661.1 Policy 661 High Risk Caseload Management October 1, 2025 POLICY All local programs must have the services of a registered dietitian nutritionist (RDN) or qualified nutritionist to provide counseling and oversight to high-risk participants and to support staff and WIC program to provide quality nutrition services to WIC participants. PURPOSE To ensure that all high-risk participants have access to the specialized expertise of a RDN or qualified nutritionist to establish a personalized care plan and receive nutrition counseling to meet their health care needs at the required frequency. RELEVANT REGULATIONS 7 CFR §246.11 ¶(e)(5)—Participant Contacts 1997 State Technical Assistance Review (STAR) by USDA (Approved by CLHO MCH Committee January 2001, Approved by CLHO Executive Committee February 2001 and May 2006) WIC Policy Memorandum #2105-07 Medicaid Primary Payer for Exempt Infant Formulas and Medical Foods OREGON WIC PPM REFERENCES ♦ 440—Staff training requirements ♦ 626—Hemoglobin and Hematocrit Screening in WIC ♦ 660—Competent Professional Authority: Requirements ♦ 675—Risk Criteria Codes and Descriptions ♦ 765—Medical Documentation REFERENCES Nutrition Services Standards. United States Department of Agriculture. Food and Nutrition Services. August 2013. APPENDICES Page 661.7 Appendix A Oregon WIC Program List of High Risks DEFINITIONS High-risk participant: Participants who are assigned a high risk level based on identified health risks that meet the state’s high-risk criteria as defined in Appendix A. WIC nutritionist: A nutrition professional who meets one or more of the following qualifications: a master’s degree in nutrition; a registered dietitian nutritionist (RDN) with the Commission on Dietetic Registration(CDR) or eligible for CDR registration.

High Risk Caseload Management, Continued 661.2 Individual care plan: A written plan that outlines actions that will assist the participant for improving identified nutrition and health-related problems. BACKGROUND WIC recognizes participants with certain health conditions require specialized nutrition care to address the medical condition and/or to optimize their health. To assist staff in identifying health conditions that require specialized nutrition care, risk codes are designated as high risk. These participants are provided the opportunity to meet one-on-one with a qualified RDN/WIC nutritionist. This individualized care is a program benefit which enables participants to modify their lifestyles and eating habits to improve and/or maintain their nutritional status and general health. PROCEDURE WIC nutritionist position 1.0 Each local agency is required to have an RDN/WIC nutritionist on staff or on contract. Services provided by the RDN/WIC nutritionist include: • Nutrition assessment, counseling and follow-up care for participants at high nutritional risk, and other participants as needed • Training and support to paraprofessional staff, including the provision of quarterly in-services • State WIC recommends that the training supervisor be a registered dietitian • Tailoring food packages to meet nutritional needs of participants • Facilitating nutrition and breastfeeding group sessions for participants • Reviewing and approving locally developed group sessions, on-line or self- paced lessons • Management of the high-risk caseload • Review of medical documentation forms and when requested, identifying appropriate supplemental foods • Communication with other health care providers when needed • Collaborating with community partners • Administrative duties such as writing local policies, collecting data, completing required reports, creating a yearly nutrition services plan, and providing outreach Requirement for WIC Nutritionist 2.0 Local programs will have on staff or on contract a full-time or part-time WIC Nutritionist(s) to provide nutrition services to high-risk participants. 3.0 WIC Nutritionists must meet the training requirements to be a Competent Professional Authority (CPA). Refer to  440—Staff training requirements and  660—Competent Professional Authority: Requirements 4.0 A WIC nutritionist is a nutrition professional who meets one or more of the following qualifications and maintains 75 hours of continuing education in a 5 year period:

High Risk Caseload Management, Continued 661.3 • A master’s degree in nutrition; • A registered dietitian nutritionist (RDN) registered with the Commission on Dietetic Registration (CDR); • Eligible for registration with CDR; 5.0 Nutrition professionals who completed their dietetic training in another country may not meet credentialing requirements to be a registered dietitian in the United States. However, they may be an eligible candidate for an Oregon WIC nutritionist position if the candidate can demonstrate the following: • Evidence of an earned degree with course work in a nutrition-related field which fulfilled the criteria to advance to an accredited, supervised practice program • Completion of an accredited, supervised practice program at a health care facility, community or foodservice corporation • Passed a national examination administered by the credentialing entity in their country of origin and able to provide a verification statement • Preference given to work history in pediatric nutrition setting • Completes continuing professional educational requirements to maintain registration on an ongoing basis Referral for high-risk services 6.0 Participants identified as high risk shall be offered at least two nutrition interventions from the RDN/WIC nutritionist during a one-year certification period or one nutrition intervention when the certification period is less than one year.

