Nutrition Counseling Protocols and 2699-. b. If providing Breastfeeding Counseling, Code W9401BF and V241-. c. If providing BOTH Nutrition Education per protocol and Breastfeeding Support 7.5 minutes of each), Code W9401 with 2699- and W9401BF with V241-.

D. Group WIC Secondary Nutrition Education Session 1. Group sessions are allowable for follow-up contact based on the professional judgement. 2. The State WIC office must approve all group education sessions. a. For a list of approved group education session, contact the State WIC Office. b. Any group session developed by a local WIC agency, must be approved by the State WIC Office prior to use. 3. Staff who may provide group nutrition education: a. Certifying Health Professionals b. Designated Breastfeeding Experts (DBE)Trained WIC paraprofessional-may provide group nutrition education for children age 2 and older with the following risk codes: Feeding Practices (4250, Presumed Dietary Risk (401), and Regression (501). c. If utilizing Trained WIC paraprofessional, see Training Requirements for the WIC Paraprofessional in the section. 4. Following registration, the participant, guardian or proxy will be directed to the appropriate group session. 5. Food benefit issuance and return appointments are prepared as the group session is being completed. The group sessions typically take 15-30 minutes. 6. The group education provider will code the appropriate group education level provided on the PEF. a. Use W9431 for Group nutrition education, with 2699-. b. Use W9432 for Group breastfeeding education, with V241-. c. Use W9435 for WIC Group nutrition education provided by a paraprofessional, with 2699-. 7. Documentation of the group session: a. Group Follow-Up Education label which includes group session provided, name of group session and is signed and dated by provider. b. If no label is used, documentation shall include date, nutrition education provided by group, name of session, provider signature and title. c. Provided referrals, when appropriate. d. Any additional information provided that is not part of the group lesson plan. E. Kiosk WIC Secondary Nutrition Education. 1. Contact the Nutrition Services Branch for guidance and approval prior to offering Follow- Up Kiosk Nutrition Education.

WIC Exit Counseling A. The WIC exit counseling shall reinforce important health messages previously discussed, with emphasis on: 1. Postpartum/Breastfeeding Women a. Recommendation to breastfeed infants for the first year of life and beyond. b. Review the American Academy of Pediatrics safe sleep environment for infants. c. Folic acid and the prevention of birth defects. 2. All Applicable Status a. Choose My Plate Dietary Guidelines to make healthy food choices. b. Avoiding sugar sweetened drinks.

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c. Recommendation of an average of 30 minutes for women and 60 minutes for children of physical activity each day. d. Health risks associated with alcohol, tobacco and drug use. e. Following the recommended schedule for immunizations. f. For children, limit screen time to no more than 2 hours/day and remove the television from the child’s bedroom.

Safe Sleep Environment for Infants The Kentucky Department of Public Health supports the American Academy of Pediatrics policy on Safe Sleep to reduce the incidence of Sudden Unexplained Infant Death (SUID) and Sudden Infant Death Syndrome (SIDS). The AAP Safe Sleep Policy includes: A. Placing baby on their back for every sleep time. B. Placing baby on a firm sleep surface. Sitting devises such as car seats, strollers, swings, infant carriers and infant slings are not recommended for routine sleep. C. Placing baby in the same room where the parents sleep but not on the same bed (room sharing without bed sharing). D. Keeping soft objects, loose bedding, or any object that could increase risk of entrapment, suffocation or strangulation out of the crib. These objects include pillows, blankets, bumper pads. E. Not using wedges or positioners. F. Breastfeeding as much and for as long as a mother can. G. Offering a pacifier at nap time and bedtime. With breastfeeding infants, delay pacifier introduction until breastfeeding is firmly established, usually around 3-4 weeks. H. Not letting the baby get too hot. In general, infants shall be dressed appropriately for the environment, with no more than 1 layer more than an adult would wear to be comfortable in that environment. I. Scheduling and going to all well-child visits. J. Keeping baby away from smokers and places where people smoke. K. Not using home cardiorespiratory monitors or to help reduce the risk of SIDS. L. Not using products that claim to reduce the risk of SIDS. M. The AAP recommends supervised, awake tummy time daily to facilitate development and minimize the occurrence of positional plagiocephaly (flat heads).

Training Requirements for WIC Paraprofessionals Before Paraprofessional will be trained by the State WIC Office, the local WIC agency must assure that a Registered Dietitian (RD, LD) with at least one year of WIC experience is on staff to provide the observation component of the training and supervision once the training has been completed. Once trained, WIC paraprofessionals may provide specific and limited nutrition information to WIC participants as detailed in the Individual WIC Follow-Up Nutrition Education and Group Follow-up Nutrition education sections above. A. Staff of a local WIC agency are not Certifying Health Professionals or DBE(i.e., support services staff or clinical assistants) may be trained as a paraprofessional, if they meet the following basic criteria: 1. Are an employee of the agency; 2. Have a high school diploma, GED, or higher education; 3. Have a minimum of one year experience with a Maternal and Child Health Program; 4. Have knowledge of local health department system, community resources and ability to refer; and 5. Can communicate with clients on appropriate educational, economic and cultural level. B. Initial paraprofessional training includes: 1. Instructional component provided by the Nutrition Services Branch; and 2. Initial observational component provided by the local WIC agency Registered Dietitian.

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C. Once the instructional and observation components of training have been completed, the local WIC agency Registered Dietitian will complete and submit the “WIC Paraprofessional Candidate Submission Form” (see form in this section) to allow the Paraprofessional to code on the Patient Encounter Form (PEF). D. At the completion of the instructional component of the training, the paraprofessional must demonstrate competency in following areas: 1. Basic Understanding of the WIC Program; 2. Communication skills; 3. Referral skills; 4. Documentation skills; and 5. Through knowledge of the paraprofessional nutrition education topics completed during the initial training. E. After successful completion of the instructional component, the paraprofessional must successfully complete the observation component in the clinic under the direction of the local WIC agency Registered Dietitian. During the observation component the paraprofessional must: 1. Observe a Certifying Health Professional providing nutrition education (individual/group contact) to clients; 2. Be observed by the local WIC agency Registered Dietitian conducting at least three (3) nutrition education services (individual/group). a. If paraprofessional will be providing individual counseling, they must be observed conducting at least three individual contacts. b. If paraprofessional will be providing group sessions, they must be observed conducting at least three (3) group session contacts. F. The local WIC agency Registered Dietitian must provide ongoing supervision by: 1. Conducting yearly chart reviews of paraprofessional nutrition education documentation; 2. Observing the paraprofessional providing nutrition education services (individual/group) and coding on the Patient Encounter Form (PEF) at least once a year; 3. Acting as a resource and mentor; 4. Ensuring the trained paraprofessional receives at least four (4) hours of continuing education per year (these hours may be attained by attending webinars, local nutrition in- service training, and other nutrition conferences and/or workshops and reading approved by Registered Dietitian); and 5. Ensuring continuing education hours are documented and maintained at the local level. 6. Submit one form for each newly trained paraprofessional. 7. The local WIC agency Registered Dietitian will be notified by the Nutrition Services Branch of the starting date the paraprofessional may begin providing and coding the paraprofessional nutrition education service (individual/group) for WIC.

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WIC PARAPROFESSIONAL CANDIDATE SUBMISSION FORM Complete the form for approval for a trained WIC Paraprofessional to provide and code WIC paraprofessional nutrition education. Upon state agency approval, WIC Paraprofessional services may be provided and coded. Agency: Date:

Paraprofessional Candidate Name:

Employee Number of Paraprofessional Candidate:

1. Paraprofessional 101 Course completion date:

Name of Nutrition Services Branch trainer:

2. Paraprofessional Observational component completion date:

Name of Registered Dietitian (RD) observer:

Request for Coding Services: 3. Employee needs the ability to code the following WIC paraprofessional nutrition education services on the Patient Encounter Form (PEF): (check all that apply)

WP401 WIC Low Risk Follow-up Contact (7.5)

WP402 WIC Low Risk Follow-up Contact (15)

W9435 WIC Group low risk nutrition-paraprofessional 4. Employee needs the ability to code these services at the following site(s):

5. Local agency’s RD responsible for ongoing supervision and ongoing training for Paraprofessional:

6. Person submitting this form:

Mailing address:

Email address:

Phone #:

7. Indicate Nutrition Modules Completed. 8. Please submit completed form to: Clinical Nutrition Section Supervisor Nutrition Services Branch Cabinet for Health and Family Services 275 East Main Street, HS2W-D Frankfort, Kentucky 40621-0001

** Paraprofessional may only provide counseling on Nutrition Module completed and must follow policies and procedures in the WIC and Nutrition Manual when providing WIC paraprofessional nutrition education. STATE AGENCY USE ONLY  Paraprofessional Candidate has completed required training (101 Paraprofessional Module & Observational Component and at least one (1) Nutrition module.)  Request sent to Local Health:

 Employee approved to begin coding service:

 Local agency notified

4 Authorized by NSB Staff:

Date:

 Nutrition Modules Completed** Date Module 1: Calcium Module 2: Iron Module 3: Food Safety Module 4: Vitamin A Module 5: Vitamin C Module 6: Dried Beans and Fiber Module 7: Fruits and Vegetables Module 8: Kids in the Kitchen Module 9: Screen Time Other (list)

Page 1 WIC High-Risk Secondary Education Policy 405 December 2024

Policy 405 WIC High-Risk Secondary Nutrition Education

POLICY WIC High-Risk Counseling visits must be provided, and individualized care plans must be developed for all high- risk participants following each certification/mid-certification health assessment where they were identified as high- risk. PURPOSE To provide guidance for high-risk counseling, including methods, documentation, etc. To ensure all high-risk participants receive an individualized care plan with personalized nutrition information to meet their health care needs. RELEVANT REGULATIONS 7 CFR 246.11(e)(5) United States Department of Agriculture, Food and Nutrition Services, Nutrition Service Standards PROCEDURES WIC High-Risk Counseling A. Certifying Health Professionals during certification visits must identify and assign nutrition risk code criteria for each participant. 1. Participants assigned the following risk codes must receive at least one WIC High-Risk Counseling visit within that certification period in which that risk code was assigned.

Nutritional Risk Criteria Codes Requiring High-Risk Nutrition Counselling WIC High-Risk Counseling: NRCC Code Risk Criteria Name 211 Elevated Blood Lead 141 Low Birth Weight 111,113 Overweight 101,103 Underweight 302 Pregnancy Induced Conditions: Gestational Diabetes 341,342,343,345,346, 347,348,349,351,352,353, 354,356,358,359,360, 363 Nutrition/Metabolic Conditions: All except: Lactose Intolerance, Short Term Antibiotic Use-Drug/Nutrient Interaction, Asthma-Persistent asthma requiring daily medication, and Food allergies-per patient request and/or professional discretion 135 Infant Weight Loss 134 Failure to Thrive 362 Complications/Potential Complications which Impair Nutrition/Delays/Disabilities that impair chewing/swallowing/require tube feeding 358 Eating Disorders

B. Certifying Health Professionals must provide WIC High-Risk (In-Depth) Secondary Counseling visits to WIC participants who are identified as High-Risk during their Certification or Mid-Certification Health Assessment. When available, the High-Risk secondary visit should be provided by a Registered Dietitian or Nutritionist. 1. WIC High-Risk (In-Depth) Secondary Counseling must be provided to WIC participants at least once during their certification period. 2. It is recommended to provide the WIC High-Risk Counseling at the Mid-Certification Health Assessment appointment. The MCHA Nutrition Education Counseling satisfies the High-Risk (In- Depth) counseling requirements.

