716.1 Policy 716 Breastfeeding Peer Counseling (BFPC) Program Requirements June 9, 2020 POLICY Local programs receiving State BFPC program funds will meet all program requirements for administering and implementing evidence based BFPC services. PURPOSE To inform local agencies of BFPC Program federal and state requirements and guide staff to implement effective BFPC services. RELEVANT REGULATIONS USDA FNS Breastfeeding Policy and Guidance, 2016 USDA FNS Allowable Costs for Breastfeeding Peer Counseling Programs updated January 2020 USDA FNS WIC Breastfeeding Model for Peer Counseling OREGON WIC PPM REFERENCES

 435—Staffing Requirements  440—Staff Training Requirements  450—Confidentiality  511—Food Benefit Issuance  820—Quarterly Nutrition Education Contacts APPENDICES Page 716.8 Appendix A Breastfeeding Peer Counseling (BFPC) Coordinator Roles and Responsibilities Page 716.10 Appendix B Breastfeeding Peer Counselor - Roles and Responsibilities DEFINITIONS Breastfeeding Peer Counseling (BFPC) Coordinator: A designated WIC staff person who provides leadership to the local agency peer counseling program, trains and mentors Peer Counselors, monitors peer counseling services, and assists participants to prevent or overcome breastfeeding challenges. The Coordinator is an International Board-Certified Lactation Consultant (IBCLC). Breastfeeding Peer Counselor: A paraprofessional staff person who gives breastfeeding information and encouragement to pregnant and breastfeeding participants on the WIC Program. WIC Peer Counselors are recruited and hired from WIC’s target population, and, to the extent possible, represent the same racial/ethnic background as the participants they support. WIC Peer Counselors have previous experience breastfeeding, having breastfed at least one baby.

Breastfeeding Peer Counseling (BFPC) Program Requirements, Continued 716.2 Breastfeeding self-efficacy: A person’s belief in their ability to effectively breastfeed. Scope of practice: A staff position’s range of unique roles and activities in the provision of information, counseling and support to WIC participants. Each staff position’s scope of practice is defined by the required qualifications and job-specific responsibilities for that position. Yield: To request assistance from the IBCLC or qualified staff person when an issue or concern is outside of the Peer Counselor’s scope of practice. PROCEDURE BFPC services 1.0 WIC participants enrolled in the BFPC Program shall receive the following services: 1.1. The Peer Counselor will meet monthly, at a minimum, with assigned prenatal participants and continue to provide services through at least 6 months postpartum unless breastfeeding is discontinued prior to 6 months. 1.1.1. In addition to the minimum monthly contact, the Peer Counselor will provide additional follow-up contacts, as needed. 1.1.2. An attempted contact is required within two weeks of a participant’s expected due date or actual delivery date. This is a critical time frame for checking in. 1.1.3. Other important time frames for contact are every 2-3 days in the first week after delivery, within 24 hours if the participant reports problems with breastfeeding, weekly throughout the rest of the first month, 1-2 weeks before planned date to return to work or school, and 1-2 days after returning to work or school. 1.2. Participants will be scheduled for either group BFPC sessions or individual peer counseling visits. 1.2.1. Local agencies will use the Prenatal Session Guide to develop and lead group sessions. 1.3. Contacts will occur primarily in the WIC office. The Peer Counselor may make home and hospital visits depending on local agency policy and procedure. 1.4. The Peer Counselor will be on-site at the WIC clinic during specific times of operation to recruit participants, introduce themselves, and meet with participants. 1.5. The Peer Counselor will be available for participant-initiated contacts during and outside of WIC office hours. BFPC Appointments 2.0 Peer counseling is an adjunct service, provided in addition to regular WIC services. Local agencies must ensure required elements, such as mid-certification visits, are not missed. See ⧫820—Quarterly Nutrition Education Contacts for more details. 2.1. When coordinating WIC visits for participants enrolled in the BFPC Program, local agencies will ensure BFPC contacts are in addition to and do not replace required quarterly nutrition education contacts.