Schedule the participant with the RDN/WIC nutritionist within 3 months.

If assigned Risk 201 due to a very low hemoglobin, the participant must be seen by the RDN/WIC nutritionist within 1-2 months. Refer to  626—Hemoglobin and Hematocrit Screening in WIC

The timing of the follow-up appointments with the RDN/WIC nutritionist are based on the individual care plan developed by the RDN/WIC nutritionist.

High-risk services may be provided at any appointment type (certification, mid- certification health assessment, quarterly nutrition education).

A referral to an RDN/WIC nutritionist for nutrition assessment and counseling does not replace a referral to other health care providers such as the participant’s primary care practitioner for medical conditions or for other health care needs. High-risk Counseling 7.0 The RDN/WIC nutritionist shall provide all high-risk participants with nutrition-focused counseling and follow-up care appropriate to their condition. See Appendix A for a listing of high risks.

Nutrition intervention includes assessment, counseling and the development and documentation of an individual care plan for each high-risk participant.

High Risk Caseload Management, Continued 661.4 8.0 A certifier may use their professional discretion to refer a participant to the RDN/WIC nutritionist when beyond their scope of practice or knowledge base or participant request. Documentation Requirements 9.0 Document Individual care plans for high-risk participants in the data system using the Care Plan/Progress Notes and include at a minimum:

Assessment based on subjective and objective information

Progress made associated with assigned risk or status of assigned nutrition risk(s)

Nutrition Education topic (if not documented in the NE drop down section of the WIC data system)

Counseling provided and further details about nutrition education topic as needed

Identification of participant behavior change whenever possible

A plan for future intervention that addresses risks and follow up plan for staff High risk resolution and reassessment 10.0 High-risk participants are followed by the WIC nutritionist until the high risk has been resolved and/or stabilized. 11.0 When the WIC nutritionist determines and documents that the high risk has been resolved and/or stabilized, the record must clearly reflect this decision and no future WIC nutritionist contacts are required during the current certification period. 12.0 Each high-risk participant must be referred to the WIC nutritionist for reassessment in each certification period. This is true for all high-risk participants including those with documentation of resolution of the high-risk in a prior certification. Coordination of care 13.0 If high-risk participants are being seen by an RDN or other health professional outside of WIC, the WIC nutritionist will provide coordination of care as needed. 14.0 Coordination of care includes documenting the outside RDN or health professional’s care plan in the participant’s record. Documenting this outside RDN care plan can be counted toward a quarterly NE visit for the participant. 15.0 Communicate with the non-WIC RDN to develop or obtain an individual care plan. 16.0 Confirm that the nutrition education and food package that WIC is providing is appropriate. If the RDN/WIC nutritionist determines through follow-up care that the health risk for a high-risk participant has been resolved, this shall be documented in the individual care plan in the participant’s record. Include a statement that follow-up by the RDN/WIC nutritionist is not required for the remaining time in the certification period. This determination needs to be reassessed for each certification period.

High Risk Caseload Management, Continued 661.5 Declined high-risk counseling 17.0 If a participant explicitly declines follow up with the WIC Nutritionist: Document the declination in the care plan Document all information provided by the participant related to the high risk(s) Refer the participant record to the WIC Nutritionist 18.0 When the WIC Nutritionist receives a record with a high risk declination, the WIC Nutritionist: Reviews the record and risks to assess the participant needs Documents a high risk care plan as outlined in section 9.0. 19.0 CPA will carry out the RDN/WIC Nutritionist’s follow up plan. 20.0 If the participant remains high risk in a new certification period, referral to the WIC Nutritionist is required. Missed high-risk counseling 21.0 In situations where the high-risk appointment with the nutritionist is missed, contact each high-risk participant reschedule the participant with the WIC nutritionist as soon as is possible. 22.0 Online nutrition education lessons or self-paced lessons may not be used in place of a missed high-risk appointment with the RDN/WIC nutritionist. A “no-show” for an RDN/WIC nutritionist follow-up appointment is not considered a refusal to participate Oversight of High Risk Caseload and Medical Documentation Forms 23.0 Local agencies are responsible for ensuring that high risk services are consistently being provided to all high-risk participants. Oversight may include periodically running and reviewing high risk reports to ensure: Accuracy of high risk assignment All high-risk participants are referred to the RDN/WIC nutritionist within 1-3 months Each high-risk participant has a documented individual high-risk care plan, even when services are declined The minimum number of counseling sessions per their certification period 24.0 Oversight of medical documentation forms Food package III requires medical documentation in order to provide infant medical formulas (also known as exempt infant formulas) and WIC-eligible nutritionals to infants, children and women participants who have a diagnosed medical condition that precludes or restricts the use of conventional foods. The RDN/WIC Nutritionist shall review medical documentation forms and provide oversight to ensure provision of nutritional care required for