Page 2 WIC High-Risk Secondary Education Policy 405 December 2024

3. All additional Secondary Nutrition Education may be provided by any approved WIC Secondary Nutrition Education Counseling method outlined in Policy 404-WIC Secondary Nutrition Education for Low-Risk Participants. High-Risk Counseling Methods A. The preferred method of delivering high-risk (In-Depth) secondary nutrition counseling to participants is through in-person individualized visit. Individualized telephone contacts are allowable for high-risk (In- Depth) secondary nutrition education. High-Risk Counseling A. WIC High-Risk Counseling shall include: 1. Nutrition interventions, which include assessment, counseling, development, and documentation of an individualized care plan for each participant. 2. Review and discuss the growth chart, height/weight, and hematological data. 3. At least one high-risk criteria must be addressed during the counseling visit. 4. Assess progress toward goal established at certification visit/previous nutrition education visit. a. Acknowledge progress as well as challenges for participants in meeting goals. Provide participants with appropriate nutrition education to assist in working toward goals. b. Goals may be revised or changed to meet participant’s needs. c. If previous goals have been met, acknowledge achievement and work with the participant to set a new goal. 5. Make referrals for other programs or services (when appropriate). 6. Any additional nutrition information or pamphlets provided not listed in the protocol. Counseling protocols for required counseling and education are found in the Individual High-Risk Counseling Nutrition Education Protocols Table below in the policy. a. All risk codes are provided on the Individual High-risk Counseling Protocols. b. To ensure participant-centered education, the Certifying Health Professional can cover topics, in addition to the High-Risk Code, based on participant needs and interests. 7. Review and update/tailor the food package as appropriate. Documentation A. High-risk counseling (In-Depth) secondary nutrition visits must have an individualized care plan documented in the participant’s medical record. B. Individualized Care Plan documentation must include: 1. Participant progress toward goals established during a previous visit/updates to goals. 2. Nutrition assessment (anthropometric/hematological/dietary/health updates) 3. Nutrition topics discussed based on protocol. 4. Referrals for other programs (when appropriate). Document acceptance or decline of referral. 5. Any additional nutrition information or pamphlets provided not listed in the protocol. 6. Plans for follow-up visits. (For example, follow up in 3 months for nutrition education via online, in person, group, telephone, with RD for MNT, etc.) 7. Code service on the Patient Encounter Form (PEF) as listed below: a. Code W9401 WIC Nutrition Education/Counseling (7.5 minutes) when following Individual Nutrition Counseling Protocols and 2699-. (Use W9402 for a 15-minute education visit.) b. If providing Breastfeeding nutrition education, Code W9401BF (7.5 minutes) and V241-.

Referrals A. The Certifying Health Professional (CHP) may determine during the WIC High-Risk Counseling visit that a referral to the healthcare provider, social service program, food pantry, smoking cessation program, alcohol or drug addiction program, or Medical Nutrition Therapy (MNT) would be beneficial for the participant.

Page 3 WIC High-Risk Secondary Education Policy 405 December 2024

B. This referral must be documented in the Individualized Care Plan in the participant’s medical record. The Certifying Health Professional should document the acceptance or decline of referral.

Individual WIC High-Risk Counseling Nutrition Education Protocols

Status: P= any Pregnant Status; BF= any Breastfeeding Status; PP= Postpartum Status; C= Child Status; I= any Infant Status

PROVIDER: CERTIFYING HEALTH PROFESSIONAL Topic /Status/ Counseling/Education Low Hematocrit/Low Hemoglobin Status: P, PP, BF, I, C • Discuss Iron and Vitamin C sources in the diet. • Discuss the importance of Iron and the role of iron in red blood cells. • Discuss the absorption of iron sources and the role of vitamin C in Iron absorption. Elevated Blood Lead Status: P, PP, BF, I, C • Discuss the importance of adequate intake of calories, calcium, iron, vitamin C, and low-fat foods (after age 2), which decreases lead absorption. • Discuss the importance of regular meals and snacks. Low Head Circumference Status: I, C (up to age 2) • Discuss age-appropriate feeding for the infant. Preterm/Early Term Birth Status: I, C (up to age 2) • Discuss age-appropriate feeding for infant development or up to age 2 children. • Review the growth chart and weight goals. Low Birth Weight /Very Low Birth Weight Status: I, C (up to age 2) • Discuss age-appropriate feeding for infant’s or child’s development. • Review the growth chart and weight goals. At Risk for Overweight Status: I, C • Discuss the importance of prevention of overweight. • Discuss age-appropriate feeding for infant’s or child’s development. • Discuss the importance of regular physical activity. • Review dietary concern(s) and appropriate action.

Overweight, Obese, High Weight for Length Status: P, PP, BF, C, I Infant/Child • Review the growth chart and weight goals. • Discuss age-appropriate feeding for the child’s development. • Discuss the importance of regular physical activity. Pregnant/Postpartum/Breastfeeding Women • Review weight goals. • Discuss possible reasons for weight status. • Review Choose My Plate Dietary Guideline Tip Sheet or MyPlate to encourage appropriate weight status. Discuss the importance of regular physical activity. At Risk for Underweight Status: I, C #2, #3, #7-10 (C) Infant/Child • Review the growth chart and weight goals. • Discuss age-appropriate feeding for infant’s or child’s development. Underweight Infant/Child

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Status: P, PP, BF, I, C • Review the growth chart and weight goals. • Discuss age-appropriate feeding for infant’s or child’s development. Pregnant/Breastfeeding/Postpartum Women • Review weight goals. • Discuss possible reasons for weight status. • Review Choose My Plate Dietary Guideline Tip Sheet or MyPlate to encourage appropriate weight status. At Risk for Short Stature Status: I, C • Review the growth chart and height goals. • Discuss age-appropriate feeding for infant’s or child’s development. • Discuss the importance of protein for growth. Short Stature Status: I, C • Review the growth chart and height goals. • Discuss age-appropriate feeding for infant’s or child’s development. • Discuss the importance of protein for growth. Growth Problems Status: I, C • Discuss age-appropriate feeding for infant’s or child’s development. • Review the growth chart and weight goals. • Discuss the importance of protein for growth.

Inappropriate Weight Gain Pattern Status: P, PP, BF, I, C Infant/Child • Discuss age-appropriate feeding for infant’s or child’s development. • Review the growth chart and weight goals. Pregnant/Breastfeeding/Postpartum Women • Review weight goals. • Discuss possible reasons for weight status. • Review Choose My Plate Dietary Guideline Tip Sheet or MyPlate to encourage appropriate weight status.

Alcohol and Substance Use Status: P, PP, BF • Discuss the importance of discontinuing the identified substance use (alcohol, tobacco, drugs, and other harmful substances) (ATOD). • Discuss how the identified use can affect the mother and her fetus, infant, or other household members. • Discuss the importance of discontinuing smoked tobacco, electronic nicotine delivery systems (ENDS), vapes, smokeless tobacco (chewing tobacco, snuff, dissolvable,) hookahs, cigars, pipes, and nicotine replacement therapies (gums, patches). Environmental Tobacco Exposure Status: P, PP, BF, I, C • Discuss the importance of continuing a healthy diet. • Discuss the risk of thirdhand smoke. Breastfeeding Infant/BF Woman at Nutritional Risk Status: I, BF • Discuss an adequate diet for the infant. • Discuss using WIC foods to promote optimal health. • Discuss the recommended number of servings from MyPlate and the importance of WIC foods. Breastfeeding Complications Status: I, P, BF • Reinforce the importance of an adequate diet. • Reinforce the importance of frequent feeding. • Discuss specific condition(s)/problem(s). Breastfeeding Infant/BF Woman with Feeding Practices Status: I, P, BF • Discuss an adequate diet for the infant. • Discuss using WIC foods to promote optimal health. • Discuss the recommended number of servings from MyPlate and the importance of WIC foods. Infant of a WIC Mother/ Mother at Risk Status: I • Discuss an adequate diet for the infant.

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Infant of a Mother with Complications that Impair Nutrition Status: I • Discuss an adequate diet at an appropriate level of comprehension for the client. Impaired Ability to Prepare Food Status: P, PP, BF, I, C • Discuss the importance of an adequate diet. • Discuss specific condition(s)/problem(s). Pregnancy Induced Conditions Status: P, PP, BF • Encourage appropriate weight gain. • Discuss increased nutrient needs. • Reinforce an adequate diet. • Discuss specific condition(s)/problem(s). • Discuss adequate diet at an appropriate level of comprehension for the client Delivery of Preterm/Early Term / Low Birth Weight Infant Status: P, PP, BF Pregnant • Discuss the problems identified and the effect on current health. • Stress the importance of appropriate weight gain. Breastfeeding/Postpartum • Discuss the problems identified and the effect on current health. Fetal or Neonatal Death Status: P, PP, BF • Reinforce the importance of an adequate diet for health. General Obstetrical Risk Status: P, PP, BF • Discuss specific condition(s)/problem(s). • Discuss the importance of an adequate diet. Nutrition/Metabolic Conditions/Infectious Acute or Chronic Disease Status: P, PP, BF, I, C • Discuss specific condition(s)/problem(s). • Discuss the importance of an adequate diet. Impaired Ability to Prepare Food Status: P, PP, BF, I, C • Discuss the importance of an adequate diet. • Discuss specific condition(s)/problem(s). Complications which Impair Nutrition Status: P, PP, BF, I, C • Discuss specific conditions/problem. • Discuss the importance of an adequate diet. • Discuss an adequate diet at an appropriate level of comprehension for the client. Dental Problems Status: P, PP, BF, I, C • Discuss specific condition(s)/problem(s). • Discuss the importance of an adequate diet. Other Health Risk/Fetal Alcohol Spectrum Disorder Status: P, BF,PP, I, C • Discuss the importance of a good diet. Presumed Dietary Risk Status: P, PP, BF, C (age 2 and older). • Discuss the importance of a good diet. Feeding Practices Status: P, PP, BF, I, C • Discuss specific problems and their relationship to health, growth, or development. Inappropriate Nutrient Intake Status: P, PP, BF, C • Discuss the importance of an adequate diet. Eating Disorders • Discuss specific condition(s)/problem(s).

