840.1 Policy 840 Documentation of Nutrition-Focused Education and Counseling October 5, 2018 (revised)

POLICY Local WIC programs shall document nutrition-focused education and counseling provided to WIC participants in each individual participant’s record in TWIST. PURPOSE To ensure local staff document interactions with participants in a consistent manner and in adequate detail to provide smooth continuity of care throughout the certification period. RELEVANT REGULATIONS 7 CFR §246.11—Nutrition Education ¶(c)(4)—Procedures to ensure that nutrition education is offered, ¶(e)(4)—Documentation of nutrition education provided, and ¶(e)(5)—Provision of individual care plan based on need 7 CFR Part 246 Federal Register, Vol. 59, No. 48, Friday, March 11, 1994 OREGON WIC PPM REFERENCES

 661—Competent Professional Authority: Appropriate Counseling for Risk Levels  810—Nutrition-Focused Education and Counseling  820—Quarterly Nutrition Education Contacts  830—Counseling and Services for High-Risk Participants

TWIST TRAINING MANUAL REFERENCES Chapter 3, Section 9, Lesson Plan 902—Nutrition Education Refusal APPENDICES Appendix A Sample WIC Nutrition Education Agreement Appendix B Sample WIC Nutrition Education Documentation Form BACKGROUND Local programs are required to document and monitor the provision of nutrition education services. Documenting each interaction with a WIC participant is important and required by federal regulations. Capturing a record of what occurred during a WIC appointment indicates whether policies are being followed and provides continuity of care. DEFINITIONS Certification period: Length of time participant will be enrolled in WIC and receive WIC benefits.

Documentation of Nutrition-Focused Education and Counseling, Continued 840.2 High-risk participant: A participant with a health risk that has been identified to meet one of the state’s high-risk criteria. See ⧫661—Competent Professional Authority: Appropriate Counseling for Risk Levels. Individual care plan: A written plan that outlines actions that will assist the participant in assuming responsibility for improving identified health-related problems on a prioritized basis. Non-WIC nutrition education: Nutrition education not sponsored by the WIC program. Nutrition-focused counseling: An interactive helping process focused on eating behaviors, physical activity, and lifestyle, designed to improve health status and help participants to achieve their personal goals. Quarterly nutrition education: Nutrition education opportunities that are offered at least every three months (quarterly) in an individual or group setting. Includes nutrition education provided during a mid-cert health assessment, online lesson, or counseling with the RDN/ WIC nutritionist. WIC nutritionist: A professional who meets one of the following qualifications: a registered dietitian nutritionist (RDN) with the Academy of Nutrition and Dietetics (AND), or eligible for AND registration; a master’s or doctoral degree in the field of nutrition from an accredited college or university; or an Oregon Licensed Dietitian (LD).

SECTION LIST 1.0 Certification and recertification appointments 2.0 Mid-certification health assessment 3.0 Quarterly nutrition education contact 4.0 Individual nutrition-focused counseling 5.0 Group nutrition education 6.0 Quarterly contact for multiple family members 7.0 Quarterly nutrition education contact by non-WIC agency or provider 8.0 Participant does not attend quarterly nutrition education 9.0 Documentation for high-risk participants

PROCEDURE Certification and recertification appointments 1.0 The nutrition-focused counseling that occurs as part of an individual’s certification or recertification appointments must be documented in the participant’s TWIST record on the “NE Provided” screen. Documentation will include at a minimum: 1.1. The date the education/counseling was provided; it generally matches the certification or recertification date. 1.1.1. Document the nutrition education contact within two working days of the individual’s certification or recertification date. 1.2. The counseling topics discussed. Topics should address nutritional risk(s) identified at certification or recertification and individual nutritional needs.

