Division of Community Nutrition

Subject: Nutrition Staffing Levels Policy: NEd 04.0 Reference: CFR 246.11 Effective: August 12, 2013 Supersedes: October 1, 2002

Page 1 of 10 I. Policy

Five levels of nutrition interventions have been developed for staff that provides nutrition education. Levels 1, 2, 3, 4 and 5 correspond to increasing levels of complexity of the nutrition intervention as well as increasing competency and technical skills required to provide the intervention.

The five levels are defined as:

Level 1: Nutritionist Assistant Non CPA Lowest Intervention Level – Limited assessment, cannot certify participants. Provides follow up education to low risk participants under nutritionist's supervision. Must complete designated WIC Web Based Paraprofessional Training Program Modules. Level 2: Breastfeeding Peer Counselor

Moderate Intervention Level – Limited assessment, cannot certify participants. Provides WIC pregnant and breastfeeding participants with education, counseling, and support on maintaining a positive breastfeeding relationship with their infants through the first year. Basic breastfeeding services are rendered under the Breastfeeding Coordinator’s supervision. Must complete Virginia’s Loving Support Through Peer Counseling© Training Program modules as part of orientation. Level 3: Nutritionist Associate (Paraprofessional CPA) Moderate Intervention Level – Expanded assessment, can certify all participants. Provides initial nutrition education to all participants and follow up education to low risk participants under nutritionist’s supervision. Must complete all of WIC Web Based Paraprofessional Training Program Modules. Includes LPNs, dietetic technicians and home economists with a general bachelor's degree. Level 4: Nutritionist (Professional CPA) High Intervention Level – Expanded assessment, can certify all participants. Provides initial and routine follow up nutrition education to low risk participants. Functions as local agency breastfeeding coordinator (if applicable). Includes home economists with a major in food/nutrition, nutritionists, registered nurses, nurse practitioners, physician assistants and physicians. Level 5: Registered Dietitian Highest Intervention Level – Can assess and provide initial and follow up nutrition education to high risk participants. Required provider for required high risk counseling. Reinforces medical care plan provided by the health care system and provides Medical Nutrition Therapy (MNT)* services. Functions as local agency breastfeeding coordinator (if applicable). Works with other community programs to integrate nutrition services. In some settings, may perform management functions (i.e. supervise WIC nutrition and administrative staff). Must be Registered Dietitian

Division of Community Nutrition

Subject: Nutrition Staffing Levels Policy: NEd 04.0 Reference: CFR 246.11 Effective: August 12, 2013 Supersedes: October 1, 2002

Page 2 of 10 with the Commission on Dietetic Registration. * MNT involves assessment of the participant's nutritional status and diet modification, counseling and specialized nutrition therapies such as diabetes and renal services, performed by Registered Dietitians if funded beyond WIC funding.

The following tables define the roles of Level 1 through Level 5 staff in more detail:

Division of Community Nutrition

Subject: Nutrition Staffing Levels Policy: NEd 04.0 Reference: CFR 246.11 Effective: August 12, 2013 Supersedes: October 1, 2002

Page 3 of 10

TABLE 1

NUTRITION SERVICE LEVEL 1 Nutritionist Assistant/Non CPA Lowest intervention level Assessment Limited assessment  Maintains and calibrates equipment  Explains procedure for collecting measurements to clients  Collects height, weight and blood work  Documents measurements (i.e. anthropometrics and blood work)  Collects identification information  Conducts assessment of income and residency eligibility Education  Assists nutritionist in providing general information about healthful foods, food buying and food preparation  Presents nutrition education classes using established curriculum under close supervision and specialized training provided by Level 4 or 5 personnel  Orders and maintains nutrition education outreach materials/aids and supplies  Creates a breastfeeding friendly environment Record Keeping  Collects and records routine information  Assists with the issuing, recording and security of food instruments Outreach  Explains WIC services to (potential) clients

Staff Qualifications  High school graduate or equivalent Staff Requirements Completes WIC Web Based Nutrition Paraprofessional Training Program Modules as part of orientation  Basic Education – Module 3  Nutrition for WIC Participants- Module 4  Nutrition Education – Module 7  Breastfeeding – Module 10 Continuing Education Requirement  Receives a minimum of 3 hours a year of nutrition training.  Receives a minimum of 5 hours a year of lactation education training.