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Status: P, PP, BF • Discuss the importance of an adequate diet. Recipient of Abuse Status: P, PP, BF, I, C • Discuss the importance of an adequate diet. Foster Care Status: P, PP, BF, I, C • Discuss the importance of an adequate diet. Children – • Discuss specific condition(s)/problem(s) such as chronic health problems, birth defects, short stature, and inadequate nutrition. Homelessness or Migrancy Status: P, PP, BF, I, C • Discuss the importance of an adequate diet with an emphasis on homelessness or migrancy. Possibility of Regression Status: C • Discuss the importance of an adequate diet. Possibility of Regression- Priority III Status: C • Discuss the importance of an adequate diet. Transfer of Certification- Priority IV Status: P, PP, BF, I, C • Provide nutrition education, as appropriate.

Individual WIC High-Risk Counseling Nutrition Education Protocols

PROVIDER: DESIGNATED BREASTFEEDING EXPERT/LACTATION SPECIALIST Topic /Status Counseling/Education Breastfeeding Infant/BF Woman at Nutritional Risk Status: I, P, BF • Discuss an adequate diet for the infant. • Discuss using WIC foods to promote optimal health. • Discuss the recommended number of servings from MyPlate and the importance of WIC foods. Breastfeeding Complications Status: I, P, BF • Reinforce the importance of an adequate diet. • Reinforce the importance of frequent feeding. • Discuss specific condition(s)/problem(s). Breastfeeding Infant/BF Woman with Feeding Practices Status: I, P, BF • Discuss an adequate diet for the infant. • Discuss using WIC foods to promote optimal health. • Discuss the recommended number of servings from MyPlate and the importance of WIC foods.

Page 1 Nutrition Services Plan and Regional Breastfeeding Coordinator Program Plans Policy 406 December 2024

Policy 406 Nutrition Services Plan and Regional Breastfeeding Coordinator Program Plans POLICY Local WIC Agencies shall complete an annual Nutrition Services Plan consistent with the State’s goals and objectives. Regional Breastfeeding Coordinators shall complete an annual Program Plan consistent with the State’s goals and objectives.

PURPOSE To ensure local WIC agencies plan and evaluate nutrition and breastfeeding services provided to program participants.

RELEVANT REGULATIONS 7 CFR 246.11(d)(2) – Nutrition Education: Local WIC Agency responsibilities United States Department of Agriculture, Food and Nutrition Services, Nutrition Service Standards

PROCEDURES Nutrition Services Program Plan A. Local WIC Agencies shall complete a Nutrition Services Program Plan that is consistent with statewide nutrition education goals and objectives as described in the annual guidance provided by the State WIC office. B. Components of the Nutrition Services Program Plan shall include: 1. Evaluation of the previous year’s plan. 2. Clinic Needs Assessment 3. Goals as determined by the State WIC Office and based on identified needs at the local level. 4. Measurable objectives designed to meet each goal. 5. Specific methods or activities to achieve each objective.

Regional Breastfeeding Coordinator Program Plan A. Each Regional Breastfeeding Coordinator shall complete a Program Plan for their region that is consistent with statewide breastfeeding goals and objectives as described in the annual guidance provided by the State Breastfeeding Coordinator. B. Components of the Regional Breastfeeding Coordinator Program Plan shall include: 1. Evaluation of the previous year’s plan. 2. Goals as determined by the State WIC Office or based on identified needs at the local level. 3. Measurable objectives designed to meet each goal. 4. Specific methods or activities to achieve each objective. 5. Identification of Community Partners within region 6. Activities planned with all Local WIC Agencies within region 7. Activities planned with community partners across region

Timeline A. Each year, guidance for completing the Nutrition Services Plan and Regional Breastfeeding Coordinator Program Plan will be provided on the following schedule.

Page 2 Nutrition Services Plan and Regional Breastfeeding Coordinator Program Plans Policy 406 December 2024

1. The Plans and support guidance will be emailed to Local WIC Coordinator and Regional Breastfeeding Coordinators in early October and must be completed and returned to the State Agency in early November each year. 2. State Program staff will review the plans by the end of December and will notify local WIC agency staff whether their plans are approved, or whether it needs modification. 3. Plans that require revision must be re-submitted by the end of January the following year.

Extension A. Local WIC Agencies or Regional Breastfeeding Coordinators may ask the State Agency for an extension to complete their plans in extenuating circumstances. B. The State agency recommends that local WIC agencies evaluate their nutrition services and breastfeeding support on an ongoing basis to ensure that they are providing effective and needed services.

Page 1 Medical Nutrition Therapy Policy 407 December 2024

Policy 407 Medical Nutrition Therapy

POLICY Medical Nutrition Therapy (MNT) may only be provided by Registered Dietitians/Registered Dietitian Nutritionists (RD/RDN) and Certified Nutritionists (CN)

PURPOSE To ensure local health departments are providing MNT services based on federal and state laws and regulations.

PROCEDURES Referral Guidelines for Medical Nutrition Therapy A. MNT is individualized dietary instruction and counseling for a nutrition-related problem. B. This level of specialized instruction is above basic nutrition education counseling and includes an individualized dietary assessment. C. MNT services may only be provided by an RD/RDN with an LD. D. A CN may provide MNT, but the services may not be reimbursed by all third-party payors. 1. Reimbursement of MNT by Medicaid/Medicare rate (as of July 2024) is: i. New Patient MNT Individual (CPT 97802) $35.81/unit ii. Established Patient MNT Individual (CPT 97803) $31.03/unit iii. MNT Group (CPT 97804) $15.17/unit E. Medical Nutrition Therapy is above the scope of WIC and may not be billed to the WIC Program. F. WIC may refer participants to MNT services. G. Local Health Departments may accept MNT referrals from their community. H. MNT is not a Core DPH Service, however many communities lack access to MNT and their communities may have high rates of diabetes, obesity, cardiovascular disease, high blood pressure or other chronic diseases for which MNT services can help manage. I. The table below indicates conditions that can be referred for MNT services. MNT services may be offered for a variety of health and feeding conditions and is not limited to this information.

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The below table are conditions or concerns that may be identified in a WIC visit that may be referred for Medical Nutrition Therapy which is above and beyond the WIC Nutrition Education Protocol or for which a local health department with a RD/RDN on staff may receive an outside referral to provide MNT services.

Ages/Status Problem/Condition for Medical Nutrition Therapy Infants – Adult Pregnant Women Postpartum & Breastfeeding Women Infants, Children All Adults Weight Management • Underweight = Pre-pregnancy Body Mass Index (BMI) < 18.5 • Overweight = Pre-pregnancy BMI > 25.0 • Low maternal weight gain, 2nd or 3rd trimesters, single pregnancy o Underweight women who gain <4 pounds/month o Normal weight women who gain <3.2 pounds/month o Overweight women who gain <2 pounds/month o Obese women who gain <1.6 pounds/month • Weight loss during pregnancy o Any weight loss below pregravid weight during 1st trimester (0 – 13 weeks) o >2 pounds during 2nd or 3rd trimesters • High maternal weight gain, all trimesters, singleton pregnancy o Underweight women who gain >5.2 pounds/month o Normal weight women who gain >4 pounds/month o Overweight women who gain >2.8 pounds/month o Obese women who gain >2.4 pounds/month • Underweight = Pre-pregnancy BMI or Current BMI < 18.5 (within 6 months of delivery) • Underweight = Current BMI < 18.5 (> 6 months of delivery) • Overweight = Pre-pregnancy BMI or Current BMI > 25.0 (within 6 months of delivery) • Overweight = Current BMI > 25.0 (> 6 months of delivery) • High maternal weight gain last pregnancy o Underweight Postpartum Woman and gained 40 pounds o Normal weight PP Woman and gained > 35 pounds o Overweight PP Woman and gained > 25 pounds o Obese PP Woman and gained > 15 pounds • Low Birth Weight (LBW) <5 pounds, eight ounces • Failure to Thrive (FTT) • Obesity > 95th percentile weight for height/length • Unexplained weight loss • Any patient requesting weight management • Underweight = BMI < 18.5 • Overweight = BMI > 25.0 All Adolescent Adult Hyperlipidemia • Total cholesterol > 200 mg/dl • LDL > 130 mg./dL. • Total cholesterol > 240 mg./dL. • HDL < 40 mg./dL. • LDL > 160 mg./dL. • TG > 200 mg./dL.

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Ages Problem/Conditions that may be All Elevated Blood Lead Pregnant Women Pregnancy Induced Conditions • Hyperemesis Gravidarum • Gestation diabetes (this pregnancy) All Nutrition/Metabolic such as: • Nutrient Deficiency Diseases • Gastro-Intestinal Disorders • Glucose Disorders • Thyroid Disorders • Hypertension • Renal Disease • Cancer/treatment for cancer • Central Nervous System Disorders • Genetic/Congenital Disorders • Inborn Errors of Metabolism • Infectious Diseases (present in the last 6 months) • Celiac Disease • Drug/Nutrient Interactions • Recent Major Surgery, Trauma, Burns • Other Medical Conditions Pregnant/Postpartum/Breastfeeding Women/Child Inappropriate Nutrient Intake/Nutritional Concerns • Vegan • Highly restrictive diet in calories or specific nutrients Complications which Impair Nutrition • Delays/disorders that impair chewing/swallowing/require tube feeding Pregnant/Postpartum/Breastfeeding Women/Adolescents/Children Eating Disorders Infants Nutrition/Metabolic Conditions • Pyloric Stenosis • Baby Bottle Tooth Decay

Reimbursement of Medical Nutrition Therapy (MNT) A. Registered Dietitians/Registered Dietitian Nutritionists (RDN) employed by health departments with the credential of Licensed Dietitian (LD) by the Kentucky Board of Licensure and Certification for Dietitians and Nutritionists are recognized as individual health care providers who can bill third-party payors such as Medicare, Medicaid, private insurance plans, HMO’s, and PPO’s for MNT services they provide for services. B. Master’s degree level nutritionists with the credential of Certified Nutritionists (CN) by the Kentucky Board of Licensure and Certification for Dietitians and Nutritionists may be recognized to bill third-party payors, however, not all third-party payors will reimburse for services provided by CNs. C. Medicaid and other private insurance companies each have their individual policies and procedures to become credentialed providers to bill for MNT services. In order to provide and be reimbursed for MNT services, the RD/RDN must be a D9 provider and the CN must be a DA provider. Not all MNT services are reimbursable.

Requesting Prior Authorization for MNT Services A. The Health Department must assure that they are providing MNT services according to each Medicaid MCO company provider handbook of policies and procedures to secure reimbursement for MNT services.

