July 2010
Missouri Department of Health and Senior Services
Bureau of WIC & Nutrition Services
Self-Paced
CPA Module
Must be completed by: CPA and Nutritionist.
1
CPA Training Module
Purpose of Module
The purpose of the CPA Module is to introduce the new employee (herein after referred to as trainee) to policies and procedures of the WIC Program.
This self-paced module will guide you through the first steps necessary to gain the skills needed:
1. Be knowledgeable in verification and analysis of the Nutrition Assessment.
2. Determine medical and health eligibility by assigning risk factors.
3. Identify and demonstrate active listening, paraphrasing, reflecting, clarifying and asking open-ended questions and show how to summarize and close an individual education session.
4. Recognize the benefits of involving adults as decision makers in the goal setting process.
If you have questions during your training do not hesitate to call me. This module contains a wealth of information you may need to refer to from time to time. It is recommended you keep it in a binder for future reference.
Sincerely,
D’Anne Ward, LPN, Nutritionist III
WIC Nutrition Trainer
Missouri Department of Health and Senior Services
Bureau of WIC and Nutrition Services
P.O. Box 570
Jefferson City, MO 65109
Phone: 573/526-0209
Fax: 573/526-1470
E-mail:
Training Requirements
The trainee will complete the self-paced module and activities before attending the face-to- face training in Jefferson City. The self-paced module is also intended for use as a ”refresher” training for current staff or staff returning from a break in service over 1 year.
Materials Needed
Trainee will need the following:
ü Access to the WIC Operations Manual (WOM)
ü Access to the Food and Formula Reference Guide
ü Access to the internet
ü Access to the Health and Nutrition Assessment Handbook (HNAH)
Instructions for Trainee
1. Read the WIC Certifier Self-Paced module.
2. Complete all hands-on exercises located throughout the module.
3. The supervisor will submit the post test and “Verification of Completion” form to the State WIC Nutrition trainer or trainee can bring to face-to-face training.
Learning Objectives
Upon completing this module, the trainee should be able to:
1. Provide nutrition education guidance using the Nutrition Assessment forms.
2. Provide secondary nutrition education contacts to WIC participant.
3. Determine the appropriate food prescriptions when tailoring based on the participant’s need.
4. Determine when a SOAP note (high-risk care plan) is required and how to complete the information in MOWINS.
5. Determine the participant’s follow-up schedule for future visits.
6. Describe when medical documentation requirements are required.
7. Complete the medical documentation forms.
8. Identify changes to food packages for participants with qualifying medical conditions.
9. Understand the differences in food packages for women who are partially breastfeeding less than or equal to the max versus women partially breastfeeding greater than the max.
10. Describe dairy alternatives available on the food list and when medical documentation is required.
Nutrition Assessment (VENA)
As discussed in the WIC Certifier Self-Paced module the nutrition assessment is required at each certification/recertification appointment for all participants. It is the first step in providing quality nutrition services. It is used for two purposes: (1) to determine eligibility of the applicant; and (2) to serve as the basis from which all subsequent WIC nutrition services are provided. More specifically, the information gathered during the assessment process is used to assess the applicant’s nutritional status and risk (associated with an increased likelihood of poor outcomes), tailor the food package, design appropriate nutrition education, and make referrals to health and social services.
The Dietary Guidelines for Americans [Dietary Guidelines], first published in 1980, provides science-based advice to promote health and to reduce risk for chronic diseases through diet and physical activity. The recommendations contained within the Dietary Guidelines are targeted to the general public over 2 years of age who are living in the United States. The basic premise of the Dietary Guidelines is that nutrient needs should be met primarily through consuming foods. Foods provide an array of nutrients (as well as phytochemicals, antioxidants, etc.) and other compounds that may have beneficial effects on health. In some cases, fortified foods may be useful sources of one or more nutrients that otherwise might be consumed in less than recommended amounts. Additional information can be found at this link: http://www.health.gov/dietaryguidelines/dga2005/document/
The WIC nutrition assessment directs nutrition education by answering the questions: “What
topic(s) is most important to cover at this time?”, “What counseling method or teaching
strategy will most effectively assist the participant to improve her health status and/or achieve
a positive change in dietary habits. Based on the assessment, WIC counseling staff will use their critical thinking skills and professional judgment to establish the participant’s nutrition education goal and determine how to best meet the participant’s needs and maximize the nutrition services offered to the participant. Only the CPA or nutritionist can assign the dietary risk factors 401 and 428.
