Policy and Procedure Manual

Volume 1, Chapter 11 Assessment

Washington State WIC Nutrition Program DOH 960-367 August 2021

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Assessment | Page i

Assessment

CONTENTS Section 1: Assessment During WIC Certification 1 POLICY: Nutrition Assessment Requirement ......................................................................... 1 POLICY: Use the Assessment Questions to Complete the Assessment .................................. 3 POLICY: Coordination of WIC and MSS Assessment Process .................................................. 5 POLICY: Use an Interpreter .................................................................................................... 6 Section 2: Appendix 8 Guidance – Using Participant-centered Skills to Complete the Assessment ........................... 9 Key Elements and Examples for Using Participant-centered Skills ........................................ 11

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| Page ii Assessment

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Assessment | Page 1 Section 1: Assessment During WIC Certification

POLICY: Nutrition Assessment Requirement

The Competent Professional Authority (CPA) must complete a nutrition assessment at each initial certification, subsequent certification and mid-certification health assessment. The CPA uses participant-centered skills to complete the assessment.

A nutrition assessment includes obtaining, documenting and assessing: • Measurements • Iron test results • The participant’s answers to the Assessment Questions.

Note: Only a few designated Assessment Questions are required at the mid- certification health assessment.

See Volume 1, Chapter 18 – Certification for more information.

PROCEDURE:

The CPA:

A. Uses participant-centered skills to complete the assessment.

• See Guidance - Using Participant-centered Skills to Complete the Assessment

B. Takes the participant’s length or height and weight measurements and documents in the participant’s file.

1. Assess the participant’s weight and growth by viewing the growth or weight gain grid.

• See Volume 1, Chapter 9 - Anthropometrics for more information.

C. Performs a blood test or gets the results from a health care provider. Documents value in the participant’s file, and explores further by asking additional questions if auto- calculated value identifies participant as High Risk.

• See Volume 1, Chapter 10 – Hematology for more information.

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| Page 2 Assessment D. Has a conversation with the participant, using the Assessment Questions to assess the participant’s health and nutrition status.

E. Documents the participant’s nutrition and health risks.

1. Review to determine if participant is at high risk.

a. The Washington WIC Nutrition Program determines some risks as high risk.

• See Volume 1, Chapter 14 – Nutrition Risk Criteria

F. Documents relevant health and nutrition information.

G. Summarize the assessment information to assure you captured the participant’s needs and concerns.

Information:

The Assessment Questions guide a participant-centered conversation by: • Incorporating critical thinking and prompting to gather and analyze assessment information. • Exploring the participant’s nutrition risks and gathering relevant health and nutrition information. • Considering the participant’s cultural background, beliefs, and needs when completing the assessment. The CPA uses the results of the assessment to determine the participant’s nutrition status and risk, decide the appropriate nutrition education and counseling, tailor the food benefits and make appropriate referrals.

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Assessment | Page 3 POLICY: Use the Assessment Questions to Complete the Assessment

The CPA asks the bolded introduction and questions on the paper-copy of the Assessment Questions at each new certification and subsequent certification. The CPA asks the 5-8 month Assessment Questions for the Infant Health Assessment. The CPA enters participant’s responses into the computer.

The CPA asks a few follow-up Assessment Questions at the mid-certification health assessment. • See Volume 1, Chapter 18 – Certification for information about the mid-certification requirements.

The CPA uses the information gathered from the Assessment Questions to: 1. Find nutrition risks for WIC eligibility. 2. Discover nutrition education topics. 3. Personalize referrals. 4. Assign the food benefits.

PROCEDURE:

The CPA:

A. Shares the bolded introductory statement at the beginning of the Assessment Questions to inform participants that WIC asks everyone the same questions.

B. Asks the Assessment Questions based on category and age.

• Use or refer to the paper copy to see the required bolded questions to ask. • The paper copy includes all the Assessment Questions for each category and feeding type, while Cascades only provides some of the questions. • The Assessment Questions are on the Washington WIC website. The questions are available in several languages on the WIC Forms and Materials web page.