Breastfeeding Peer Counseling (BFPC) Program Requirements, Continued 716.3 2.1.1. If a participant misses a mid-certification or other high priority visit, staff will attempt to reschedule the original appointment rather than scheduling the participant into a BFPC group visit. 2.2. Issue three months of food benefits, unless there is a situation warranting less than triple issuance. 2.2.1. Reasons for restricting issuance to a single month are listed in ⧫511—Food Benefit Issuance. Scheduling participants into monthly BFPC visits is not a valid reason to limit issuance to one month. 2.2.2. Missing a nutrition education appointment could be a reason for single month issuance if the participant has not attended quarterly nutrition education visit during the certification period. Once a participant attends a quarterly nutrition education visit, the requirement is met until their next quarterly nutrition education visit. 2.3. In limited circumstances, attendance at group BFPC sessions may fulfill a quarterly nutrition education contact requirement. Such arrangements require prior State agency approval. 2.3.1. The local agency must have a written procedure in their local agency policy approved by the state BFPC Coordinator before implementing this exception. 2.3.2. At a minimum, a portion of the BFPC staff’s salary facilitating the group education must be paid for with non-BFPC funds. If the BFPC staff are 100% BFPC grant funded, then a non-BFPC staff must co- facilitate a portion of the group visit. 2.3.3. Additionally, all requirements listed in Section 2: Quarterly Nutrition Education Contacts and Section 3: Group Nutrition Education of ⧫820—Quarterly Nutrition Education Contacts must be met. Contact the state BFPC Coordinator for further details and to request approval. Staffing: BFPC Coordinator 3.0 Local programs shall designate a BFPC Coordinator. 3.1. The BFPC Coordinator is an IBCLC. 3.2. The BFPC Coordinator is assigned enough hours to perform required duties. 3.3. If the BFPC Coordinator position is not 100% BPFC funded, it may be combined with a CPA position. • A daily time sheet is required detailing hours worked in each position if the Coordinator works under more than one program. 3.4. For Local Agency Breastfeeding Peer Counseling (BFPC) Coordinator duties and responsibilities, see Appendix A. Staffing: WIC Peer Counselors 4.0 Local WIC programs will recruit and hire persons who meet the appropriate definition of a WIC Peer Counselor:

Breastfeeding Peer Counseling (BFPC) Program Requirements, Continued 716.4 • Recruited and hired from people who best match the clinic’s prenatal and breastfeeding population • Preferably a previous or current WIC participant • Has fully breastfed at least one baby through the first year of life or longer • Passionate about breastfeeding and providing breastfeeding support • Paraprofessional, and not a lactation professional, such as an IBCLC 4.1. The Peer Counselor works enough hours to provide services to their assigned caseload. 4.2. Combining the Peer Counselor position with the CPA position is not allowed. By program design, the Peer Counselor is to be viewed as a trusted friend who is just like the participants they serve. They form a special and unique relationship with participants in a way no other staff can. 4.2.1. Peer Counselors may be allowed to perform limited WIC clerical duties outside of BFPC duties if pre-approved by the State WIC Office. Clerical duties must be limited to tasks not involving eligibility determination or assignment of benefits. BFPC grant funds may not be used to pay for staff performing non-BFPC duties. A detailed time sheet tracking all time spent on BFPC and non-BFPC activities and funding sources is required. Duties and responsibilities 4.3. For Breastfeeding Peer Counselor duties and responsibilities, see Appendix B. Scope of practice 4.4. Peer Counselors will work within their scope of practice: • Offer breastfeeding encouragement • Provide information on the significance of breastfeeding and the risks of not breastfeeding • Help participants identify their concerns and barriers around breastfeeding • Teach participants basic techniques that help ensure a successful start in breastfeeding • Recognize signs of the normal course of breastfeeding • Provide basic education, problem solving and support • Help participants advocate and plan for a positive birth/hospital experience • Help participants plan for a return to work/school that supports the continuation of breastfeeding • Refer families to appropriate resources Yield 4.5. Peer Counselors will yield participants to the BFPC Coordinator or other designated staff when situations arise outside of their scope of practice.

Breastfeeding Peer Counseling (BFPC) Program Requirements, Continued 716.5 Assuring ongoing participant services 4.6. The local program shall have a plan to ensure that participant services are not disrupted in the event of peer counseling staff attrition or long-term absence, for example maternity leave. Confidentiality 4.7. Peer Counselors shall follow participant confidentiality regulations. Peer Counselors must read and sign a confidentiality statement. See ⧫450— Confidentiality for details. Training 5.0 Peer Counselors will receive all required training. A training checklist and resources are available on the Breastfeeding Peer Counselor Coordinator Resources webpage. 5.1. Training prior to providing participant services will include the following: • Training listed in ⧫440—Staff Training Requirements. • On-site shadowing and observation of BFPC and WIC staff 5.2. Ongoing training will include the following: • Local program staff trainings and in-services, as appropriate • Monthly BFPC meetings facilitated by the local Peer Counseling Coordinator. Meetings will include in-service training specific to BFPC program services, and opportunity for Peer Counselors to meet and learn from each other. Mentoring 6.0 The local BFPC Coordinator will: 6.1. Closely monitor counseling services provided by Peer Counselors and provide feedback and coaching. 6.2. Provide opportunities to practice providing care using case studies and role playing, initially and later as needed. 6.3. Be available to help with problem-solving as needed. 6.4. Observe Peer Counselors during participant contacts and review peer counseling documentation. Assigning participants to Peer Counselors 7.0 Local programs providing state-funded peer counseling programs shall offer peer counseling to pregnant and breastfeeding participants by the following method: 7.1. Prenatal participants are offered peer counseling services early in pregnancy, usually during the prenatal certification visit. 7.2. A weekly caseload assignment will be given to the Peer Counselor. Documentation 8.0 All BFPC participant contacts will be documented in TWIST. 8.1. The name and WIC ID number of participants who accept or request peer counseling will be collected and entered in TWIST.