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B. It is recommended to verify the client’s eligibility for the services prior to the provision of MNT services and follow the payor guidelines for billing and edits. This process involves teamwork and communication between the RD/RDN, the health department billing/financial staff, referring physicians, and the specific insurance provider billed for the services. C. The following are general steps for requesting an authorization for MNT services: 1. Contact the MCO responsible for the client’s medical coverage. 2. Verify if the provider must complete the process to become an approved provider for the MCO. 3. Follow policies and procedures as outlined by each MCO to request reimbursement for MNT services. 4. Complete the MCO authorization form with appropriate client information to receive authorization MNT services, if required. 5. Submit all necessary information and follow all instructions as outlined by each MCO for the prior authorization letter, if needed. Include copies of the client’s WIC-75 and growth chart to document clinical information to support the medical necessity for the MNT service. 6. Be aware, that problem visits and MNT cannot be billed together. a. Preventative visits and MNT can be billed together. These are national edits that were adopted from the Centers for Medicare and Medicaid Services (CMS) National Coding Initiative (NCCI) standard payment methodologies. b. These methodologies prevent reimbursement for services that cannot be billed simultaneously. c. An example of a problem visit that cannot be billed with MNT is an Evaluation Management (EM) visit. Therefore, these visits will have to scheduled on different days in order to receive reimbursement for both services. A preventative visits such as WIC can be scheduled with MNT. 7. Bill according to each MCO’s policies and procedures.

MNT Documentation Guidelines A. MNT providers must develop a nutrition care plan appropriate for each client or client group according to the Academy of Nutrition and Dietetics Nutrition Care Manual and based on the guidance below. B. Contact the Nutrition Services Branch to request access to the Nutrition Care Manual for RD/RDNs and CNs. C. The below-required elements are recorded on the MNT forms on the following pages. This information is required to reimburse MNT services. D. Medical Nutrition Therapy documentation shall contain the following elements: 1. Date of MNT visit along with the beginning and end time of visit 2. ICD-10 code-define type of visit/counseling 3. Subjective Data a. Client’s reason for visit b. Primary Care Physician c. History d. Subjective Data i. Past and present medical ii. Nutrition including food patterns ad intake iii. Weight iv. Medications v. Exercise e. Objective Data i. Laboratory results ii. Height, weight iii. BMI iv. Calorie Needs v. Drug/Nutrient Interactions f. Individual Assessment of Diet/Intake i. Individual assessment of diet/intake

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g. Plan i. Individualized dietary instruction that incorporates diet therapy counseling and education handouts for a nutrition-related problem ii. Plan for follow-up iii. Documentation of referral for identified needs, as appropriate iv. It is recommended to send a letter to the client’s physician describing the dietary instruction provided. A copy of this letter shall be included in the client’s medical record. h. Date and legible identity of provider i. All entries must be signed and dated by the provider. See the Administrative Reference, Medical Records Management Section.

Medical Nutrition Therapy Assessment Forms-Individual Contact A. Medical Nutrition Therapy (MNT) Assessment forms are required for documentation of an initial individual contact. The MNT forms are found on the following pages in this section. B. All initial individual MNT visits are to be documented on the forms. These forms were developed to collect the required information for reimbursement. C. An entry must be included on the Service Record/Progress Notes (CH-3) referencing the MNT form. D. Per medical documentation and registration/licensure requirements, all entries must contain a goal for the patient and/or the progress toward a goal. See Administrative Reference, Medical Records Management Section. E. The following MNT Assessment forms are to be utilized as appropriate: 1. MNT – Adult 2. MNT – Pediatric 3. MNT – Diabetes 4. MNT – Gestational Diabetes 5. MNT – Renal 6. MNT – Follow Up (optional)

Page 6 Medical Nutrition Therapy Policy 407 December 2024 Rev. 10/15

Medical Nutrition Therapy (Adult) Begin Time:

End Time:

Primary ICD9/10: V653- /Z71.3 Secondary ICD9/10:

Name:

ID Number:

or Place PEF label here

S: Reason for visit: MD/Where do you receive medical care? Medical history: Present treatment: Education level: Language barrier: Support systems: Smoking: No  Yes   cigarettes  pipe  cigars #/day Medications: OTC medications: Drug allergies: Herbal remedies/Vitamin mineral supplements: Job: Work schedule: Schedule changes/weekends/school schedule Rate your appetite: Good  Fair  Poor  Past/present eating disorder?  Yes  No Type: Do you have any eating or digestion problems? Chewing  Swallowing  GERD  Diarrhea  Constipation  Food allergy/intolerance  Other: Has your weight changed in the last year?  Yes  No By how much: Highest weight? Wt. Loss methods tried: What would you like to know more about?  Weight loss  Exercise  Eating out  Label reading  Alcohol use  Sweeteners Patient requested topics/questions: What eating concerns do you have? Who prepares the meals?  Self  Spouse  Roommate  Other Do you have a meal plan? Yes  No  If yes, how many calories? Eating out frequency: Breakfast /week Lunch /week Dinner /week Type(s) of restaurant(s): Are there any special considerations in meal planning? Have you had previous diet instruction?  Yes  No Date/Who: How often are you able to follow it? never  same  always  Have you been told to follow any other diet restrictions? Yes  No  If yes, please check which restrictions:  Low calorie  Low cholesterol  Low salt/sodium  Low protein  Low fat  High fiber  Other: Food frequency: Whole grains

Grains Vegetables Fruit Milk Meats

Other: Do you drink alcohol?  No  Beer  Wine  Liquor How often? How much? Do you exercise now?  Yes  No How often? How long? Type? PRENATALS ONLY Problems during previous pregnancy: Prepregnancy weight: Gestational Age: EDC: Vomiting?  Yes  No Heartburn?  Yes  No Constipation  Yes  No Nausea  Yes  No Weight gain last pregnancy: Weight gain to date: Birth weight of Children (if any): Feeding method planned:  Breast  Formula Time: Breakfast or first meal: Time: Snack: Time: Lunch or second meal: Time: Snack: Time: Dinner or third meal: Time: Snack: Patient comments: O: See CH-12 and available lab reports, growth charts. Age:  Male  Female Ethnicity: Calorie Needs: Medical clearance for exercise:  Yes  No Exercise limitations: Drug/Nutrient Interactions: MNT - Adult

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A: Assessment of Diet - Adequate Intake: Weight:  WNL  Overweight  Underweight Weight gain (Prenatal only):  Normal  Above  Below Recommended Weight: Readiness to change: Precontemplation  Contemplation  Preparation  Action  Maintenance  Other: Women EER = 354 – (6.91 X age) + PA X [9.36 X (wt. in lb./2.2) + (726 X ht. In inches/39.4)] PA levels: Sedentary = 1 Low activity = 1.12 Active = 1.27 Very active = 1.45 Men EER = 662 – (9.53 X age) + PA X [15.91 X (wt in lb/2.2) + 539.6 X (ht in inch/39.4)] PA levels: Sedentary = 1 Low activity = 1.11 Active = 1.25 Very active = 1.48

P: Next Primary Care Physician Appointment: Follow-up Nutrition Appointment: Exercise: Referral:  MD  RN  Social Services  Medicaid Goals/Instructions: Follow-up: Handouts used: Identified Barriers: Signature: Date: MNT - Adult

Rev. 10/18

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Medical Nutrition Therapy (Pediatric) MNT-Pediatric Begin Time:

End Time:

Primary ICD9/10: V653-/ Z71.3 Secondary ICD9/10:

Name:

ID Number:

or Place PEF label here

S: Reason for visit: MD/Where does the child receive medical care? Medical history: Present treatment: Language barrier: second hand smoke exposure: Drug Allergies: Medications: OTC medications: Herbal remedies/Vitamin mineral supplements: Drug/Nutrient Interactions: Child Digestive Problems  Chewing  Swallowing  GERD  Diarrhea  Constipation  Food allergy/intolerance  Other: Rate your child’s appetite: Good  Fair  Poor  Past/present eating disorder  Yes  No Type: Weaned from bottle: Is your child breastfed? How many times in 24 hours? Child eat nonfood items such as dirt, paper, paint chips  Yes  No Parent/care giver concerns about child’s diet: Fluoride Source  Yes  No family meals Daily  Couple times per week  No meals eaten as family Special Considerations in meal planning: Foods or food groups avoided: Number of Meals/Snacks per day: Eating out frequency: Breakfast /week Lunch /week Dinner /week Type(s) of restaurant(s): Food frequency: Whole grains

Grains Vegetables Fruit Milk

Meats

Type of Milk

Other liquids

Breastmilk

Other: Food Insecurity in the home: Previous diet instruction received:  Yes  No Date/Who: Previous diet instruction followed: never  same  always  Hours per day child watches tv, dvd’s or playing computer games: Physical activity received daily:  Yes  No Type and duration of activity: Time: Breakfast or first meal: Time: Snack: Nighttime Feedings: Time: Lunch or second meal: Time: Snack: Time: Dinner or third meal: Time: Snack: O: See CH-12, available lab reports and growth charts. Age:  Male  Female Ethnicity:

Page 9 Medical Nutrition Therapy Policy 407 December 2024

Calorie Needs: Medical clearance for exercise:  Yes  No Exercise limitations: A: Assessment of Diet - Adequate Intake: Infants/Children Appropriate  Yes Weight for Height  No Range: Height/Age: % Weight/Age: % Height/Weight: %

X

=

calories pounds total calories  Maintain  Lose  Gain weight Infant Calorie needs 0-6 months = 49 cal./lb. body weight 6 – 12 months = 45 cal./lb. body weight FTT/Low Birth Weight = 55 cal./lb. body weight Child Calorie needs Child Sedentary Moderately Active Active 2-3 yrs 1000 kcal 1000-1400 kcal 1000-1400 kcal Female 4-8 yrs 1200 kcal 1400-1600 1400-1800 9-13 yrs 1600 1600-2000 1800-2000 14-18 yrs 1800 2000 2400 19+yrs 2000 2000-2200 2400 Male 4-8 yrs 1400 kcal 1400-1600 1600-2000 9-13 yrs 1800 1800-2200 2000-2600 14-18 yrs 2200 2400-2800 2800-3200 19+yrs 2400 2600-2800 3000 P: Next Pediatrician Appointment: Follow-up Nutrition Appointment: Exercise: Referral:  MD  RN  Social Services  Medicaid Goals/Instructions: Handouts used: Follow-up: Parents readiness to learn/Comprehension of education: Identified barriers: Signature: Date:

*Calorie Levels for Children taken from IOM: Dietary Guidelines and Dietary Reference Intakes 2002.

