Patricia Cumiskey-Czeto Regional Director Supplemental Food Programs

Patricia Cumiskey-Czeto Regional Director Supplemental Food Programs

How to Implement VENA

Regional Overview § Preparation, Training & Tools § Phase I, Self Evaluation § Regional & State Resources § Phase II, Implementation Plan

VENA Competencies Training n Critical thinking skills n Rapport building n Health outcome based nutrition assessments

VENA Strategy Session n n Implementation process * Self-Evaluation * Implementation Plan Next Steps

Phase I: VENA Self-Evaluation

VENA Tool Box - 1 n n n VENA Guidance WIC Program Regulations, Section 246. 7 VENA - WIC Nutrition Assessment Policy WIC Nutrition Education Guidance Policy Memorandum 98 -9, Revision 8, WIC Nutrition Risk Criteria Nutrition Services Standards, Standard 7 Nutrition Assessment

VENA Tool Box - 2 n n n Regional and State Training FNS Staff State Ambassadors

State Sharing-DC Baby Step 1: Staff Training Motivational Interviewing Special Project Grant: Doris Kuehn, MS, RD, DEUG Nutrition Education Coordinator District of Columbia WIC State Agency nutritionists have been trained by Dr. Resnicow in Motivational Interviewing skills in a 2 day workshop in May 2006

State Sharing-MD hanging to VENA Mary Dallavalle, RD, LDN, MS The Maryland WIC Program

State Sharing-PA The Five Focus Areas Shirley H. Sword, MS, RD, LDN Chief, Nutrition Services Section The Pennsylvania WIC Program WIC Policies WIC Nutrition Assessment Processes & Practices Quality Assurance/ Monitoring Staff Competencies/ Training MIS