Documentation of Nutrition-Focused Education and Counseling, Continued 840.3 1.3. Identification of participant’s nutrition-related behavior change on the “Next Steps” screen, including the updating of the status field of the previous Next Step, when appropriate. 1.4. Future follow-up (if any) needed. 1.5. When appropriate, include the participant’s response to the topics discussed on the “Progress Notes” screen. For example, “verbalized understanding”, “had many questions”, etc. 1.6. If the certification or recertification was not completed in person at a clinic or satellite site, this must be noted in the Progress Notes. Document the special circumstances requiring the exception and the alternative means used to complete the certification or recertification. Example: “Home visit certification. Completed by home visitor. All measurements and bloodwork obtained at home since participant unable to come into the clinic.” 1.7. Identify and schedule the next quarterly nutrition education contact using either the “Appointment Scheduler” function for individual, group or online sessions, or the “Schedule Non-WIC NE” function if it is an offsite group. 1.7.1. The quarterly nutrition education contact should be appropriate to the individual participant’s nutritional needs and, whenever possible, address nutritional risk(s) identified at certification. 1.7.2. The quarterly nutrition education contact should meet the participant’s preference for the type of contact – individual session, group session, or online lesson. 1.7.3. Certifiers may recommend specific groups or online lessons. Provide instructions, including the time frame that it needs to be completed, and the month to contact WIC staff for benefits to continue uninterrupted. 1.8. If the participant refuses the quarterly nutrition education contact offered during the initial certification or subsequent recertifications, this refusal must be documented in the participant’s TWIST record. 1.8.1. Click the “NE Refusal” button found on either the “Next Appointment” screen on the NE Plan tab, or the “Family Appointment Record” screen to open the “NE Refusal Popup”. 1.8.2. Complete the fields for WIC ID and Refusal Reason, then click OK to save the information. See TWIST Chapter 3, Section 9, Lesson Plan 902—Nutrition Education Refusal for additional details. 1.8.3. Participants who refuse nutrition education must contact their WIC clinic either in person or over the phone the month their food benefits end to continue receiving benefits on the program. See ⧫810—Nutrition-Focused Education and Counseling for further information.

Documentation of Nutrition-Focused Education and Counseling, Continued 840.4 Mid-certification health assessment 2.0 When the participant returns for the mid-certification appointment, the certifier completes an updated health history and diet assessment. The nutrition-focused counseling that occurs as part of this appointment is documented in the participant’s TWIST record on the “NE Provided” screen. Documentation will include at a minimum: 2.1. The date the education/counseling was provided; 2.1.1. Document the nutrition education contact within two working days of the individual’s appointment. 2.2. The counseling topics discussed. Topics should address nutritional risk(s) previously identified and nutrition-related topics of interest identified by the participant. 2.3. Updating the “Next Steps” screen, including the status field of the previous Next Step, when appropriate. 2.4. Future follow-up (if any) needed. 2.5. Identifying and scheduling the next quarterly nutrition education contact using either the “Appointment Scheduler” function or the “Schedule Non-WIC NE” function. Quarterly nutrition education contact 3.0 Local programs shall document the provision of nutrition-focused education and counseling at each quarterly appointment. Use the “NE Provided” drop down and Progress Notes (if applicable) to document the nutrition content provided and use the “Appointment Scheduler” function or the “Schedule Non-WIC NE” function to indicate the type of appointment. 3.1. Documentation shall include at a minimum: 3.1.1. The date the appointment occurred. 3.1.2. Whether it was an individual or group contact. 3.1.3. The title of the group or the counseling topic(s) discussed. 3.1.4. The type of appointment (FD, IE, etc.) and status of “show”. The data system will indicate “no show” for applicable appointments at end of day. 3.1.5. The name of the competent professional authority (CPA) who provided the individual appointment or group presentation. 3.2. If the quarterly contact was not completed in person at a clinic or satellite site, this must be noted in the Progress Notes. Document the alternative means used for the contact and note the special circumstances that required this. Examples: • “Home visit. Participant seen in home by RN due to vulnerable status of infant.”

Documentation of Nutrition-Focused Education and Counseling, Continued 840.5 • “Telephone contact. Participant unable to come to clinic due to physical injury.” • “Interactive video call. Participant had transportation issues.” • “Text message contact for quarterly nutrition education due to participant’s scheduling conflict.” • “Email contact for quarterly nutrition education because of satellite clinic closure due to smoke.”

Individual nutrition-focused counseling 4.0 For individual contacts, in addition to the components listed in ¶ 3.1, document the following: 4.1. Nutrition topics discussed during the appointment, using the dropdown function in the NE Provided field in TWIST and Progress Notes (if applicable). More than one topic can be selected by inserting additional lines. 4.2. Behavior change or Next Step identified by the participant. Be specific, listing measurable goals. Update status of previous Next Step if applicable. 4.3. Any nutrition information not captured elsewhere, such as the provision of a handout and/or future follow-up plans, may be recorded in the Progress Notes section.

Group nutrition education 5.0 For individuals in group nutrition education classes, use the “Group Education Classes” screen in the “Appointment Scheduler” in TWIST. Documentation shall include at a minimum: 5.1. The participant’s name and WIC identification number. 5.2. The date of the group education. 5.3. The class topic and class title (this takes the place of the NE Provided tab for group classes). 5.4. The name of the qualified person facilitating the class. 5.5. The appointment status – mark as “Show” or “No Show” on the Family Appointments screen.

Quarterly contact for multiple family members 6.0 When the quarterly nutrition education contact is provided to more than one family member at the same time, document the contact in each family member’s record. 6.1. If only one family member is scheduled for the appointment in TWIST but family-based nutrition-focused counseling is provided, other family members may receive credit for the topic(s) discussed. Document the interaction in

Documentation of Nutrition-Focused Education and Counseling, Continued 840.6 each family member’s record using the dropdown function in the “NE Provided” field and the “Progress Notes” field (if applicable).