MNT-Pediatric Rev. 10/2018

Medical Nutrition Therapy Assessment MNT-Diabetes Begin Time:

End Time:

Primary ICD9/10: V653-/ Z71.3 Secondary ICD9/10:

Name:

ID Number:

or Place PEF label here

S: Patient reason for visit: MD/Where do you receive medical care? Medical History: Present diabetes treatment: Education level: Language barrier: Support systems: Smoking: No  Yes   cigarettes  pipe  cigars #/day Medications: OTC medications: Drug allergies: Herbal remedies/ Vitamin-mineral supplements: Job: Work schedule: Schedule changes/weekends/school schedule Year of diagnosis: Hypoglycemia:  Yes  No  None experienced Frequency: Rate your appetite: Good  Fair  Poor  Do you have any eating or digestion problems? Chewing  Swallowing  GERD  Diarrhea  Constipation  Food allergy/intolerance  Other: Has your weight changed in the last year?  Yes  No By how much: Highest weight? Wt. Loss methods tried: What eating concerns do you have? Who prepares the meals?  Self  Spouse  Roommate  Other Do you have a meal plan? Yes  No  If yes, how many calories? Eating out frequency: Breakfast /week Lunch /week Dinner /week Type(s) of restaurant(s): Are there any special considerations in meal planning? How much of the time are you able to follow it? never  same  always  Have you been told to follow any other diet restrictions? Yes  No  If yes, please check which restrictions:  Low calorie  Low cholesterol  Low salt/sodium  Low protein  Low fat  High fiber  Other: Date/Who: Food frequency: Whole grains

Grains Veggies Fruit Milk Meats

Other: Do you drink alcohol?  No  Beer  Wine  Liquor How often? How much? Do you exercise now?  Yes  No How often? How long? Type? Time: Breakfast or first meal: Time: Snack: Time: Lunch or second meal: Time: Snack: Time: Dinner or third meal: Time: Snack: Patient comments: O: See CH-12 and available lab reports, growth charts.  Male  Female Ethnicity: Lab Data: Diagnosis of diabetes: Type 1 Type 2  A1C BG Fasting Chol. HDL LDL Triglycerides BP Microalbumin GFR: Other BG Post Meal Target Goals: Target BG:

mg/dL to mg/dL Fasting 2hr PP: Target A1C < 7% Target LDL <100mg/dl Target HDL >40 mg/dl men >50 mg/dl women Target BP <130/80 Target chol. <200 mg/dl Target TG <150 mg/dl Target Microalbumin <30 mcg/mg SMBG: Frequency Times of Day Machine: Medical clearance for exercise:  Yes  No Drug nutrient interactions: Exercise Limitations: Other: Page 10 Medical Nutrition Therapy Policy 407 December 2024

MNT-Diabetes Rev. 10/18

Page 11 Medical Nutrition Therapy Policy 407 December 2024

A: Readiness to change: Precontemplation  Contemplation  Preparation  Action  Maintenance  Weight assessment:  WNL  Overweight  Underweight  Recommended Wt. change  N/A

lbs. loss/gain Women EER = 354 – (6.91 X age) + PA X [9.36 X (wt. in lb./2.2) + (726 Men EER = 662 – (9.53 X age) + PA X [15.91 X (wt in lb/2.2) + 539.6 X (ht in X ht. In inches/39.4)] PA levels: Sedentary = 1 Low activity = 1.12 inches/39.4)] PA levels: Sedentary = 1 Low activity = 1.11 Active = 1.27 Very active = 1.45 Active = 1.25 Very active = 1.48

P: 1 starch = 15 g. CHO, 3 g. protein, 1 fat, 80 calories 1 fruit = 15 g. CHO, 60 calories 1 milk = 12 g. CHO, 8 g. protein, 1 fat, 90 calories 1 veggie = 5 g. CHO, 2 g. protein, 25 calories 1 meat(subst.) = 7 g. protein, 5(3) fat, 75 (55) calories 1 fat = 5 fat, 45 calories Time Breakfast Snack Lunch Snack Dinner Snack Total servings/day CHO (g) Protein (g) Fat Calories Starch Fruit Milk Vegetables Meat/Subst. Fat X4 X4 X9 Total calories OR Total calories: Time Meal # CHO choices CHO grams Breakfast Snack Lunch Snack Dinner Snack Totals

Goals/Instructions: Follow-up: Handouts used: Identified Barriers: Signature: Date: MNT-Diabetes

Page 12 Medical Nutrition Therapy Policy 407 December 2024 MNT-Gestational Diabetes REV. 10/18

Medical Nutrition Therapy Assessment MNT-Gestational Diabetes Begin Time:

End Time:

Primary ICD9/10: V653-/ Z71.3 Secondary ICD9/10:

Name:

ID Number:

or Place PEF label here

S: EDD: Medical History: Name of doctor/Where do you receive medical care? Obstetric History: Medications/Herbal remedies/ Vitamin-mineral supplements: Present MNT Therapy: Insulin Therapy: Date started: Occupation Hours worked? What are your usual work hours? Schedule changes/weekends/school schedule Psychosocial/economic Hypoglycemia: Yes  No  Rate your appetite: Good  Fair  Poor  Any eating/digestion problems? Chewing  Swallowing  Stomach ache  Diarrhea  Constipation  Other: What eating concerns do you have? Who prepares the meals?  Self  Spouse  Roommate  Other Eating out: What type of restaurant(s)? How often each week do you eat in restaurants, cafeterias, or away from home? Breakfast /week Lunch /week Dinner /week Do you have a meal plan? Yes  No  If yes, how many calories? Are there any special considerations in meal planning? Have you had previous instruction on diet?  Yes  No If yes, who provided the instruction and date? How much of the time are you able to follow it? 0-25%  25-50%  50-75%  75-100%  Have you been told to follow any other diet restrictions? Yes  No  If yes, please check which restrictions:  Low calorie  Low cholesterol  Low salt/sodium  Low protein  Low fat  High fiber  Other: What time of day do you eat these foods? Regular soda pop Sweet roll/pastries Cookies

Candy, candy bars Ice cream Frozen desserts Pie, Cake

Other Do you drink alcohol?  No  Beer  Wine  Liquor How often? How much? If the doctor recommends a change in your current eating habits, would this be difficult? Yes  No  If yes, why? Appetite/allergies/intolerances Food /drug allergies: What would you like to know more about?  Weight loss  Exercise  Eating out  Label reading  Alcohol use  Sweeteners Other: What would you hope to accomplish or gain from this appointment?  Improve blood glucose  Lose weight  Lower cholesterol/triglycerides  Improve eating habits  Start exercising  Get more information  Other: Are there concerns for gestational diabetes? Are you exercising now?  Yes  No If no, what would you consider? Exercise:  Walking  Exercise class Other: Patient comments: Food frequency: Whole grains

Grains Veggies Fruit Milk Meats

Time: Breakfast or first meal: Time: Snack: Time: Lunch or second meal: Time: Snack: Time: Dinner or third meal: Time: Snack: O: See CH-12 and available lab reports, growth charts. Pre-pregnancy Weight: Age: Pre-pregnancy Weight Category:  Underweight  Normal  Overweight  Obese Total Weight Gain: Adequate  Inadequate  Excess  Lives with: OGTT: Date OGTT: Glucose Meter: B/P Hgb SMBG: Frequency: Testing Times: Records/log kept:  Yes  No Medical clearance for exercise: Yes  No  Exercise limitations:

Page 13 Medical Nutrition Therapy Policy 407 December 2024

A: Readiness to change: Precontemplation  Contemplation  Preparation  Action  Maintenance  EER: 1st trimester = no additional calories 2nd trimester = additional 340 calories/day 3rd trimester = additional 452 calories/day

P: 1 starch = 15 g. CHO, 3 g. protein, 1 fat, 80 calories 1 fruit = 15 g. CHO, 60 calories 1 milk = 12 g. CHO, 8 g. protein, 1 fat, 90 calories 1 Vegetable = 5 g. CHO, 2 g. protein, 25 calories 1 meat(subst.) = 7 g. protein, 5(3) fat, 75 (55) calories 1 fat = 5 fat, 45 calories Time Breakfast Snack Lunch Snack Dinner Snack Total servings/day CHO (g) Protein (g) Fat Calories Starch Fruit Milk Veggie Meat/Subst. Fat X4 X4 X9 Total calories OR Total calories: Breakfast Lunch Dinner # CHO choices Time: Time: Time: CHO grams # CHO choices # CHO choices # CHO choices Protein grams CHO grams CHO grams CHO grams

Snack Snack Snack Time: Time: Time: # CHO choices # CHO choices # CHO choices CHO grams CHO grams CHO grams

Goals/Instructions: Follow-up: Handouts used: Identified Barriers Signature: Date: Comprehension 

MNT-Renal Rev. 10/18 Page 14 Medical Nutrition Therapy Policy 407 December 2024

Medical Nutrition Therapy Assessment MNT-Renal

Name:

MNT-Gestational Diabetes Begin Time:

End Time:

Primary ICD9/10: V653-/ Z71.3 Secondary ICD9/10:

ID Number:

or

Place PEF label here S: Referring Physician: Other diagnoses: Diet Order: Previous Diet Instruction: Yes  No  Previous diets: Dentition:  good  missing some teeth  edentulous  dentures  chewing problems Food Allergies: No  Yes  If yes, list foods: Appetite: excellent  good  fair  poor  Medications: Herbal remedies/Vitamin-mineral supplements: OTC medications: Oral nutrition supplement: No  Yes  If yes, list

Time: Breakfast or first meal: Time: Snack: Time: Lunch or second meal: Time: Snack: Time: Dinner or third meal: Time: Snack: Do you have any eating or digestion problems? Swallowing  Stomach ache  Diarrhea  Constipation  Other: Activity Level:  Non ambulatory  moderate  active Vision: good  impaired  blind  Hearing:  good  HOH  deaf Psychosocial:  lives by self  with others Language barrier:  Yes  No Shopping done by: Occupation: Education level: Cooking done by: Support systems (e.g., food stamps, Meals on Wheels) How often each week do you eat in restaurants, cafeterias, or away from home? Breakfast /week Lunch /week Dinner /week Smoking: No  Yes  # packs/day

Alcohol: Yes  No  Salt substitute: Yes  No  O: Height: Present Weight: BMI: IBW: % IBW: Usual weight: % usual weight: Frame: Adj. Wt.: (obesity) Adj. Wt.: (amputees) % wt. Change: Loss/gain X (time) Age: Male  Female  Marital status:  single  married  widowed  divorced  separated Nutrition related medications: Chemistries: Date: Vitamins Hgb./Hct. Non RX vitamins Fe+/Ferritin P04 Binders % Trans sat Vit. D/Vit. D analogs BUN/Creatine Iron supplements K+/Na+ Epogen/Procrit Alk. Phos/Ca+ Anti-diabetic agents PO4/PTH BP Meds Glucose/A1C Laxatives/stool softeners Chol./TG Anti-hyperlipidemics GFR/Creat. Clear. Other Other Physical exam – Rate as follows: 0 = Normal 1 = Mild 2 = Moderate 3 = Severe Loss of subcutaneous fat

Muscle wasting

Ankle edema

Sacral edema

Ascites

Skin condition: intact  open areas  If open areas, describe:

Page 15 Medical Nutrition Therapy Policy 407 December 2024

A: Nutrient needs: calories

protein

Current diet order meets dietary needs: Yes  No  If no, review with MD Current intake: adequate  inadequate  Unable to determine  30 days loss/gain % 90 days loss/gain % 180 days loss/gain % Nutritional status: well nourished  at risk  mild malnourished  moderate malnourished  severe malnourished  Voices understanding of diet instruction: Yes  No  Expresses readiness to learn: Yes  No  Comments: Functional Capacity: No dysfunction  Dysfunction  Duration