High Risk Caseload Management, Continued 661.6 participants with medical conditions. Periodic review of medical documentation forms by the WIC Nutritionist may be required to assess continued appropriateness for food and formula. Refer to  765—Medical Documentation for information on the role of the RDN/WIC nutritionist for coordinating care and/or assigning supplemental foods. Remote RDN/WIC nutritionist 25.0 Local agencies may develop a contract with a RDN/WIC nutritionist to provide nutrition services, provided the following criteria are met. 26.0 The contract is written to include the hours necessary for the RDN/WIC nutritionist to provide individual counseling and follow-up care to all high-risk participants, develop individual care plans, communicate with other health care providers when needed, review medical documentation forms, and provide training and support to paraprofessional staff. Evidence of effective management of high risk caseload will be evaluated at each biennial review. High-risk intervention when RDN/ WIC nutritionist is not available 27.0 If an RDN/WIC nutritionist services are temporarily unavailable, high-risk participants may receive their high-risk counseling from another health professional as defined in  660—Competent Professional Authority: Requirements. For agencies that are unable to hire or contract with a local RDN to provide on-site high-risk counseling, using interactive video technology may be an optional delivery method for face-to- face counseling when utilization of this technology provides adequate services given assigned caseload and is approved by the state office. 27.1. In the absence of a RDN, health professionals trained as CPA’s may be utilized for high-risk counseling in limited circumstances such as during the time that a program works to fill a vacant nutritionist position. 27.2. Under no circumstances can high-risk counseling be provided by a paraprofessional. Refer to  660—Competent Professional Authority: Requirements for the definition of a paraprofessional.

POLICY HISTORY Date * Major Revision, Minor revision 7/12/2018 Revision 7/01/2025 Major revision 10/01/2025 Minor revision

The date located at the top of the policy is the implementation date unless an “effective date” is noted on the policy. Policies will become compliance findings 6 months from the implementation date. Release notes can be found in the corresponding document on the Policy and Procedure Manual page. If you need this in large print or an alternate format, please call 971-673-0040. This institution is an equal opportunity provider.

High Risk Caseload Management, Continued 661.7 *Major Revisions: Significant content changes made to policy. Minor Revisions: Minor edits, grammatical updates, clarifications, and/or formatting changes have occurred. Date of Origin: Date policy was initially released

APPENDIX A List of High Risks Risk Code Risk Criterion 103 Underweight for Infants and Children Birth to <24 months: < 5th percentile weight-for length 2 to 5 years: < 10th percentile BMI for age 134 Failure to thrive 135 Infant weight loss 141 Low birth weight < 5#8 oz (2500 grams) 201 Low hemoglobin, low hematocrit. Change risk level from medium to high risk if hemoglobin/hematocrit levels are : Category Hemoglobin Hematocrit Infants 9 to <12 months 9.9 or lower 29.9% or lower Children 12 to < 24 months 9.9 or lower 29.9% or lower Children 2-5 years 10.0 or lower 29.9% or lower

Pregnant women First trimester (0-13 weeks) 9.9 or lower 29.9% or lower Pregnant women Second trimester (14-26 weeks) 9.4 or lower 28.9% or lower Pregnant women Third trimester (27-40 weeks) 9.9 or lower 29.9% or lower Postpartum women 10.9 or lower 32.9% or lower

See  626—Hemoglobin and Hematocrit Screening in WIC Appendix A for standing orders. 211 Elevated blood lead levels 301 Hyperemesis gravidarum 302 Gestational diabetes

High Risk Caseload Management, Continued 661.8 Risk Code Risk Criterion 341 Nutrient deficiency or disease 342 Gastrointestinal disorders 343 Diabetes Mellitus 345 Hypertension and Prehypertension 346 Renal disease 347 Cancer 348 Central nervous system disorders (e.g. cerebral palsy, neural tube defects) 349 Genetic and congenital disorders (e.g. Down’s, cleft lip/palate) 351 Inborn errors of metabolism (e.g. PKU, galactosemia) 352A Infectious diseases-Acute (pneumonia, meningitis) 352B Infectious diseases-Chronic (HIV, AIDS) 354 Celiac disease 357 Drug nutrient interactions 358 Eating Disorders 360 Other medical conditions 362 Developmental delays, sensory or motor delays interfering with the ability to eat 363 Pre-Diabetes 382 Fetal Alcohol Syndrome 383 Neonatal Abstinence Syndrome 902 Woman or infant/child of a primary care provider with limited ability to make feeding decisions and/or prepare food

For complete description of each risk criterion, see  675—Risk Criteria Codes and Descriptions.