Breastfeeding Peer Counseling (BFPC) Program Requirements, Continued 716.6 Inactive status 8.2. The participant’s status in TWIST must be changed to inactive if they stop breastfeeding, no longer needs or desires contact, or does not attend sessions or visits and there is no communication between the participant and their Peer Counselor for two consecutive months. 8.2.1. The participant’s status may be changed back to active at any time if they request peer counseling services again. Funding 9.0 To receive state funding and technical support in providing breastfeeding peer counseling, local WIC programs are required to do the following: 9.1. Prepare and submit an annual budget to the state for approval. 9.2. Report allowable expenditures on the state revenue expenditure form. 9.2.1. Funding for peer counseling will be provided via grant adjustment. 9.2.2. Expenditures above the rate specified in the annual service contract will not be reimbursed by the state. 9.2.3. Special funding requests must be pre-approved. 9.2.4. Expenditures must be allowable BFPC expenses. 9.3. Monitor Breastfeeding Peer Counseling Program expenditures to ensure they are correctly reported in a timely manner. Required written procedures 10.0 Local programs must have written procedures for their BFPC program. Sample local agency policies are available on the Breastfeeding Peer Counseling Coordinator Resources webpage. The procedures will include the following, at a minimum: • BFPC services (see ¶1.0) • Monitoring of peer counseling contacts (see ¶6.0) • Referral protocol for lactation issues outside of Peer Counselor’s scope of practice (see ¶4.5) • Documenting breastfeeding peer counseling contacts (see ¶8.0) • Providing training and support to Peer Counselors (see ¶5.0-6.0) Other Requirements 11.0 Local programs shall establish community partnerships to enhance the effectiveness of their peer counseling program. At a minimum this shall include local hospitals, resources within the agency, and community health workers. 11.1. Local programs shall also maintain a list of breastfeeding resources and referrals in the community and at large.

Breastfeeding Peer Counseling (BFPC) Program Requirements, Continued 716.7 REFERENCES 1. U.S. Department of Agriculture, Food and Nutrition Service. Loving Support through Peer Counseling: A Journey Together– For WIC Managers. 2016

2. U.S. Department of Agriculture, Food and Nutrition Service. Loving Support through Peer Counseling: A Journey Together– For Peer Counselors. 2011 3. USDA FNS WIC Nutrition Services Standards – Standard 9, August 2013

POLICY HISTORY Date * Major Revision, Minor revision 5/2/2005 Date of Origin 2/2/2011 Revision 12/1/2015 Revision 4/5/2019 Revision 6/9/2020 Major 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. *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 If you need this in large print or an alternate format, please call 971-673-0040. This institution is an equal opportunity provider.

Breastfeeding Peer Counseling (BFPC) Program Requirements, Continued 716.8 APPENDIX A Breastfeeding Peer Counseling (BFPC) Coordinator – Roles and Responsibilities

DEFINITION: A designated WIC staff person who provides leadership to the local agency peer counseling program, trains and mentors Peer Counselors, monitors peer counseling services, and assists participants to prevent or overcome breastfeeding challenges. The Coordinator must be an International Board-Certified Lactation Consultant (IBCLC). QUALIFICATIONS: • Is an International Board-Certified Lactation Consultant (IBCLC). • Has demonstrated experience in project management. • Has a minimum of one-year experience counseling breastfeeding people.

DESIRABLE QUALIFICATIONS: • Meets the qualifications for a CPA. • Demonstrated expertise and advanced knowledge of breastfeeding promotion and support strategies. • Has experience working with people from diverse backgrounds. • Has leadership experience and success working with groups. • Possesses communication skills that support success with peers, management and participants. • Spanish speaking ability, if local program employs a Spanish-speaking Peer Counselor.

ROLES: • Contributes to the development of program goals and objectives for the local agency BFPC program. • Conducts an annual needs assessment to identify gaps in breastfeeding resources and services within the local agency and community that the WIC BFPC program can address. • Oversees the training of peer counselors. • Oversees the planning, management, implementation and evaluation of local agency peer counseling activities. • Keeps current with up-to-date breastfeeding information and disseminates this as well as FNS-provided information to local agency staff. • Mentors peer counselors, providing routine follow-up and guidance. • Provides ongoing monitoring and feedback for peer counselors. • Reports on peer counseling program activities to supervisor and the State agency. • Coordinates with local community stakeholders such as hospitals and health care providers to enhance the effectiveness of the peer counseling program. • Ensures that effective, appropriate and accurate breastfeeding information and services are provided to WIC participants.