C. Ask clarifying questions to gather additional information needed to identify nutrition risks.

D. Listen for participant’s concerns and needs, and gather information and insight into the participant’s: • Cultural values

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| Page 4 Assessment • Food preferences • Food buying practices • Cooking and food preparation abilities • Mealtime practices • Other related diet and health areas

Information: CPA has understanding of the nutrition risk criteria to assess for all risks and complete a thorough assessment.

• See Volume 1, Chapter 14 – Nutrition Risk Criteria for definitions and justifications of nutrition risk factors.

E. Explores the pregnant participant’s thoughts and knowledge about breastfeeding.

• See Volume 1, Chapter 15 – Breastfeeding, for more information about breastfeeding.

F. Asks all the bolded Assessment Questions from the hard copy before moving into the Care Plan part of the appointment.

G. Document responses to the Assessment Questions in the participant’s file.

H. Identifies participant’s nutrition risks and documents them in the participant’s file.

I. Selects one of the following risks if no other risk is identified from asking the Assessment Questions; and documenting length or height and weight measurements or iron test results:

1. “Not Meeting Dietary Guidelines – Children 2-5 years and Women” risk for women and children 2 years and older.

2. “Not Meeting Feeding Guidelines – Infants and Children” risk for infants 4 – 12 months of age and children 12 – 23 months of age.

J. Documents additional notes about the participant’s risks, nutrition needs, and eating or feeding practices in Cascades as appropriate.

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Assessment | Page 5 POLICY: Coordination of WIC and MSS Assessment Process

Staff may use information gathered during the pregnant woman Maternity Support Services (MSS) assessment as part of the WIC assessment when the following conditions are met:

1. The person completing the MSS assessment is the CPA completing the pregnant woman WIC certification.

2. The WIC and MSS assessments occur on the same day.

3. The CPA asks (or gets the answers to) all bolded paper copy Assessment Questions not asked during the MSS assessment.

4. The CPA assures and documents all Assessment Question responses in Cascades as appropriate.

5. The CPA asks and documents the participant’s plans to breastfeed.

PROCEDURE:

The CPA:

A. Asks MSS assessment questions and all paper copy bolded WIC Assessment Questions for a pregnant woman during the initial certification.

B. Assesses and selects all appropriate nutrition risks in Cascades.

C. Documents additional information in Cascades as appropriate.

D. Gathers information to provide appropriate nutrition education, referrals and food benefits.

Information:

First Steps Maternity Support Services (MSS) provides preventive health services. These services supplement medical coverage for Medicaid-eligible women who are pregnant or within 60 days post-pregnancy. The goal of MSS is to provide services as early in a pregnancy as possible. This effort promotes positive pregnancy and parenting outcomes.

Private and public agencies throughout Washington provide MSS services. This wide range of services include assessment, health education, intervention and counseling from a multi- disciplinary team of professionals who provide a comprehensive plan of care.

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| Page 6 Assessment POLICY: Use an Interpreter

Staff must:

• Document interpreter needs on the Family Demographics screen.

• Use an interpreter for the WIC appointment when bi-lingual staff aren’t available to interpret for a participant with Limited English Proficiency (LEP).

o Staff must not use family members as interpreters.

• Document the use of an interpreter in the Nutrition Assessment section of the Care Plan Summary screen in the participant’s file for any:

o Initial or Subsequent Certification – this includes the Presume Eligible and Presume Eligible Complete Assessment

o Mid-certification Health Assessment

o Second Nutrition Education Contact – this includes High Risk contacts

Note: It’s best practice to document the use of an interpreter for all other services provided including Food Benefit Issuance.

PROCEDURE:

Staff:

A. Determine the primary language of the participant who needs or requests an interpreter and document on the Family Demographics screen.

• Provide an “I Speak Statements” document or the person to identify his or her language.

B. Use an interpreter service when bi-lingual staff aren’t available.

C. Document the use of an interpreter on the Nutrition Assessment screen in the participant’s file.

Information:

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Assessment | Page 7 Washington state WIC contracts with a phone interpreter service. The hours of operation are available 24 hours, seven days a week.

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| Page 8 Assessment Section 2: Appendix

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Assessment | Page 9 Guidance – Using Participant-centered Skills to Complete the Assessment

A. Builds rapport and sets the tone for the appointment by greeting the participant in a friendly way and introduces him or herself.