VENA Tool Box - 3 n n n VENA Track at NWA Resource grid List of concerns MARO WIC VENA Resource Grid WIC Policies Currently, 24 hour diet recall is used to assess dietary intake & risk assignment. Nutrition risk criteria based on USDA Nutrition Risk Criteria SFP 98 -9, Revision 2 -7 & focuses on the collection of objective data, such as anthropometrics. WIC Nutrition Assessment Process and Practices Nutritional status based on the nutrition profile of participant & their individualized nutrition care plan. The system maintains a medical notes section. Staff Competencies/Training Orientation focusing on policy & the assessment process. Employee shadowing is standard for new employees. Trainings are being altered to make them more competency based. MIS Automated risk codes are assigned, automated growth charts are produced, and BMI is automatically calculated. System edits: 1) prevent measurement & date errors, 2) relating to capturing breastfeeding duration Quality Assurance and Monitoring tools used for evaluating the nutrition assessment process: Clinic monitoring Monthly reports (blank & RTF formula & hemoglobin) Quarterly reports (breastfeeding initiation & duration) Evaluations are completed by staff regarding effectiveness of trainings. Delaware n Diet and Health Questionnaire collects dietary, health & family environmental information & is the central tool for nutrition risk assignment; the questionnaire is being revised to delete the 24 hour recall. District of Columbia n Informal interviewing assesses environmental & family nutrition assessment factors. n Nutrition assessment process encourages critical thinking & assessment of interrelationships. n Diet recall is evaluated against the My. Pyramid servings. n Processes are in place for collection of biochemical & anthropometric data. Starting in FY 2007 changes to several certification and nutrition education policies and procedures were made to reflect VENA policy, including implementation of Revision 8, of Policy memo 98 -9. Currently, food frequency questionnaires & 24 -hour recalls assess dietary intake. A qualitative tool for dietary assessment is currently being developed based on survey feedback & other assessment tools. Coordination with other social service programs is standard. Data collection elements are based on FRED and CDC requirements. n All applicants receive a complete nutrition assessment which includes collection of qualitative dietary data & family/environment information. n Changes have been made to WOW computer screens & intake instruments to collect anthropometric, biochemical, dietary, & family/environmental information. Most questions regarding dietary data are qualitative. n WOW assigns all risk factors for an application based on data entered by staff. n “Goal/focus area” field has been added to WOW allowing staff to document participant-set goals or summarize the counseling session. n Training modules are didactic & client focused n Annual “Building on the Basics” paraprofessional training n Hands on, competency based training for new staff regarding certification & nutrition assessment n Paper based modules containing essential information for WIC staff are provided to local agencies n Videos addressing nutritional risk are used n Train the trainer workshops are conducted n Six-one day regional VENA trainings for all local WIC staff occurred in March 2007 & concentrated on WIC ACCESS uses a guided script & required response fields to facilitate data collection. Some risks assignment & relationships are automated and remaining risks are assigned by CPA’s assign interrelationships Documentation follows SOAP format The system allows for documentation of goals from a pre-set list and includes fields to document follow-up. Program goals and objectives for the Statewide Nutrition Education Plan are based on positive health Mandatory training on The Best Start Three Step Counseling Methodbreastfeeding training. Annual anthropometric & hematological training Nutrition education training & meetings are conducted. Introductory VENA, health outcome based nutrition assessments, and rapport building trainings were held at outcomes. Referral history is maintained for follow up New Jersey n Automated system, DC CARES, allows for unlimited documentation & standardization of risk codes. n Some health & lifestyle information is stored. n Unlimited electronic notes n Computer pop-ups of pertinent information (e. g. needs blood work) each time a client’s electronic record is Bi-annual management evaluations & regular site visits assess compliance with guidelines & policy. Local agencies conduct quarterly monitoring of local agency clinic site operations. Qualitative evaluations are assessed as part of every training session. Pre- and post-test tools are used to measure competency. opened. n Automatic calculation of anthropometrics n Automated system works with food items directly & eliminates the need for a complex food matrix. n System allows for easy process of adding/eliminating formulas. n System allows for capturing health services that are already available to the participant. n System prompts staff to request further information on assessment items that are not formally covered in n WIC on the Web (WOW) helps to eliminate laborious tasks required to identify risk factors. n Changes have been made to WOW computer screens & intake instruments to collect relevant data. n WOW assigns all risk factors for an application based on data entered by staff. n “Goal/focus area” field has been added to WOW allowing staff to document participant-set goals or summarize the session. n Management evaluation process to monitor local agency compliance with VENA & determine staff training needs. n Local agencies perform internal monitoring & assess staff’s needs for on-going training. n Participant feedback forms were completed during recent statewide VENA training sessions & will be used to assess further training needs. health outcomes; RIT curriculum were used n WIC ACCESS automatically assigns High Risk criteria related to data collected during the health and nutrition assessment; data records of participants identified as high risk are flagged to require an individualized care plan & follow up. n SOAP note automatically populated with relevant data to assist in prioritizing health and nutrition risks. n Biannual on-site reviews n Local agencies conduct internal monitoring each year. n State monitors monthly reports related to risk assignment, food packages, exempt formulas, permissions, etc. n Effectiveness of training monitored by staff feedback on training evaluations. n Staff is working to develop a performance based evaluation tool to assess competency skills following training. n Easy transfer between clinic sites or local agencies of client records due to Quick WIC system. n Online documentation is required n Easily calculates & plots percentiles for all growth parameters n Historical data is available n Enhancements will be made to the comments section on Quick WIC so templates will be accessible. n Consistency in evaluation of nutrition education delivery by staff is achieved by use of standard Nutrition The current system needs to be altered to reflect open ended questions & to adhere to the VENA guidance. Regional Nutrition Supervisor visits clinics and performs evaluations of the participant nutrition assessments through observations. State WIC staff certify CPA’s by confirming that all required skills performed during observations are satisfactory. The State office performs on-site local agency management evaluations biannually & local agency WIC coordinators perform self management evaluations the year between State office visits. Mid- and end of the year WIC Service Plan reports are submitted. State office reviews newly developed nutrition education materials. WIC Coordinator Advisory Certification Committees evaluation the nutrition assessment process & identify strengths and weaknesses. Local agency WIC Coordinators conduct annual performance evaluations of all staff. The assessment process is evaluated by the WIC Coordinator Advisory Certification Committee. Surveys and focus groups provide participant feedback. Best practices are shared among local agencies the quarterly nutrition services meetings. RIT materials have been modified to adhere to the state’s needs and will be used in mandatory local trainings. Staff are working to