Division of Community Nutrition

Subject: Nutrition Staffing Levels Policy: NEd 04.0 Reference: CFR 246.11 Effective: August 12, 2013 Supersedes: October 1, 2002

Page 4 of 10

TABLE 2

NUTRITION SERVICE LEVEL 2 Breastfeeding Peer Counselor Moderate intervention level Assessment  Receives referrals from Health Department and WIC personnel.  Completes Breastfeeding Referral/Contact Form (WIC-386) for pregnant and breastfeeding WIC participants.  Collects and documents weight and length for breastfeeding infants.  Collects breastfeeding, health, and nutrition information pertinent to breastfeeding family.  Identifies the needs and concerns of breastfeeding family.  Identifies high risk breastfeeding families and refers to Breastfeeding Coordinator.  Utilizes information collected to assess and document breastfeeding status in Crossroads. Counseling and Education  Promotes breastfeeding as the preferred infant feeding method.  Provides basic level information on breastfeeding, infant feeding, and nutrition.  Provides WIC pregnant and breastfeeding participants with continual education, counseling, and support on maintaining a positive breastfeeding relationship with their infant through the first year.  Works individually, in groups, and/or in classes with pregnant and breastfeeding WIC participants.  Contacts participants on the phone from home or in person at the hospital, clinic setting, or their home.  Creates a breastfeeding friendly environment Record Keeping  Completes Breastfeeding Referral/Contact Form (WIC-386)  Completes Breastfeeding Peer Counselor Activity Report (WIC-385)  Collects and records routine information in Crossroads Outreach  Explains WIC breastfeeding services to (potential) participants.

Staff Qualifications  High School graduate or equivalent.  Has successfully breastfed one or more infants for 6 months or more. Staff Requirements  Completes Virginia’s Loving Support Through Peer Counseling© as part of orientation.  Completes WIC Web Based Nutrition Paraprofessional Training Program Modules as part of orientation:

Division of Community Nutrition

Subject: Nutrition Staffing Levels Policy: NEd 04.0 Reference: CFR 246.11 Effective: August 12, 2013 Supersedes: October 1, 2002

Page 5 of 10 Basic Nutrition Education- Module 3 Nutrition for WIC Participants-Module 4 Providing Nutrition Education-Module 7 Information about Other Cultures-Module 8 Communication and Counseling with WIC Participants-Module 9  Promoting Breastfeeding-Module 10 Continuing Education Requirement  Receives a minimum of 5 hours continuing lactation education annually.

Division of Community Nutrition

Subject: Nutrition Staffing Levels Policy: NEd 04.0 Reference: CFR 246.11 Effective: August 12, 2013 Supersedes: October 1, 2002

Page 6 of 10

TABLE 3

NUTRITION SERVICE LEVEL 3 Nutritionist Associate/CPA Moderate intervention level Assessment Expanded assessment  Collects height, weight and blood work  Documents measurements (i.e. anthropometrics and blood work)  Conducts dietary assessment  Assesses for health risks  Refers high risk clients to registered dietitian for follow-up education Counseling and Education  Provides certification counseling to all clients  Prescribes an appropriate WIC food package  Assists and/or conducts nutrition education activities  Provides appropriate referrals  Determines frequency /content of follow-up nutrition education  Presents nutrition education classes using established curriculum  Monitors client care follow up recommendations and referrals  Creates a client friendly environment  Creates a breastfeeding friendly environment Record Keeping  Collects and records routine information Outreach  Explains WIC services to (potential) clients

Staff Qualifications  High school graduate or equivalent Staff Requirements  Completes WIC Web Based Nutrition Paraprofessional Training Program Modules (to include activities and certification) Continuing Education Requirement  Receives a minimum of 5 hours a year of nutrition training  Receives a minimum of 5 hours a year of lactation education training

Division of Community Nutrition

Subject: Nutrition Staffing Levels Policy: NEd 04.0 Reference: CFR 246.11 Effective: August 12, 2013 Supersedes: October 1, 2002