Example: Three family members are due for a quarterly nutrition-focused contact in the same month. One member was booked into an individual appointment slot in the “Appointment Scheduler” in TWIST. When the family members come to the appointment, family-based counseling is provided to all three family members. The family member booked into the appointment is marked as “show” and the nutrition topics discussed are documented in the “NE Provided" drop down and the “Progress Notes” field (if applicable) of all three family member’s records.

Quarterly nutrition education contact by non-WIC agency or provider 7.0 For participants categorized as low or medium risk, quarterly nutrition education may be provided by a non-WIC agency or provider. Individual education is documented in the participant’s record in the “NE Provided” drop down and Progress Notes field (if applicable). Education provided in a group setting is documented in either the “Schedule Non-WIC NE” function on the “Next Appointment” screen or the “Group Education Classes” screen in the “Appointment Scheduler”. 7.1. Local programs who use non-WIC nutrition education for the participant’s quarterly nutrition education contact shall have a written agreement with the agency providing the nutrition education. 7.2. Keep a copy of each written agreement on file at local program for monitoring purposes. See ⧫820—Quarterly Nutrition Education Contacts for further details. See also Appendices A and B in this policy for sample agreement and documentation forms.

Participant does not attend quarterly nutrition education 8.0 If a participant misses a quarterly nutrition education contact, document this in the individual’s record. 8.1. Participant attendance is documented in the “Appointment Scheduler” module in TWIST. Document attendance for each scheduled appointment or group session. 8.2. At the end of the day, TWIST automatically enters a “no-show” for participants who don’t attend their quarterly nutrition education appointment. 8.2.1. Contact each participant to reschedule another nutrition education appointment within the same month. If this is not possible, reschedule the participant for a nutrition education activity the following month. One month’s food benefits may be issued when nutrition education is missed and two-way communication is made with the participant or cardholder to reschedule the nutrition education activity. Two-way contact

Documentation of Nutrition-Focused Education and Counseling, Continued 840.7 means the participant has responded to clinic staff in person or by calling, texting or emailing back. 8.2.2. Contact the participant after each missed appointment. If two- way communication has occurred, continue to provide benefits on a month by month basis until they “show” for an appointment or until it is time for the participant to be recertified. 8.3. A missed nutrition education appointment is not considered a refusal to participate. Participant refusals occur at certification or recertification appointments when participants state that they do not want any follow-up nutrition appointments. Participant refusals are documented differently, using the “NE Refusal” button. Section 1.8 provides details on how to document refusals. 8.4. For high-risk participants who have missed their follow-up appointment with the RDN/WIC nutritionist, reschedule the nutrition education appointment as soon as possible. If the participant does not show up for the next appointment, contact the participant to offer an alternative such as a telephone or interactive video appointment. See ⧫830—Counseling and Services for High-Risk Participants for more information. A “no-show” for an RDN/WIC nutritionist follow-up appointment is not considered a refusal to participate. 8.4.1. If a participant explicitly refuses to participate in nutrition-focused education or counseling with the RDN/WIC nutritionist, this shall be documented in the “Progress Notes”. 8.4.2. The RDN/WIC nutritionist develops an individual care plan for each high-risk participant, including participants who refuse follow-up care. See ¶ 9.9 for information on the RDN/WIC nutritionist’s review of the participant’s record and the documentation of this in TWIST.

Documentation for high-risk participants 9.0 Individuals determined to be high-risk are referred to the RDN/WIC nutritionist for follow-up care, and the development of an individual care plan. See ⧫661— Competent Professional Authority: Appropriate Counseling for Risk Level and ⧫830—Counseling and Services for High-Risk Participants for additional information. 9.1. The appointment type for appointments with the RDN/WIC nutritionist is FD, whether it is a face-to-face appointment or an appointment by an alternative means – telephone, interactive video, text message, or secure email. After the appointment is completed, the appointment status is changed to “show”. 9.2. The individual care plan shall be developed during a face-to-face contact with the participant. See ⧫830—Counseling and Services for High Risk Participants for exceptions. 9.3. Documentation requirements for appointments with the RDN/WIC nutritionist include the following: 9.3.1. In the “NE Provided” dropdown, select See progress notes.