develop a statewide competency based training program. The FFY 2007 Statewide Nutrition Education Plan included a section addressing VENA which included free training opportunities for CPA’s. Staff are establishing guidelines for ongoing evaluation & follow up training using self study CD ROMs & the WIC Works online learning tool. State is using CD modules developed by the NJ WIC Dietetic Internship Program. Revision of the dietary assessment policy to eliminate the food frequency questionnaire & comply with VENA is near completion. Policies currently exist for several components of the assessment process such as nutrition risk criteria, dietary assessment, anthropometrics, & food package tailoring, among others. Nutrition education committee is developing guidelines for the format of nutrition contact notes online. Templates have been designed to provide guidance to staff on what information should be captured. Appropriate documentation of goal setting is encouraged. Plans are to strengthen language for policies to “require” current measurements rather than “suggest. ” Currently, 24 -hour recall & food frequency questionnaires are used to collect information related to nutritional risk; a revised assessment questionnaire will be developed after VENA training. Puerto Rico communication & counseling skills. n Motivational interviewing & rapport building trainings were recently conducted. n Critical thinking will be addressed at the quarterly in-service training. n MIS contractor will provide special training on VENA system changes. the assessment questionnaire. Maryland Pennsylvani a n Trainings involve simulated WIC scenarios & interactive teaching. n Training includes competency based Hemo. Cues training. n Annual & quarterly training focuses on anthropometrics, peer counseling, breastfeeding, nutrition needs, & High risk participants establish participant-set goals. Assessment process collects information regarding anthropometrics, hematological measures, & dietary State is interested in pursuing e-learning Trainings currently exist for breastfeeding promotion & support, formulas, anthropometrics, Hemo. Cue testing, child nutrition, & obesity prevention. Instructions for system changes are communicated through Power. Point presentations that are available via the Quick WIC system. Training version of the Quick WIC site is available as a site for local agency staff to practice without having to worry about impacting real participant data. Case studies are utilized for training. Training on the new dietary assessment is planned at the Nutrition Education Coordinator’s meeting in June 2007. Staff are trained on topics related to the nutrition assessment such as anthropometrics, hematological measures, growth charts, and basic nutrition concepts. An industrial psychologist was contracted to provide training on effective communication, emotional intake. Education Contact Evaluation tool. n Proficiency tests are administered twice each year. intelligence, & time & stress management. The assessment process will be changed to utilize open-ended questions during interviews. The interview process will be reinforced with critical thinking and rapport building. VENA competencies training will occur for critical thinking, rapport building, & health outcomes. Speakers for VENA training will be from University of Puerto Rico. Virgin Islands Current nutrition assessment focuses on identifying nutrition risk as eligibility criteria using diet & health history forms. Nutrition assessment collects anthropometric, hematological, dietary, & health history information. WIC Form 305, the diet assessment form, has been revised to reflect VENA guidance allowing for increased dialogue between staff & participant. Local agencies operate following the VA WIC Nutrition Policy & Procedure manual. WIC NET or the nutritionist assigns risk criteria based on information collected. Interrelationships between risks are considered at each certification visit. High risk participants are scheduled for follow up visit with a nutritionist within 60 days of initial certification. Participants should be engaged & actively participating during goal setting. Web based course, WIC 101, used to train staff on essential competencies. Existing modules that incorporate basic nutrition information for children & mothers & communication & WIC NET computer system assigns risk priority for CPA based on participant category & type of risk. The state will adopt the system developed by the Crossroads SAM Consortium, which will adopt all of the counseling skills are used. Policy Ned 4. 0 defines which personnel levels complete which modules based on job level competencies. State WIC Office Nutrition Liaisons provide training & technical assistance to local agencies & are involved in correcting policy violations resulting from management evaluations. State WIC staff will provide training in VENA key competencies for all WIC Staff. VENA principles. All policies are standardized in the territory & have been revised to implement the new dietary risk codes. Present policies exist for anthropometric, biochemical, clinical, dietary, & other environmental & family risk factors. Present policy outlines the general type of nutrition/health information needed to be given to each category of participant. Risk code policies identify parameters delineating high risk status. Risk codes are automatically or manually assigned Goal setting can be documented for future follow up Dietary risk is assessed in a system based questionnaire format Staff have been trained in changes resulting from Policy Memo 98 -9 Revision. Staff have joint territorial biannual trainings & nutritionists & professional CPAs have additional trainings. Paraprofessional staff receive training in nutrition assessment, interviewing, counseling, & other skills Adoption & implementation Maryland’s WOW computer system has put VI in a better place for VENA implementation. The nutrition assessment process in monitored biannually in the territorial clinic monitoring process. State Agency adds monitoring as it deems necessary. Dietary intake is assessed by completing a 24 hour recall & food frequency. Additional time is taken during an appointment to ask a series of questions for Ped. NSS & PNSS. Virginia Some risks are automated while others are CPA assigned. Nutrition Education will be relevant to the participant’s assigned risk code, rather than what the participant Program notes section in the current system is available where goals can be tracked. The state is currently in SAM consortium to develop a new system & VENA areas will be considered in the All competencies are routinely assessed through internal & external monitoring & performance evaluations. necessary for client certification and nutrition education. Staff will receive a 2 day VENA training in St. Croix. wants to discuss or shows readiness cues to change. West Virginia New employee training includes computer system, anthropometric & hematological training at the State WIC Agency. The State Agency developed a training DVD for new employees. Nutritionists have received motivational interviewing training. All CPA’s are required to take 12 hours of continuing education training annually. In April and May all nutritionists were trained in VENA by State staff to include critical thinking skills, rapport building, stages of change, & health based outcomes using RIT curriculum. development.

Phase II: VENA Implementation Plan Activity Policies and Procedures Develop or revise current policies and procedures to enhance the quality of WIC nutrition assessment (to include policies and procedures that enhance the use of assessment information for personalizing nutrition interventions). Training Identify VENA training needs and develop training plans for all staff related to WIC nutrition assessment, to include but not limited to the 3 areas covered in the Regional VENA Competency Trainings (critical thinking; rapport building and; Health Outcome-Based WIC Nutrition Assessment). Action(s) Needed Please identify actions needed for each activity. Priority Please prioritize actions needed for each activity. Target Dates Please identify target dates for completion of actions needed for each activity. Anticipated Costs Please identify anticipated costs (if any) for actions needed for each activity.

Thank you! Patricia Cumiskey-Czeto patricia. cumiskey@fns. usda. gov