West Virginia WIC Policy & Procedure 5.06 Effective Date: 6/27/2022 5.06

Guidelines for Serving High Risk Participants ____

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POLICY:

The Nutrition Associate/Nutritionist (CPA) will determine the appropriate nutrition risks for every WIC participant. WIC participants who are determined to have certain health conditions and nutritional inadequacies that can be prevented or improved through nutrition interventions will be considered high-risk. All high-risk participants will be scheduled for a high-risk follow-up with a Nutritionist (CPA) during their current certification period to encourage stabilizing or improving the risk condition(s).

High-risk nutrition care includes assessment of nutrition-related health problems, nutrition education based on the participant’s needs, regular monitoring and documentation of progress, appropriate food package prescription, and referral(s) to other needed services.

Note: The term “high risk” is for office use only. Avoid “labeling” participants as “high risk”. Use wording, such as “follow-up”, instead

PROCEDURE:

A. Nutrition Risk Criteria

1. The Nutrition Associate/Nutritionist (CPA) will determine if a participant is high- risk at the certification (initial or subsequent) appointment.

2. High-risk nutrition risk codes can be assigned by the Crossroads Computer System or by the Nutrition Associate/Nutritionist (CPA).

a. The Crossroads Computer System may assign one of the following high- risk nutrition risks based upon data entered for the applicant/participant. The high-risk codes assigned by the system are:

i. 103 (Underweight or at risk for Underweight): birth to 24 months <2.3%tile weight for length; 2-5 years <5th%tile BMI for age.

ii. 131 (Low Maternal Weight Gain): low rate of weight gain or low weight gain at any point in pregnancy.

iii. 135 (Slowed/Faltering Growth Pattern): infants <6 months old.

iv. 141 (Low Birth Weight and Very Low Birth Weight): <24 months old and birth weight <5 pounds.

v. 201 (Low Hemoglobin): infants (9-12 months) <9.5g, children (12 to 24 months) <10g, children (2-5 years) <10g, pregnant (0-40 weeks, non-smoking, smoking up to 2+ packs/day) <10g, breastfeeding/postpartum (non-smoking, smoking up to 2+ packs/day) <10g.

West Virginia WIC Policy & Procedure 5.06 Effective Date: 6/27/2022 5.06

Guidelines for Serving High Risk Participants ____

Page 2 of 4

vi. 201 (Low Hemoglobin) + 371 (Maternal Smoking): if selected together for a pregnant woman.

vii. 331 (Pregnancy at a Young Age): <15 years old and currently pregnant or <15 years old and breastfeeding/postpartum most recent pregnancy.

b. The Nutrition Associate/Nutritionist (CPA) can assign certain high-risk codes based upon the nutrition assessment with the applicant/participant. The high-risk codes assigned by the Nutritionist (CPA) are:

i. 134 (Failure to Thrive): infants, children (12mo -5 years), physician diagnosis. ii. 302 (Gestational Diabetes): pregnant. iii. 303 (History of Gestational Diabetes): pregnant, breastfeeding/postpartum.

3. If the participant is determined to be at high-risk, the Nutritionist (CPA) must complete a high-risk follow-up appointment with the high-risk participant during their current certification period.

a. The high-risk follow-up can be scheduled at three (3) months (90 days) in conjunction with their nutrition education appointment.

b. The high-risk follow-up can be scheduled at six (6) months in conjunction with their mid-certification follow-up appointment.

c. The high-risk follow-up can be scheduled at nine (9) months in conjunction with their nutrition education appointment.

Note: The high-risk follow-up appointment should be scheduled by the Nutrition Associate/Nutritionist (CPA) using their professional judgement and in consideration of the participant’s situation. High-risk follow-up appointments must be entered into the Crossroads Scheduler.

B. High-Risk Referral

1. The Nutrition Associate/Nutritionist (CPA) must immediately send a referral to the participant’s healthcare provider when:

a. A high-risk hematological value is identified. b. An infant or child anthropometric measurements determine they are underweight.

2. The Nutrition Associate/Nutritionist (CPA) can make any additional referrals.

3. If the participant does not show improvement during the high-risk follow-up visit, the Nutritionist (CPA) will make a referral to the participant’s healthcare provider.

West Virginia WIC Policy & Procedure 5.06 Effective Date: 6/27/2022 5.06

Guidelines for Serving High Risk Participants ____

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4. The referral must be documented in the participant’s record, on the Crossroads Referral Program Screen.

C. High-Risk Nutrition Follow-Up

1. If the high-risk designation is generated by an anthropometric nutrition risk criterion, anthropometric measurements must be collected during the high-risk follow-up appointment and entered into the Crossroads Anthro/Lab Screen. This includes height/length and weight (see Policy 2.12 Anthropometric Measurements).

a. The participant will be considered high-risk until a series of three (3) anthropometric measurements are collected. These will be collected at certification, high-risk follow-up and/or mid-certification follow-up and mid- certification follow-up and/or certification.

b. The Nutritionist (CPA) will use their professional judgment to determine if the participant should continue to have a high-risk designation.

i. The Nutritionist (CPA) must document in the Nutrition Care Plan their justification for determining the participant to no longer be high-risk.

2. If the high-risk designation is generated by a hematological nutrition risk criterion, a hematological measurement must be collected during the high-risk follow-up appointment and entered into the Crossroads Anthro/Lab Screen (see Policy 2.13 Hematological Testing).

a. The participant will be considered high-risk until the hematological value has improved to normal levels or until a series of three hematological measurement have been collected. These will be collected at certification, high-risk follow-up and/or mid-certification follow-up and mid- certification follow-up and/or certification.

b. The Nutritionist (CPA) will use their professional judgement to determine if the participant should continue to have a high-risk designation.

i. The Nutritionist (CPA) must document in the Nutrition Care Plan their justification for determining the participant to no longer be high-risk.

D. Food Package Prescription

1. The appropriate food package will be assigned and tailored to meet the individual needs of the high-risk participant (see 4.09 Food Package III, Women, Infants and Children with Qualifying Medical Conditions).

West Virginia WIC Policy & Procedure 5.06 Effective Date: 6/27/2022 5.06

Guidelines for Serving High Risk Participants ____

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2. Only a Nutrition Associate/Nutritionist (CPA) is authorized to prescribe supplemental foods in quantities that meet the maximum monthly allowance (MMA) and are appropriate for the participant, taking into consideration the participant’s age and nutritional needs.

E. Nutrition Education Contacts

1. The participant must complete four (4) nutrition education contacts during their current certification period.

2. Individual nutrition education is provided during the certification appointment and the high-risk follow-up appointment/mid-certification appointment.

3. High risk assessment and counseling by a registered dietitian outside the WIC Program may qualify as a high-risk nutrition education contact.

a. This contact does not count as one of the four (4) nutrition education contacts within the certification period.

b. A copy of the dietitian’s progress notes, or assessment/plan must be included in the participants chart prior to the end of the certification period.

REFERENCES:

1. CFR 246.7, 246.10 and 246.11 – WIC Regulations 2. USDA Nutrition Services Standards, Standard 7 – Nutrition Education and Counseling 3. USDA Nutrition Service Standards, Standard 8 – Breastfeeding Education, Promotion and Support 4. Risk Code Chart, West Virginia WIC, March 2020 5. Nutrition Risk Determination Charts, West Virginia WIC, January 2018