Page 7 of 10

TABLE 4

NUTRITION SERVICE

LEVEL 4 Nutritionist High intervention level Assessment Expanded assessment  Collects and documents height, weight and blood work  Conducts dietary assessment  Assesses for health risks Counseling and Education  Provides nutrition certification counseling to clients/families  Prescribes appropriate WIC food package  Determines frequency /content of follow-up nutrition education  Provides appropriate referrals  Monitors client care follow up recommendations and referrals  Prepares nutrition education materials/aids  Creates a client friendly environment  Creates a breastfeeding friendly environment  Plans and schedules nutrition education classes Record Keeping  Collects and records information  Completes Local Agency Coordinator’s Quarterly Activity Report (WIC-398) (if functioning as local agency breastfeeding coordinator) Consultation  Provides limited nutrition consultation to internal/external customers  Coordinates client care to improve health care outcomes  Consults with health care providers to develop care plan  Provides in-service education to paraprofessionals and record review  Provides in-service training to paraprofessionals regarding scheduled low-risk group nutrition education contacts Planning & Evaluation  Defines the market and number and characteristics of customers served  Assists with development, implementation and evaluation of WIC Services Plan  Assesses, plans, and evaluates the local agency’s breastfeeding activities annually (if functioning as local agency breastfeeding coordinator)

Staff Qualifications  Nutritionist - See Code of Virginia §54.1-2731 and Board of Health Professions 18 VAC 75-30-10: Regulations Governing Dietitians and Nutritionists. (Appendix 3). Staff Requirements  Completes WIC Web Based Nutrition Paraprofessional Training

Division of Community Nutrition

Subject: Nutrition Staffing Levels Policy: NEd 04.0 Reference: CFR 246.11 Effective: August 12, 2013 Supersedes: October 1, 2002

Page 8 of 10 Program Modules as part of orientation. Level 4 staff may test out of Modules and have the option of not completing the activities. Continuing Education Requirement  Receives a minimum of 10 hours a year of nutrition training  Receives a minimum of 5 hours a year (8 hours if functioning as local agency breastfeeding coordinator) of lactation education training which may be included in the total of the ten hours of yearly training.

Division of Community Nutrition

Subject: Nutrition Staffing Levels Policy: NEd 04.0 Reference: CFR 246.11 Effective: August 12, 2013 Supersedes: October 1, 2002

Page 9 of 10

TABLE 5

NUTRITION SERVICE LEVEL 5 Registered Dietitian Highest intervention level Assessment  Conducts a comprehensive nutritional assessment to develop care plan  Conducts a comprehensive community assessment  Assesses productivity/cost effectiveness of nutrition services Counseling and Education  Provides nutrition counseling to high-risk clients/families  Provides reimbursable Medical Nutrition Therapy upon health care provider's request and with funding beyond the Virginia WIC Program  Assures and coordinates the client's nutrition care needs as identified by the family and health care team  Prepares nutrition education materials/aids  Creates a client friendly environment  Plans and evaluates nutrition education Record Keeping  Collects and records information in the Crossroads system  Completes Local Agency Coordinator’s Quarterly Activity Report (WIC-398) (if functioning as local agency breastfeeding coordinator) Consultation  Provides nutrition consultation to internal/external customers  Coordinates client care to improve health care outcomes  Consults with health care providers to develop care plan  Provides in-service education to paraprofessionals and nutritionists  Provides in-service training to paraprofessionals regarding scheduled low-risk group nutrition education contacts  Provides record reviews of paraprofessionals Planning & Evaluation  Assists with determining health priorities and in developing goals and objectives  Plans, implements and evaluates community interventions  Analyzes and interprets data to monitor nutrition programs  Assists with development, implementation and evaluation of WIC Services Plan  Assesses, plans, and evaluates the local agency’s breastfeeding activities annually (if functioning as local agency breastfeeding coordinator)

Staff Qualifications  Registered Dietitian – See Code of Virginia §54.1-2731 and Board of Health Professions 18 VAC 75-30-10: Regulations Governing

Division of Community Nutrition

Subject: Nutrition Staffing Levels Policy: NEd 04.0 Reference: CFR 246.11 Effective: August 12, 2013 Supersedes: October 1, 2002

Page 10 of 10 Dietitians and Nutritionists. (Appendix 3). Staff Requirements  Completes WIC Web Based Nutrition Paraprofessional Training Program Modules as part of orientation. Level 5 staff may test out of Modules and have the option of not completing the activities Continuing Education Requirement  Receives a minimum of 15 hours a year of nutrition training.  Receives a minimum of 5 hours a year (8 hours if functioning as local agency breastfeeding coordinator) of lactation education training which may be included in the total of the fifteen hours of yearly training.