ü Risk Factor 401: Failure to Meet Dietary Guidelines for Americans is assigned to women and children two years of age and older who meet the eligibility requirements of income, category, and residency status who may be presumed to be at nutrition risk based on failure to meet Dietary Guidelines for Americans [Dietary Guidelines]. This risk factor stands alone, which means it cannot be assigned with any other risk factors on the initial cert/recertification record.
ü Risk Factor 428: Dietary Risk Associated with Complementary Feeding Practices is assigned to an infant (4 to 12 months) or child (12 to 23 months of age) who has begun to or is expected to begin to 1) consume complementary foods and beverages, 2) eat independently, 3) be weaned from breast milk or infant formula, or 4) transition from a diet based on infant/toddler foods to one based on the Dietary Guidelines for Americans. This age is at risk of inappropriate complementary feeding. A complete nutrition assessment for risk #411, Inappropriate Nutrition Practices for Infants, or #425, Inappropriate Nutrition Practices for Children, must be completed prior to assigning this presumed risk factor #428.
Note: Additional information regarding this topic will be discussed at the WIC Paraprofessional/Professional Training.
High-Risk Participants
Risk factor (also called risk criteria) refers to a nutritional/medical condition or set of circumstances which can be identified through the certification process that indicate a person may be more likely to have a nutritional problem. The term “risk factor” is also used when referring to the specific risk factor number assigned to the risk factor condition. All applicable risk factors are based on standards used to determine if a WIC applicant or participant is at nutritional risk. The standards were developed so that nutritional risk would be defined uniformly throughout the state.
The high-risk care plan, recorded in SOAP notes, by WOM definition is a plan of action for monitoring and/or improving the health and nutritional status of a high-risk participant. The CPA can initiate the development of a high-risk care plan for prenatal, infant, and child participants who have specific high-risk risk factors assigned to them.
The Nutritionist provides the follow-up visits with individuals assigned a high-risk risk factor. High-risk care plans are not required for breastfeeding and non-breastfeeding women. However, the counseling staff may initiate a care plan on any participant when deemed necessary. The purpose of the high-risk care plan is to assure that participants who are at highest risk receive appropriate nutrition counseling specific to their risk(s).
The CPA will need to document the required high-risk contact in MOWINS by selecting the “high-risk” topic from the listing on either the primary or secondary nutrition education contact tab. Stop and review the policy “Guidelines for Nutrition Education and Coding (2.06100)” located in the WOM.
There are three types of notes in MOWINS: general notes, breastfeeding notes and SOAP notes. Any entries on these screens are permanent and no spell check feature is available. Entries cannot be revised or deleted once saved in MOWINS.
SOAP notes are used for the certifying staff to record any medical, health or nutrition information. This note is also used for high-risk participants. Standardized format for narrative progress notes is described by the acronym S.O.A.P.
The key feature is that the format must promote effective communication among the members of the local agency team about the participant’s health and the status of the care plan. All components of the SOAP format need not be used in each entry unless charting is infrequent.
Do not refer to yourself in the first person, such as “I think…”
ü S (Subjective): The subjective section contains information obtained directly from the participant, parent or guardian, and it must be clear to the reader where the information was obtained (i.e. “Participant’s parent stated….” Or “Per participant. ….”, etc). Use direct quotes from the participant, parent or guardian when possible.
ü (Objective): The Objective section will automatically be populated with the height, weight, blood work, referrals and risk factor information from the current certification. The height information will include the growth chart percentiles for the height and weight measurements.
ü A (Assessment): The assessment section contains the nutritionist’s professional judgment and interpretation of the subjective and objective information previously collected. This is where the nutritionist identifies the participant’s problems, and along with the participant, sets goals based on these findings.
ü P (Plan): The plan section indicates the plan for follow-up with the participant.