Breastfeeding Peer Counseling (BFPC) Program Requirements, Continued 716.9 TYPICAL DUTIES & RESPONSIBILITIES • Assists with recruitment and selection of Peer Counselors to staff the program. • Participates in the statewide peer counseling work group. • Provides initial and ongoing training and/or arranges training for Peer Counselors. • Assists in establishing peer counseling program protocols and policies. • Manages referrals and determines appropriate caseloads. • Ongoing evaluation of Peer Counselors to ensure appropriate counseling, documentation and referral. This may include observing individual and group visits, listening in on phone calls, and accompanying peers on home visits. • Coordinates and conducts individual and group peer counseling visits. • Provides training to WIC staff to enhance skills in breastfeeding support. • Completes state and local agency monitoring and reporting requirements. • Is available at designated times to provide consultation to the peer counselors. • Participates in local and state breastfeeding coalition meetings. • Collaborates with community partners to help identify and address breastfeeding support needs. Partners may include hospitals, clinics, La Leche League, Early Head Start, Healthy Start, Nursing Mothers Counsel and others. • Uses advanced training and certification to assess participant breastfeeding issues and to provide counseling, support and education for the continuation of breastfeeding in high risk families and difficult situations.

Breastfeeding Peer Counseling (BFPC) Program Requirements, Continued 716.10 APPENDIX B Breastfeeding Peer Counselor – Roles and Responsibilities DEFINITION: A paraprofessional staff person who gives breastfeeding information and encouragement to pregnant and breastfeeding participants on the WIC Program. WIC Peer Counselors are recruited and hired from WIC’s target population, and, to the extent possible, represent the same racial/ethnic background as the participants they support. WIC Peer Counselors have previous experience breastfeeding, having breastfed at least one baby.

QUALIFICATIONS: • Has fully breastfed at least one baby through the first year of life or longer. • Is a paraprofessional (as described in the Loving Support Model) from the target population. • Is passionate about breastfeeding and providing breastfeeding support

DESIRABLE QUALIFICATIONS: • Excellent communication and listening skills. • Organized, with record-keeping experience. • Possesses basic computer skills. • Enough literacy and fluency in English to complete breastfeeding training and written reporting requirements including documentation of participant contacts. • Professional and personable. • Experience working with people from diverse backgrounds. • Able to communicate ideas and directions well in situations that may not be face-to- face (i.e. over the phone).

ROLES: • Provides parent-to-parent support to prenatal and postpartum WIC parents by providing basic breastfeeding information and encouragement. • Counsels prenatal and postpartum participants during face-to-face visits in the WIC clinic and during telephone follow-up calls. • Refers participants to the BFPC Coordinator/IBCLC or other designated staff, or other appropriate health or social service agency, including outside community breastfeeding resources, for situations outside the peer counselor’s scope of practice. • Is available to participants outside of usual clinic hours and the WIC clinic environment.

TYPICAL DUTIES AND RESPONSIBILITIES: • Attends State agency Breastfeeding Basics breastfeeding training. Participates in on-going training. Overnight travel may be required to attend trainings. • Provides breastfeeding counseling for pregnant and breastfeeding participants to help prevent and handle common breastfeeding concerns.

Breastfeeding Peer Counseling (BFPC) Program Requirements, Continued 716.11 • Provides counseling during WIC office visits and during telephone follow-up. May provide breastfeeding help during home visits or hospital visits, if this is a service provided by the WIC agency. • Is available by telephone during evenings and weekends to new parents who need breastfeeding support. • Receives a specified caseload of WIC participants and makes routine periodic contacts with all participants assigned. • Respects each participant by keeping information strictly confidential. • Accurately documents all contacts made with WIC participants in the data system. • Refers participants according to clinic-established protocols to: o Breastfeeding Peer Counseling Coordinator, WIC Nutritionist or Breastfeeding Coordinator; o lactation consultant; o the participant’s physician or nurse; o public health programs in the community; and o social service agencies. • Leads or assists with prenatal education sessions and breastfeeding support groups. • Attends staff meetings and breastfeeding conferences/workshops as appropriate. • Reads assigned books and materials on breastfeeding that are provided by the BFPC Coordinator. • May assist WIC staff in promoting breastfeeding peer counseling through special projects and duties as assigned. • May assist the BFPC Coordinator in various breastfeeding promotion and support activities within the community including outreach with mother infant programs, physician offices, hospitals, and local coalitions.