Documentation of Nutrition-Focused Education and Counseling, Continued 840.8 9.3.2. On the Progress Notes screen, enter the individual care plan. See ¶ 9.4 for the required elements. 9.4. The individual care plan includes, at a minimum: 9.4.1. Date of counseling. 9.4.2. Any progress made in resolving nutritional risk. 9.4.3. Nutrition-focused education and counseling provided. 9.4.4. Identification of a participant behavior change whenever possible. 9.4.5. A plan for future intervention that addresses nutritional risk(s). 9.4.6. The name of the WIC Nutritionist/Registered Dietitian. 9.5. The RDN/WIC nutritionist may format the individual care plan however he or she deems appropriate. 9.6. The individual care plan and subsequent notes on the participant’s progress must be entered in the “Progress Notes” screen in TWIST. 9.7. If the counseling appointment occurred by an alternative means, such as telephone or interactive video technology, identify how the counseling was provided in the participant’s record. Also document the individual care plan, using the same criteria as a face-to-face high-risk nutrition education contact. Examples: • Telephone contact on 8/15/18. Emma unable to come to clinic due to physical injury – she broke her ankle when she slipped on the stairs at work. She states her pregnancy is progressing well. Her appetite is good; the nausea and vomiting has diminished almost entirely. The doctor told her that her weight is back on track, gaining about ½ # per week. Discussed nutritional needs during pregnancy and answered her questions about breastfeeding. Her goal is to continue daily walks, once ankle is healed, and to read more about BF to better prepare herself. Plans to attend the WIC BF group next month. Ima Ardee, RDN • Interactive video call. Arranged for video appointment due to Jonda’s ongoing transportation difficulties. (Continue with individual care plan) • Text message contact. Due to technical difficulties, we were not able to connect through video or chat, so conducted appointment by texting. (Continue with individual care plan) • Email contact. Unable to meet in person because of clinic closure due to smoke. Conducted appointment by secure email. (Continue with individual care plan) 9.8. For high-risk participants who are receiving care from a non-WIC RDN offsite, it is recommended that the RDN/WIC nutritionist communicate with the non- WIC RDN to coordinate care, discuss the care plan and assess whether the appropriate food package is being issued. 9.8.1. Health care providers, including RDN/WIC nutritionists, may discuss continuity of care issues without a signed consent form

Documentation of Nutrition-Focused Education and Counseling, Continued 840.9 from the participant, unless specifically required at the local agency level. 9.8.2. Document communications with other health care providers in the Progress Notes. 9.9. The RDN/WIC nutritionist provides oversight for all high-risk participants enrolled in WIC, even those who have not shown up for appointments or who have refused to see the RDN/WIC nutritionist. In these situations, the RDN/WIC nutritionist reviews the information available in the participant’s record and documents a brief assessment/plan in the Progress Notes. 9.9.1. The RDN/WIC nutritionist may contact the participant, or any other health care providers involved in the participant’s care, to obtain additional information, coordinate care and to assure that the correct food package is being provided. 9.9.2. If contact is not possible, the RDN/WIC nutritionist will document in the Progress Notes that contact was attempted but not successful. 9.9.3. High-risk participants who refuse RDN/WIC nutritionist services may still be offered quarterly nutrition education at the local agency. REFERENCES 1. WIC Nutrition Services Standards, US Department of Agriculture, Food and Nutrition Service, August 2013.

POLICY HISTORY Date * Revised, Reviewed, Released 10/5/2018 Released

The date located at the top of the policy is the date of the most recent release. Policies are to be implemented on release date and will become compliance findings 6 months from the release date. *Released: Significant changes made to policy. Release notes can be found in the corresponding document on the Policy and Procedure Manual page. Reviewed: The writer looked at this policy to make sure it was still accurate. Formatting changes may have occurred. Revised: Minor edits or formatting has occurred without need for release. USDA has accepted a policy and watermark is reviewed. 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.

Documentation of Nutrition-Focused Education and Counseling, Continued 840.10 APPENDIX A Sample

Agreement to Provide WIC Participants Documentation of Nutrition Education Received

When a WIC participant attends nutrition education through our services, on request of the WIC participant, we, __________________________________________________________, agree to provide documentation of the nutrition education completed.

We agree to use the WIC Nutrition Education Documentation form provided, and will include: • the date, • WIC participant’s name, • nutrition education topic, • agency, and • signature and credentials of the person presenting the education session.

This agreement expands the nutrition education opportunities of WIC participants interested in our services, and implies no obligation to provide information other than as noted above.

The WIC participant remains responsible for providing this documentation to the WIC clinic.

Agency Representative Signature

WIC Program Representative

Date

Date

Documentation of Nutrition-Focused Education and Counseling, Continued 840.11 APPENDIX B Sample Form

WIC Nutrition Education Documentation Form

The following nutrition education session:

Nutrition education topic

was attended by: ___________________________ ________________

_____________________________________________________________________ Name of agency providing nutrition education

________________________________________________ __________________________ Signature and credentials of the person Date providing the nutrition education

Return this form to your WIC office to receive credit for education attended.

WIC participant’s name

WIC ID number