Working sub optimally  Ambulatory  Bedridden  Is the subject independent in: Bathing?  Yes  No Transferring?  Yes  No Dressing?  Yes  No Continence?  Yes  No Toileting?  Yes  No P: Goals/Instruction: Follow-up: Handouts used: Identified Barriers: Signature: Date: Comprehension  MNT-Renal

Page 16 Medical Nutrition Therapy Policy 407 December 2024

Medical Nutrition Therapy MNT- Follow-Up Begin Time: End Time: # Units:

Primary ICD9/10: V653-/ Z71.3 Secondary ICD9/10:

Type of Meal Plan: Date: Other Comments: Medication Changes: Exercise: Lab Values/Changes: Weight Changes:

Blood Pressure:

Blood Glucose:

Cholesterol:

Other:

Identified Barriers:

Readiness to Change/Compliance: 24 hour recall Time: Breakfast: Time: Snack: Time: Lunch: Time: Snack: Time: Supper: Time: Snack: Progress Toward Goals/New Goals:

Materials Provided: Referral: Y or N Reason: MD RN Social Services Other: Follow MNT Visit: Progress Note Sent to MD: Yes No Signature: Date: Adapted from the Lincoln Trail District Health Department & Laurel County Health Department Nutrition Follow-up Medical Nutrition Therapy forms MNT- Follow UP DEV10/15 Name:

ID Number

Or place PEF label here

Page 17 Medical Nutrition Therapy Policy 407 December 2024

MEDICAL NUTRITION THERAPY GROUP NUTRITION EDUCATION A. The following is a list of topics that are appropriate for group nutrition education in the clinic setting under the MNT group class code. The lesson plans with pre-and post-test for each class are available from the Nutrition Services Branch. All MNT group classes must be taught by a Registered Dietitian or Certified Nutritionist.

Medical Nutrition Therapy Topics Possible Handouts Class Information Diabetes Meal Planning  Dining Out Made Healthy  Read It Before You Eat It/Steps to Reading a Food Label Healthy methods to eating out; artificial sweeteners, CHO counting, glycemic index, label reading, portion sizes Heart Health  Cholesterol Round-up  DASH: The Proven Way to Lower Your Blood Pressure  Trans-Fatty Acids: What, another fat?  Triglyceride Facts Class 1: Cholesterol Class 2: Sodium Class 3: DASH/hypertension Class 4: Triglycerides Dining with Diabetes West Virginia Cooperative Extension Program Lessons, overheads, and recipes, pre-test and post-test Weight Loss  Activity Pyramid  Dining Out Made Healthy  My Pyramid (specific calorie level) Physical activity, portion sizes, label reading, healthy methods of cooking; healthy eating out Documentation in each class attendees’ medical record must include: A. Class attended B. Date C. Outcome expected for the class attendee D. Follow-up appointment E. Pre- and post-test data F. Specific health measures (can be referral information from a physician) 1. Height, weight, and Body Mass Index (BMI) 2. Cholesterol 3. Triglycerides 4. LDL 5. Blood glucose 6. Blood pressure 7. Hemoglobin A1C G. Signature of class provider, title

Page 1 Section 400 Nutrition Education and Counseling Appendices December 2024

Section 400 Appendices Nutrition Education and Counseling

Page 2 Section 400 Nutrition Education and Counseling Appendices December 2024

WIC Certification Nutrition Education Counseling Protocol ........................... 3 Individual WIC High-Risk Counseling Nutrition Education Protocols ............ 9 Reference Materials for Certification and Follow-up Counseling Guidelines ............................................................................... 14 WIC Certifying Health Professional Checklist .............................................. 18

Page 3 Section 400 Nutrition Education and Counseling Appendices December 2024

WIC CERTIFICATION NUTRITION EDUCATION COUNSELING PROTOCOL

Page 4 Section 400 Nutrition Education and Counseling Appendices December 2024

WIC Certification Nutrition Education Counseling Protocol (In addition to this counseling, all WIC participants must be provided counseling on Specific Nutritional Risk) Provider: Certifying Health Professional Topic WIC Certification General Nutrition Counseling Protocol by Status Discuss WIC Program eligibility and benefits • Purpose of the WIC Program (Nutritional support through supplemental food, nutrition education, breastfeeding support and referrals) • WIC is a partnership between the participant and WIC staff. • Discuss certification process including nutrition assessment to provide individualized nutrition education, eligibility period and recertification schedule. • Discuss importance and benefits (nutrition education, breastfeeding support, referrals, and healthy foods) for continued participation in the program. Counsel on basic diet and the importance of regular physical activity. Determine what concerns or questions the participant has in regard to her nutrition, child’s nutrition, and/or infant’s nutrition? Provide counseling to address questions/concerns/dietary habits. For women and children: • Review Choose My Plate Dietary Guideline Tip Sheet or My Pyramid for Kids and Activity Pyramid. • Review dietary concern(s) and appropriate action. • Encourage an average of 30 minutes for women and 60 minutes for children of physical activity each day. • Limit screen time to no more than 2 hours/day. • Remove the television from the child’s bedroom. • Encourage healthy foods (e.g., low-fat and reduced fat food choices including 1% or less milk, (women/children > 2), 5 Fruits and Vegetables per day & Avoid Sugar Sweetened Drinks) • Refer to health care provider/Lead Program for lead screening and assessment. For infants: • Discuss Kentucky Infant Feeding Guide appropriate for age and development. • Encourage caregiver(s) to promote physical activity and motor skill development in their infant (rolling over, standing, movement, play). • Review dietary concern(s) and appropriate action. • Refer to health care provider/Lead Program for lead screening and assessment. Encourage to breastfeed unless contraindicated for health/lifestyle reasons. See Breastfeeding Counseling and Contraindications in this section. For pregnant women: • Discuss the advantages of breastfeeding. • Discuss the benefits of Kangaroo Care. For breastfeeding women: • Encourage continuation and support of breastfeeding. • Discuss the benefits of Kangaroo Care. Discuss the effects of drug and other harmful substance use (tobacco, alcohol, drugs). • Discuss how tobacco and/or alcohol can affect the woman, fetus, infant, and child. This should include information about smoking cessation if appropriate and the effects of secondhand smoke. • Discuss recommendations to not use tobacco products. Refer to 1-800-QUIT NOW (1-800-784-8669) if client smokes. • Discuss recommendations to not take any medications, over the counter or otherwise, unless specifically ordered by a physician. • Discuss recommendations to not use drugs (marijuana, cocaine, etc.). • Discuss recommendations to not drink alcohol. Discuss Safe Sleep Environment for Infants For infants: • Discuss American Academy of Pediatrics (AAP) Safe Sleep Policy. (See Safe Sleep Environment for Infants in this section)

Page 5 Section 400 Nutrition Education and Counseling Appendices December 2024

For participants being recertified for the WIC Program • Review and discuss previously set goals. • For participants who completed online nutrition education lesson, review and discuss the lesson completion certificate, participant goal set during the lesson, and links visited. Discuss specific nutritional risk for which participant qualifies. • See Table 2: WIC Certification Counseling for Specific Nutritional Risk Protocol

WIC Certification Counseling for Specific Nutritional Risk Protocol WIC participants must be provided WIC Certification Nutrition Education Counseling based on their individual risk code assignment. *Status Code: P= any Pregnant Status, BF= any Breastfeeding Woman Status, PP= Postpartum Status, C= Child Status, I= any Infant Status Provider: Certifying Health Professional Risk/Status*/ Reference Materials** Counseling/Education Referral Guidance Low Hematocrit/Low Hemoglobin Status: P, PP, BF, C, I ● Define low hematocrit/low hemoglobin. ● DISCUSS IRON-RICH FOODS. Refer for Medical Evaluation:  All status Hematocrit < 27% Hemoglobin < 9 gm./dL. Elevated Blood Lead Status: P, PP, BF, C, I • Discuss the importance of adequate calories, calcium, iron, vitamin C and low-fat foods (for children after age 2), which decrease the absorption of lead. • Discuss the importance of regular meals and snacks. • Discuss CDC recommendations regarding mother’s lead levels and breastfeeding (Breastfeeding Woman). See Blood Lead Levels & Breastfeeding. Refer for Medical Evaluation. See Lead Guidelines in Core Clinical Services Guide (CCSG). Schedule for High-Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement Low Head Circumference Status: I, C (up to age 2) • Discuss the impact of prematurity to growth and development, if age adjusted. • Discuss the importance of nutrition on growth and development Refer for Medical Evaluation. Preterm Birth/Early Term Birth Status: I, C (up to age 2) • Discuss the impact of prematurity to growth and development. • Discuss the importance of good nutrition for proper growth and development. Low Birth Weight/Very Low • Discuss the impact of birth weight to growth and development. • Discuss the importance of good nutrition for proper growth and development. Birth Weight Schedule for High-Risk Status: I, C (up to age 2) Secondary Nutrition Education, Refer for MNT per Professional Judgement At Risk for Overweight Status: I, C • Discuss the importance of prevention of overweight. • Discuss the importance of physical activity. • Reduce sedentary activity such as computer games and watching television. • Discuss appropriate quantity of food. • Discuss healthy foods (e.g., low-fat and reduced fat food choices). (children >age 2)

Page 6 Section 400 Nutrition Education and Counseling Appendices December 2024

• Discuss the importance of good nutrition for proper growth and development. (infants) Overweight, Obese, High Weight for Length Status: P, PP, BF, C, I • Review growth chart. (children) • Discuss the importance of physical activity. • Reduce sedentary activity such as computer games and watching television. • Discuss appropriate quantity of food. • Discuss healthy foods (e.g., low-fat and reduced fat food choices). (women/children >age 2) Schedule for High-Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement At Risk for Underweight Status: I, C • Review growth chart. • Discuss importance of frequent feeding. • Discuss healthy foods in relation to growth and development. Underweight Status: P, PP, BF, I, C • Review growth chart. (Infants and children) • Discuss importance of frequent feeding. • Discuss healthy foods in relation to growth, development and appropriate weight gain. Schedule for High-Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement At Risk for Short Stature Status: I, C • Discuss growth for age and stature/size of parents. • Discuss healthy foods in relation to growth and development. Short Stature Status: I, C • Discuss growth for age and stature/size of parents. • Discuss healthy foods in relation to growth and development. Growth Problems Status: I, C • Discuss growth for age and stature/size of parents. • Discuss healthy foods in relation to growth and development. Inappropriate Weight Gain Pattern Status: P, PP, BF, I, C Pregnant woman • Discuss the importance of appropriate weight on the developing fetus. Postpartum or breastfeeding woman • Discuss the importance of an adequate diet to promote lactation and/or attaining standard weight. Infant • Discuss the importance of frequent feeding in relation to weight gain. Children • Discuss healthy foods in relation to growth and development. Alcohol and Substance Use Status: P, PP, BF • Discuss the importance of discontinuing the identified substance use (tobacco, alcohol, drugs) (S-A-D). • Discuss the importance of discontinuing smoked tobacco, electronic nicotine delivery systems (ENDS), smokeless tobacco (chewing tobacco, snuff, dissolvable,) hookahs, cigars, pipes, and nicotine replacement therapies (gums, patches). Refer to counseling and/or treatment as appropriate. Environmental Tobacco Smoke Exposure Status: P, PP, BF, I, C • Discuss the importance of consuming foods high in vitamin C. • Discuss the importance of fruits and vegetables in the diet. • Discuss risk of third hand smoke. BF Infant/BF Woman at Nutritional Risk Status: I, P, BF Breastfed infant • Discuss adequate diet for lactation and health. Breastfeeding mother • Discuss the impact of mother’s health on growth and development of infant.