Protected Check Box - This control allows the user to indicate that the note contains sensitive information and it will only be displayed to the user who created the note and the staff members who have the permission for viewing these notes.
Like every other language, medical terminology has changed over time. The basis for medical terminology however, remains the same. The majority of medical terms are derived from Latin or Greek language. Accurate spelling and correct medical abbreviations should be used. For our purposes, a complete listing of approved abbreviations and symbols can be found in the Health and Nutrition Assessment Handbook (HNAH) http://www.health.mo.gov/living/families/wic/wiclwp/policies.phpl.
Nutrition Education
One of the keys to success for a CPA is her/his ability to relate well to WIC participants, help put them at ease, and assist them in identifying strategies to overcome individual barriers to nutrition issues. Equipping CPAs with strong counseling and communication skills at the beginning of their training helps increase confidence as counselors grow in their new roles of empowering participants.
It is possible that for each participant a large number of topics may apply. To avoid overwhelming the participant with nutrition-related information, it is recommended the CPA cover no more than two topics at certification or recertification visits, and no more than two topics at subsequent (follow-up) visits. The purpose of this minimum is to assure the CPA is providing a “baseline” amount of nutrition information to the participant. The main purpose is not to overwhelm the participant.
Elements of Effective Nutrition Education
WIC nutrition education is effective when it results in a positive nutrition-related behavior
change. Typically, the traditional WIC nutrition education contact/intervention has been a
face-to-face meeting between the participant and the WIC nutrition staff. Interaction between WIC staff and participants is important because the interaction encourages participants to ask questions
and to receive reliable nutrition advice that addresses their special nutrition needs.
Effective nutrition education should elicit a behavior change that will help the participant
achieve and maintain a positive change in dietary and physical activity habits, resulting in
improved nutritional status and in the prevention of nutrition-related problems regardless of the
delivery medium. Effective nutrition education contacts/interventions should also be easily
understood by participants taking into consideration participants personal and cultural
preferences, educational and environmental limitations, and be consistent with the WIC
Nutrition Services Standards (WIC NSS).
The most effective WIC nutrition education contact/intervention should incorporate the following six elements:
ü A review of the WIC nutrition assessment to identify the participant’s nutritional risk
factors, needs and concerns;
ü Messages that engage the participant in setting individual, simple and attainable goals
and provide clear and relevant “how to” actions to accomplish those goals;
ü Counseling methods/teaching strategies that are relevant to the participant’s nutritional
risk and are easily understood by the participant;
ü A delivery medium that creates opportunities for participant interaction and feedback;
ü Continuous support through informational/environmental reinforcements; and
ü Follow-up to assess for behavior change and determine intervention effectiveness.
Nutrition Education Messages
Nutrition messages should be tailored to maximize the impact and benefit for the participant
and focused towards attaining WIC’s regulatory goals for nutrition education. The nutrition
education offered may include a wide array of messages that are relevant to participant’s
nutritional risk factors and individual nutrition needs/concerns as well as emerging health
issues. WIC staff use the assessment information, critical thinking skills, and professional
judgment to select the most relevant and effective tailored nutrition education message(s) for
the participant.
Counseling Methods/Teaching Strategies
There is no one counseling method or teaching strategy that fits the needs of all participants.
Individuals vary greatly in how they learn, process, and use information and in their readiness
to change. Effective nutrition education consists of counseling methods that consider multiple
learning aptitudes identified during the WIC nutrition assessment process and subsequent
follow-up.
Regardless of the counseling method/teaching strategy used, a characteristic that has been shown to be effective in changing behavior is interaction that engages the participant. Interaction means a two-way exchange of information. Interactive approaches to nutrition education have been shown to be effective in changing behavior and provide participants the opportunity for questions and feedback. Interactive nutrition education can be achieved in an individual or group session. Using strategies that engage the participants in identifying individual goals or important issues as well as creating solutions that work for them will enhance the effectiveness of nutrition education.
Delivery Medium
The WIC nutrition educator may use multiple delivery media during nutrition education
contacts/intervention. Although face-to-face personalized contact is considered the optimal