B. Creates a setting that removes barriers to communication by: • Positioning the participant to the side of the desk. • Sitting knee to knee.

C. Begins the appointment by: • Letting the participant know how long the appointment takes and a brief description about the appointment. • Stating we keep the participant’s information private.

D. Stays non-judgmental while learning about the participant’s beliefs, health and cultural practices.

E. Affirms the participant with sincere and encouraging words. • Keeping the assessment positive; avoids making the participant feel defensive.

F. Uses participant centered skills to connect with the participant. • Asks open-ended questions to allow the participant to give full and meaningful answers from her own perspective and express her feelings. Questions starting with “what,” “when,” “where,” “how,” “tell me,” and “why,” are open-ended. • Ask clarifying questions to get more details. For example: Does your baby get anything else besides breastmilk now? (If yes) What? How much? (in a 24 hour period). • Use “encouragers” to acknowledge what the participant is saying and encourage her or him to keep talking. Encouragers are short words, phrases or gestures. For example: Hmm, I see, go on, and then, etc. • Avoid leading questions which may influence the participant’s answer. For example: If the participant shares she drinks milk, instead of saying “Do you drink milk at every meal?” ask “When do you drink milk?” • Use simple, familiar words (plain talk). Avoid technical words like pregnancy induced hypertension, iron deficiency anemia, high risk, hemoglobin, etc. Instead, use descriptive words or common words like high blood pressure, low iron, or iron test.

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| Page 10 Assessment • Show acceptance and sensitivity especially when asking questions about highly confidential areas. For example: Substance abuse, mental health concerns, miscarriages, abortions, etc. • Listen and assess for all risk criteria by using "active listening” skills. It takes effort to hear what the participant’s saying, not just the words but the total message shared. Listening closely tells the person she’s valued. “Active listening” skills include: o Using body language to show interest, enthusiasm, kindness and respect for the participant. o Lean forward to convey interest. o Have an open body position. o Use open hand gestures. o Keep eye contact when appropriate. • Restate what the person said and reflect what you think the participant is feeling. This helps to assure you understand what participant is saying and clear up any misunderstandings. For example, “You’re feeling confused because so many people are giving you advice.” • Give the participant time to answer each question and avoid interruptions, whenever possible. • Allow time for silence to give the participant time to answer the question and share more information.

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Assessment | Page 11 Key Elements and Examples for Using Participant-centered Skills

The following are the key elements and examples for guiding a nutrition assessment using participant-centered skills and the Assessment Questions.

Key Elements for Conducting Nutrition Assessment Examples for Specific Element Build Rapport Spirit of participant-centered services: • Accepting • Respectful • Individualized • Non-judgmental • Genuine • Sensitivity

Introduction • Greet the participant. • Introduce yourself. • Identify your role.

Hi Joni, I’m _________. I’ll be asking you some questions to see if you’re eligible for WIC today. Setting the agenda • Share how much time you have for the appointment. • State what happens during the appointment. • Assure information will be kept confidential. • Ask permission to proceed. • Ask an open-ended question.

This appointment will take about 30 minutes. We ask everyone these next few questions. These are to help me learn about your pregnancy and about you. Would it be OK to ask a few questions about how you’re doing? What concerns or questions would you like to talk about today?

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| Page 12 Assessment Key Elements Examples Complete the Assessment Affirmations • Sincerely compliment the participant. • Make supportive, reinforcing statements. • Focus on the positive, successes, and efforts.

You’re really determined and stayed flexible in order to get here today. Thank you. You work hard to prepare healthy meals for your child. You’re very creative when preparing snacks. Critical Thinking • Collect all relevant information. • Clarify or gather additional details. • Analyze and evaluate all the information collected. • Determine the best course of action. • Ask all bolded Assessment Questions to complete a thorough assessment. Identify questions that need clarifying depending on the response of the participant. • Consider the whole picture; the height/weight, the iron test results and the participant’s responses.