Page 7 Section 400 Nutrition Education and Counseling Appendices December 2024

Breastfeeding Complications Status: BF, P, I • Discuss the impact of an adequate diet. • Discuss the importance of frequent feeding. • Discuss specific condition/problem. Refer to IBCLC/Designated Breastfeeding Expert (DBE)/Nutritionist/Dietitian Refer for Medical Evaluation:  Mastitis or Severe nipple pain Infant of a WIC Mother/ Mother at Risk Status: I • Discuss the impact of mother’s nutritional risk during pregnancy to infant’s health. • Discuss an adequate diet for the infant. • Discuss specific condition/problem. Infant of a Mother with Complications that Impair Nutrition Status: I • Discuss an adequate diet at an appropriate level of comprehension for the client. Pregnancy Induced Conditions Status: P, PP, BF • Discuss specific condition/problem. • Discuss the additional demand on nutrient stores. Schedule for High-Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement Delivery of Preterm /Early Term/ Low Birth Weight Infant Status: P, PP, BF Pregnant • Discuss the problems identified and the effect on current health. • Stress the importance of appropriate weight gain. Breastfeeding/Postpartum • Discuss the problems identified and the effect on current health. Fetal or Neonatal Death Status: P, PP, BF • Discuss the problems identified and the effect on current health. General Obstetrical Risk Status: P, PP, BF Pregnant • Discuss the importance of appropriate weight gain for the developing fetus. • Discuss the additional demand on nutrient stores. Breastfeeding/Postpartum • Discuss the additional demand on nutrient stores. Nutrition/Metabolic Conditions/Infectious Disease Acute or Chronic Status: P, PP, BF, I, C Pregnant/Breastfeeding/Postpartum • Discuss the relationship of the specific condition/problem to nutritional status and its potential impact on woman’s current status. • Discuss impact of over-the-counter medications and nutrient interactions. Infant/Child • Discuss the relationship of the specific condition/problem to nutritional status and its importance to growth and development. • Discuss impact of over-the-counter medications and nutrient interactions. Schedule for High-Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement except:  Lactose Intolerance  Short Term Antibiotic Use – Drug Nutrient Interaction  Asthma – persistent asthma that requires daily medication.  Food allergies – per patient request and/or professional discretion Impaired Ability to Prepare Food Status: P, PP, BF, I, C • Discuss an adequate diet at an appropriate level of comprehension for the client. • Discuss the specific condition/problem. Refer to Social Programs.

Page 8 Section 400 Nutrition Education and Counseling Appendices December 2024

Complications which Impair Nutrition Status: P, PP, BF, I, C Pregnant/Breastfeeding/Postpartum • Discuss an adequate diet at an appropriate level of comprehension for the client. • Discuss the relationship of the specific condition/ problem to nutritional status and its potential impact on woman’s current status. Infant/Child • Discuss an adequate diet at an appropriate level of comprehension for the client. • Discuss the relationship of the specific condition/ problem to nutritional status and its importance to growth and development. Schedule for High-Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement For: • Complications/ Potential complications which impair nutrition/delays/disabilities that impair chewing/swallowing/require tube feeding. Dental Problems Status: P, PP, BF, I, C Pregnant/Breastfeeding/Postpartum/Child/Infant • Discuss the importance of proper dental care. • Drink/provide only water between meals. • Limit sugary foods/drinks. Limit juice intake to 100% juice & no more than 4-6 ounces per day. • Brush teeth twice daily. • Talk to dentist/doctor regarding fluoride. • Follow up with your dentist as appropriate for dental problems. Infant/Child • Breastfeeding is recommended for the 1st year of life and beyond as mutually desired. • Avoid having infant/child sleep with bottle. • Wipe the gums of young infants with a soft washcloth or soft toothbrush, even prior to tooth eruption. Other Health Risk/Fetal Alcohol Spectrum Disorder Status: P, PP, BF, I, C • Discuss adequate diet. Presumed Dietary Risk Status: P, PP, BF, C (age 2 and older) • Counsel on adequate diet. Feeding Practices Status: P, PP, BF, I, C • Counsel on specific problem (s) Inappropriate Nutrient Intake Status: P, PP, BF, C • Discuss the importance of calcium and protein sources. • Counsel on adequate diet. Eating Disorders Status: P, PP, BF • Discuss the relationship of the specific condition/ problem to nutritional status and its potential impact on woman’s current status. • Counsel on adequate diet. • Schedule for High- Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement • Refer for Medical Evaluation. Recipient of Abuse Status: P, PP, BF, I, C • Counsel on adequate diet. • Counsel based on readiness. Refer to Social Programs. Foster Care Status: P, PP, BF, I, C • Counsel on adequate diet. Children • Discuss specific problem/condition such as chronic health problems, birth defects, short stature and inadequate nutrition. Refer to Social Programs. Homelessness Status: P, PP, BF, I, C • Counsel on adequate diet with emphasis on homelessness/migrancy as appropriate. Refer to Social Programs. Migrancy Status: P, PP, BF, I, C • Counsel on adequate diet with emphasis on homelessness/migrancy as appropriate. Refer to Social Programs.

Page 9 Section 400 Nutrition Education and Counseling Appendices December 2024

Possibility of Regression- Priority III Status: C • Discuss the importance of a good diet in preventing the previous risk from recurring. Possibility of Regression- Priority IV Status: C • Encourage continuance of a good diet as appropriate for child’s age. Transfer of Certification Status: P, PP, BF, I, C • Provide nutrition education for condition/problem, if known.

Page 10 Section 400 Nutrition Education and Counseling Appendices December 2024

HIGH RISK FOLLOW-UP COUNSELING PROTOCOLS TABLE

Page 11 Section 400 Nutrition Education and Counseling Appendices December 2024

Individual WIC High-Risk Counseling Nutrition Education Protocols Status: P= any Pregnant Status; BF= any Breastfeeding Status; PP= Postpartum Status; C= Child Status; I= any Infant Status PROVIDER: CERTIFYING HEALTH PROFESSIONAL Topic /Status/ Counseling/Education Low Hematocrit/Low Hemoglobin Status: P, PP, BF, I, C • Discuss Iron and Vitamin C sources in the diet. • Discuss the importance of Iron and role of iron in red blood cells. • Discuss the absorption of iron sources and role of vitamin C in Iron absorption. Elevated Blood Lead Status: P, PP, BF, I, C • Discuss importance of adequate intake of calories, calcium, iron, vitamin C and low-fat foods (after the age of 2) which decreases the absorption of lead. • Discuss the importance of regular meals and snacks. Low Head Circumference Status: I, C (up to age 2) • Discuss age-appropriate feeding for the infant. Preterm/Early Term Birth Status: I, C (up to age 2) • Discuss age-appropriate feeding for infant development or up to age 2 children. • Review growth chart and weight goals. Low Birth Weight /Very Low Birth Weight Status: I, C (up to age 2) • Discuss age-appropriate feeding for infant’s or child’s development. • Review growth chart and weight goals.

At Risk for Overweight Status: I, C • Discuss the importance of prevention of overweight. • Discuss age-appropriate feeding for infant’s or child’s development. • Discuss the importance of regular physical activity. • Review dietary concern(s) and appropriate action.

Overweight, Obese, High Weight for Length Status: P, PP, BF, C, I Infant/Child • Review growth chart and weight goals. • Discuss age-appropriate feeding for child’s development. • Discuss the importance of regular physical activity. Pregnant/Postpartum/Breastfeeding Women • Review weight goals. • Discuss possible reasons for weight status. • Review Choose My Plate Dietary Guideline Tip Sheet or My Pyramid to encourage appropriate weight status. Discuss the importance of regular physical activity. At Risk for Underweight STATUS: I, C #2, #3, #7-10 (C) Infant/Child • Review growth chart and weight goals. • Discuss age-appropriate feeding for infant’s or child’s development.

Underweight Status: P, PP, BF, I, C Infant/Child • Review growth chart and weight goals. • Discuss age-appropriate feeding for infant’s or child’s development. Pregnant/Breastfeeding/Postpartum Women • Review weight goals. • Discuss possible reasons for weight status. • Review Choose My Plate Dietary Guideline Tip Sheet or My Pyramid to encourage appropriate weight status. At Risk for Short Stature Status: I, C • Review growth chart and height goals. • Discuss age-appropriate feeding for infant’s or child’s development. • Discuss importance of protein for growth. Short Stature Status: I, C • Review growth chart and height goals. • Discuss age-appropriate feeding for infant’s or child’s development. • Discuss importance of protein for growth. Growth Problems Status: I, C • Discuss age-appropriate feeding for infant’s or child’s development. • Review growth chart and weight goals. • Discuss importance of protein for growth.

Inappropriate Weight Gain Pattern Status: P, PP, BF, I, C Infant/Child • Discuss age-appropriate feeding for infant’s or child’s development. • Review growth chart and weight goals. Pregnant/Breastfeeding/Postpartum Women • Review weight goals. • Discuss possible reasons for weight status.

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• Review Choose My Plate Dietary Guideline Tip Sheet or My Pyramid to encourage appropriate weight status.

Alcohol and Substance Use Status: P, PP, BF • Discuss the importance of discontinuing the identified substance use (tobacco, alcohol, drugs) (SAD). • Discuss how the identified use can affect the mother and her fetus, or her infant or other household members. • Discuss the importance of discontinuing smoked tobacco, electronic nicotine delivery systems (ENDS), smokeless tobacco (chewing tobacco, snuff, dissolvable tobacco products,) hookahs, cigars, pipes, and nicotine replacement therapies (gums, patches). • Environmental Tobacco Exposure Status: P, PP, BF, I, C • Discuss the importance of continuing a healthy diet. • Discuss risk of third hand smoke. Breastfeeding Infant/BF Woman at Nutritional Risk STATUS: I, BF • Discuss an adequate diet for the infant. • Discuss using WIC foods to promote optimal health. • Discuss recommended number of servings from My Pyramid and the importance of WIC foods. Breastfeeding Complications Status: I, P, BF • Reinforce the importance of an adequate diet. • Reinforce the importance of frequent feeding. • Discuss specific condition/problem. Breastfeeding Infant/BF Woman with Feeding Practices STATUS: I, P, BF • Discuss an adequate diet for the infant. • Discuss using WIC foods to promote optimal health. • Discuss recommended number of servings from My Pyramid and the importance of WIC foods. Infant of a WIC Mother/ Mother at Risk Status: I • Discuss an adequate diet for the infant. Infant of a Mother with Complications that Impair Nutrition Status: I • Discuss an adequate diet at an appropriate level of comprehension for the client. Impaired Ability to Prepare Food Status: P, PP, BF, I, C • Discuss the importance of an adequate diet. • Discuss specific condition/problem.