With diabetes, has your doctor asked you to check your blood sugars at home? Do you take insulin? How often? How much? Tell me about your activity level. What do you drink in a typical day? So it sounds like you don’t drink cows’ milk, what milk substitutes do you drink? Open ended questions • Begin with “what”, “how”, “tell me”, “why”, etc. • Ask in a way that is open and accepting. • Use encouragers (nodding, “go on, wow, hum, etc.). • Listen with an attitude of curiosity.

Tell me a little more about that… Describe what mealtimes look like? Tell me how that makes you feel? How do you feel about the idea of breastfeeding your baby? Clarifying questions • Use to clarify or gather added details. • Use if participant provides short or generic answers.

Did the doctor prescribe iron supplements? How do you prepare the formula? How often is the cereal added to the bottle?

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Assessment | Page 13 Key Component Examples Complete the Assessment continued Leading questions • Avoids asking questions which may sway the participant's response.

Avoid asking: You eat high iron foods, like meat, every day, right? Instead, ask: Tell me what foods you eat? What is a typical meal? Other examples of leading questions to avoid: You drink milk at every meal, right? Did you quit smoking when you learned you were pregnant? You don't drink alcohol now that you are pregnant, do you? Reflections • Reassures the participant you are listening. • Corrects misunderstandings, false assumptions and misinterpretations. • Makes people feel understood.

Participant: My mom is always feeding him baby foods, even though I pump and have the breastmilk available. She says he is whiny when he doesn’t get food. I just don’t know how to get her to stop. CPA: It must feel frustrating that she doesn’t support you. Let her know that breastmilk is the best food for Jacob right now and no other foods are needed. It’s hard to tell our own mom what we want them to do. Moms think they know best. Hold off on education • Allows ability to prioritize identified needs and concerns. • Efficient use of time by focusing on the highest priority issues. • Correct misinformation at the end of session so it doesn’t come across as “criticism” during the conversation. • Bundled information is easier for a participant to remember.

That’s a good question, is it OK if I make myself a note and we come back to it after we have gone through these other questions? Let me write that down so we can talk about that later. Does that work for you? We’ll come back to that, would that be okay? We’ll talk about that more in a second. Does that work for you? Good point, if it’s okay with you, we’ll talk about those in a moment. That’s a great question, I’d like to write that down and after we get through the questions, we can talk about it. Does that work?

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| Page 14 Assessment Key Component Examples Exploration Summarize and prioritize • Summarize completed assessment. • Review risk(s) identified for the participant. • Prioritize nutrition topic with the participant. • Move into discussing nutrition topic.

Example 1 Joni, you just answered many of my questions, had your weight plotted on the weight gain grid, and took an iron test. This information helped qualify you for WIC today. You really care about having a healthy pregnancy and baby. And, it sounds like you’re unsure what to do now that your doctor says you have gestational diabetes? Tell me what you know about gestational diabetes.

Example 2 Juanita, during these past twenty minutes we took Emanuel’s height, weight and iron test and I asked you a variety of questions. Two questions came up for you. One was about introducing solids to Emanuel and the second, about what kind of sippy cup is best. These are both great questions. Which question would you like to talk about first? Exploring participant education needs • Share nutrition/health information the participant is interested in learning. Note: The participant should be doing most of the talking.

Note: This policy chapter is about completing the Assessment Questions. It doesn’t include providing participant centered education. See Volume 1, Chapter 16 – Nutrition Education.

I jotted down the questions you had on this piece of paper. Which one would you like to talk about first? We have talked about many different topics today, let’s review them. (Review each question, concern or nutrition need identified during the assessment.) Which one would you like to talk about today? Based on your answers to the questions and the questions you asked, here are several topics we might talk about (show circle chart or list of items on note pad and give a brief description of each). Which topic would you like to talk about today? On this chart are some of the things we could talk about (show circle chart and give a brief description of each topic) Which topic interests you? Ask the participant why they chose this topic.

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Assessment | Page 15

Resource:

U.S. Department of Agriculture, Food and Nutrition Service, Value Enhanced Nutrition Services (VENA). April 2006.

U.S. Department of Agriculture, Food and Nutrition Service. WIC Nutrition Services Standards. Standard 6: Nutrition Assessment. 2013