Pregnancy Induced Conditions Status: P, PP, BF • Encourage appropriate weight gain. • Discuss increased nutrient needs. • Reinforce an adequate diet. • Discuss specific condition/problem. • Discuss adequate diet at an appropriate level of comprehension for the client Delivery of Preterm/Early Term / Low Birth Weight Infant Status: P, PP, BF Pregnant • Discuss the problems identified and the effect on current health. • Stress the importance of appropriate weight gain. Breastfeeding/Postpartum • Discuss the problems identified and the effect on current health. Fetal or Neonatal Death Status: P, PP, BF • Reinforce the importance of an adequate diet for health. General Obstetrical Risk Status: P, PP, BF • Discuss specific condition/problem. • Discuss the importance of an adequate diet. Nutrition/Metabolic Conditions/Infectious Acute or Chronic Disease Status: P, PP, BF, I, C • Discuss specific condition/problem. • Discuss the importance of an adequate diet. Impaired Ability to Prepare Food Status: P, PP, BF, I, C • Discuss the importance of an adequate diet. • Discuss specific condition/problem. Complications which Impair Nutrition Status: P, PP, BF, I, C • Discuss specific condition/problem. • Discuss the importance of an adequate diet. • Discuss an adequate diet at an appropriate level of comprehension for the client. Dental Problems Status: P, PP, BF, I, C • Discuss specific condition/problem. • Discuss the importance of an adequate diet.

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Other Health Risk/Fetal Alcohol Spectrum Disorder Status: P, BF, PP, I, C • Discuss the importance of a good diet. Presumed Dietary Risk Status: P, PP, BF, C (age 2 and older). • Discuss the importance of a good diet. Feeding Practices Status: P, PP, BF, I, C • Discuss specific problem and relationship to health, growth or development. Inappropriate Nutrient Intake Status: P, PP, BF, C • Discuss the importance of an adequate diet. Eating Disorders Status: P, PP, BF • Discuss specific condition/problem. • Discuss the importance of an adequate diet. Recipient of Abuse Status: P, PP, BF, I, C • Discuss the importance of an adequate diet. Foster Care Status: P, PP, BF, I, C • Discuss the importance of an adequate diet. Children – • Discuss specific condition/problem such as chronic health problems, birth defects, short stature and inadequate nutrition. Homelessness or Migrancy STATUS: P, PP, BF, I, C • Discuss the importance of an adequate diet with emphasis on homelessness or migrancy. Possibility of Regression Status: C • Discuss the importance of an adequate diet. Possibility of Regression-Priority III Status: C • Discuss the importance of an adequate diet. Transfer of Certification- Priority IV Status: P, PP, BF, I, C • Provide nutrition education, as appropriate.

Individual WIC High Risk Counseling Nutrition Education Protocols PROVIDER: LACTATION SPECIALIST Topic /Status*/ Reference Materials** See Page 41 For Listing of Reference Materials by Number Counseling/Education Breastfeeding Infant/BF Woman at Nutritional Risk STATUS: I, P, BF • Discuss an adequate diet for the infant. • Discuss using WIC foods to promote optimal health. • Discuss recommended number of servings from My Pyramid and the importance of WIC foods. Breastfeeding Complications Status: I, P, BF • Reinforce the importance of an adequate diet. • Reinforce the importance of frequent feeding. • Discuss specific condition/problem. Breastfeeding Infant/BF Woman with Feeding Practices STATUS: I, P, BF • Discuss an adequate diet for the infant. • Discuss using WIC foods to promote optimal health. • Discuss recommended number of servings from My Pyramid and the importance of WIC foods.

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REFERENCE MATERIALS FOR CERTIFICATION AND FOLLOW-UP COUNSELING GUIDELINES

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Nutrition and Breastfeeding Education Materials for Certification and Follow-Up Counseling LOCALLY DEVELOPED NUTRITION EDUCATION MATERIALS Locally developed nutrition and breastfeeding education materials must be submitted to the State WIC Office for review and approval. Any materials developed for WIC Program outreach or nutrition education with the WIC logo, Kentucky Shape the Future Breastfeeding logo or the Kentucky Eat More Fruits and Veggies logo must be submitted to the State WIC Office for review and approval.

STATE OR USDA AVAILABLE NUTRITION EDUCATION MATERIALS Approved WIC Nutrition Education materials are listed in the table below.

The Kentucky WIC Program is currently working on printing updated nutrition education materials. Agencies have been receiving quarterly shipments of the updated nutrition and breastfeeding education materials. Below is a crosswalk that can be used to assist certifying health professionals in determining appropriate handouts to use for nutrition education and breastfeeding counseling.

Nutrition and breastfeeding education materials can be ordered from the State WIC Office or printed from the CHFS Nutrition Education Website at https://www.chfs.ky.gov/agencies/dph/dmch/nsb/Pages/nutedmaterials.aspx .

Status/Target Audience Previous Nutrition Education & Breastfeeding Education Material NEW 2024 and Ongoing Nutrition and Breastfeeding Education Materials Pregnancy/Breastfeeding Getting Started with Breastfeeding • Breastfeeding Basics for Moms • Learn to Start Breastfeeding Pregnancy/Breastfeeding Breastfeeding: Planning Ahead During Pregnancy • Breastfeeding Basics for Moms • Learn to Start Breastfeeding Pregnancy/Breastfeeding Kangaroo Care/Skin to Skin • Kangaroo Care handout is available on the CHFS WIC Nutrition Education Materials website only. Pregnancy/ Breastfeeding Family Support N/A • Breastfeeding Basics for Dads Pregnancy/ Breastfeeding Family Support N/A • Breastfeeding Basics for Grandmothers Pregnancy Kentucky Prenatal Nutrition Guides • Tips for Pregnant Moms • Healthy Eating for Pregnant and Breastfeeding Women Pregnancy Weight Gain During Pregnancy • Tips for Pregnant Moms Pregnancy Tips for Pregnant Moms • Tips for Pregnant Moms

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Post Partum Woman Postpartum Nutrition Guide • The PP Nutrition Guide is currently Under Revision, current version may be printed from the CHFS WIC Nutrition Education Materials website Infant Kentucky Infant Feeding Guides • Feeding Birth to Age 2 • Healthy Eating for Infants Infant Homemade Baby Food • Homemade Baby Food is currently Under Revision, current version may be printed from the CHFS WIC Nutrition Education Materials website Infant Safe Sleep for Your Baby • Safe Sleep for Your Baby (no change) Infant/Toddler Weaning from the Bottle • Weaning from the bottle is currently Under Revision, current version may be printed from the CHFS WIC Nutrition Education Materials website Toddler Toddler Feeding Guide Age 1 to 3 • Healthy Eating for Toddlers (My Plate) • Mealtimes for Toddlers • Reducing the Risk of Choking in Young Children at Mealtimes (Coming Soon) Child Child Feeding Guide Age 3 to 5 • Start Simple Eating for Preschoolers • Healthy Eating for Preschoolers Child Healthy Tips for Picky Eaters • Revised Healthy Tips for Picky Eaters (Coming Soon) Child Activity Pyramid • Healthy Tips for Active Play (Coming Soon) Child How to Care for Your Child’s Teeth • How to Care for your Child’s Teeth is currently Under Revision Child Healthy Tips for Active Play • Revised Healthy Tips for Active Play (Coming Soon) MyPlate/ Healthy Eating for the Family Tips to Increase Fruits and Veggies • Healthy Eating for the Family (Coming Soon) MyPlate/ Healthy Eating for the Family Choose My Plate DG Tip Sheet 1 & 7 (Choose My Plate & Build a Healthy Meal) • Healthy Eating for the Family (Coming Soon) MyPlate/ Healthy Eating for the Family My Plate DG Tip Sheet 12 & 13 (Be A Healthy Role Model & Cut Back on Sweet Treats) • Healthy Eating for the Family (Coming Soon)

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MyPlate/ Healthy Eating for the Family My Plate DG Tip Sheet 9 & 10 (Smart Shopping & Liven Up Your Meals) • Healthy Eating on a Budget (Coming Soon) MyPlate/ Healthy Eating for the Family My Plate DG Tip Sheet 2 & 3 (Add More Vegetables & Focus on Fruits) • Healthy Eating for the Family (Coming Soon) MyPlate/ Healthy Eating for the Family My Plate DG Tip Sheet 6 & 8 (Protein Foods & Healthy Eating for Vegetarians) • Healthy Eating for the Family (Coming Soon) MyPlate/ Healthy Eating for the Family My Plate DG Tip Sheet 24 (Snack tips for parents) • Healthy Eating for the Family (Coming Soon) Family Healthy Habits 5,2,1,0 Healthy Numbers for Kentucky Families Combination Brochure • Available on CHFS WIC Nutrition Education Materials website only. Family Healthy Habits (Smoking, Alcohol and Tobacco) Smoking-Alcohol-Drugs: How can it affect you and your family? • Smoking , Alcohol and Tobacco is currently Under Revision, current version may be printed from the CHFS WIC Nutrition Education Materials website Family Healthy Habits (Required Exit Counseling) Healthy Choices for You and Your Family • Family Healthy Habits is currently Under Revision, current version may be printed from the CHFS WIC Nutrition Education Materials website Lead Poisoning Prevention Lead Prevention Diet • Lead Prevention, Are You Pregnant (CDC)- coming soon • Lead Poisoning, 5 Things You Can Do (CDC)- coming soon Food Safety Food Safety • Available on CHFS WIC Nutrition Education Materials website only. Nutrient: Iron Iron for Strong Red Blood Cells • Iron for Strong Red Blood Cells is currently Under Revision, current version may be printed from the CHFS WIC Nutrition Education Materials website Nutrient: Calcium Calcium • Available on CHFS WIC Nutrition Education Materials website only Nutrient: Vitamin A & C Vitamin A/Vitamin C • Available on CHFS WIC Nutrition Education Materials website only Whole Grains Whole Grains • Available on CHFS WIC Nutrition Education Materials website only Tofu Tofu • Available on upon request, contact the State WIC office. Beans Beans • Available on CHFS WIC Nutrition Education Materials website only

Page 18 Section 400 Nutrition Education and Counseling Appendices December 2024 WIC CERTIFYING HEALTH PROFESSIONAL CHECKLIST The WIC Certifying Health Professional Checklist is shown on the following page. This is a resource for WIC Health Professionals to ensure staff completes each required step of a WIC Certification, WIC MCHA, WIC High- Risk, and WIC Low-Risk Nutrition Education visit. A copy can be requested from the Clinical Nutrition Section of the Nutrition Services Branch Office or click the following link to print a copy: WIC Certifying Health Professional Checklist