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www.itcaonline.com
Webinar
High Risk Client Referral
to a
Registered Dietitian (RD)
May 1, 2, and 5, 2014
Presented by Laura Munson, R.D.
Nutrition Services Coordinator
State Plan Part II
Policy and Procedures
• Purpose
• Certain clients identified as high-risk have
counseling needs beyond the scope of the
CNW. These clients benefit from more indepth counseling provided by an R.D.
State Plan Part II
Policy and Procedures
• Policy
• All clients meeting the minimum high-risk
criteria outlined below will be seen by a RD
within 60 days of being identified as high risk
Pregnancy
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Underweight (101)
Low Maternal Weight Gain (131)
Weight Loss During Pregnancy (132)
Hyperemesis Gravidarum (301)
Gestational diabetes (302)
History of Premature Delivery (311)
History of Low Birthweight (312)
Pregnancy at a Young Age (331)
Multifetal Gestation (335)
Fetal Growth Restriction (336)
Pregnant Woman Breastfeeding (338)
Nutrient Deficiency Diseases (341)
Gastro-Intestinal Disorders (342)
Diabetes Mellitus (343)
Thyroid Disorders (344)
Hypertension and Prehypertension (345)
Pregnancy (continued)
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Renal Disease (346)
Cancer (347)
CNS Disorders (348)
Genetic and Congenital Conditions (349)
Inborn Errors of Metabolism (351)
Infectious Disease (352)
Celiac Disease (354)
Eating Disorders (358)
Recent Surgery, Trauma, Burns (359)
Other Medical Conditions (360)
Depression (361)
Developmental Delays (362)
Postpartum
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Underweight (101)
Nutrient Deficiency Diseases (341)
Gastro-Intestinal Disorders (342)
Diabetes Mellitus (343)
Thyroid Disorders (344)
Hypertension and Prehypertension (345)
Renal Disease (346)
Cancer (347)
CNS Disorders (348)
Genetic and Congenital Conditions (349)
Inborn Errors of Metabolism (351)
Infectious Disease (352)
Celiac Disease (354)
Eating Disorders (358)
Recent Surgery, Trauma, Burns (359)
Other Medical Conditions (360)
Depression (361)
Developmental Delays (362)
Breastfeeding
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Underweight (101)
Pregnancy at a Young Age (331)
Multifetal Gestation (335)
Nutrient Deficiency Diseases (341)
Gastro-Intestinal Disorders (342)
Diabetes Mellitus (343)
Thyroid Disorders (344)
Hypertension and Prehypertension (345)
Renal Disease (346)
Cancer (347)
CNS Disorders (348)
Genetic and Congenital C
Breastfeeding (continued)
• Genetic and Congenital Conditions (349)
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Inborn Errors of Metabolism (351)
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Infectious Disease (352)
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Celiac Disease (354)
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Eating Disorders (358)
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Recent Surgery, Trauma, Burns (359)
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Other Medical Conditions (360)
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Depression (361)
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Developmental Delays (362)
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Breastfeeding Complications (602)
Infants
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Underweight (103)
At Risk of Becoming Underweight (103)
Short Stature (121)
Failure to Thrive (134)
Inadequate Growth (135)
Low Birth Weight (141)
Very Low Birth Weight (141)
Prematurity (142)
Small for Gestational Age (151)
Nutrient Deficiency Diseases (341)
Gastro-Intestinal Disorders (342)
Diabetes Mellitus (343)
Thyroid Disorders (344)
Infant (continued)
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Cancer (347)
CNS Disorders (348)
Genetic and Congenital Conditions (349)
Pyloric Stenosis (350)
Inborn Errors of Metabolism (351)
Infectious Disease (352)
Celiac Disease (354)
Recent Surgery, Trauma, Burns (359)
Other Medical Conditions (360)
Developmental Delays (362)
Fetal Alcohol Syndrome (382)
Breastfeeding Complications (603)
Children
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Underweight (103)
At Risk of Becoming Underweight (103)
Failure to thrive (134)
Inadequate Growth (135)
Low Birth Weight (141)
Very Low Birth Weight (141)
Prematurity (142)
Small for Gestational Age (151)
Nutrient Deficiency Diseases (341)
Gastro-Intestinal Disorders (342)
Children (continued)
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Diabetes Mellitus (343)
Thyroid Disorders (344)
Renal Disease (346)
Cancer (347)
CNS Disorders (348)
Genetic and Congenital Conditions (349)
Inborn Errors of Metabolism (351)
Infectious Disease (352)
Celiac Disease (354)
Recent Surgery, Trauma, Burns (359)
Other Medical Conditions (360)
Depression (361)
Developmental Delays (362)
Fetal Alcohol Syndrome (382)
All Clients identified as high-risk will be seen by an RD within:
A. 1 month
B. 30 days
C. 60 days
of being identified
All Clients identified as high-risk will
be seen by an RD within 60 days of
being identified
State Plan Part II
Policy and Procedure Manual
• High-Risk Referrals
• Each local agency will develop written
procedures for CNWs to refer high-risk clients
to the RD. This plan should be evaluated at
least two times per year to ensure that CNWs
are following the appropriate procedures and
high-risk clients are appropriately referred in a
timely manner.
State Plan Part II
Policy and Procedures
• Non-WIC Registered Dietitian
• Tribal, Indian Health Service or other R.D.’s
meeting the guidelines above may provide the
high risk counseling to WIC clients if written
documentation in the form of a S.O.A.P. note
or NCP is provided to WIC and entered into
the STARS.
State Plan Part II
Policy and Procedures
• Special Cases
• In certain cases, the client may no longer
require in-depth nutrition counseling provided
by the RD. (For example, a premature infant
who is now at the 50th%ile.) In these cases,
the RD must review the client’s file within 60
days of certification and provide a nutrition
care plan for the CNW to follow with specific
criteria for referral back to the R.D.
Documentation
• The referral to RD is documented in STARS
by scheduling an appointment with RD.
• The RD’s visit is documented in Nutrition
Education (date can be changed)
• Referral to an outside RD is documented in
Referrals
• The SOAP note is documented in Notes
S.O.A.P
SOAP Note
Subjective: Client reported relevant
information.
Objective: Information like age, what was
done like measurements completed, child not
present, observations (bottle propped)
Assessment: Judgement regarding first two,
needs lactose free diet plan, growth wnl, or
any trends noted.
Plan: Food pkg change, NE: briefly what was
discussed. Client’s nutr goal (s).
Follow up plan: 1. Ex: CNW will recheck wt
next month (visit). 2. EX: Refer back to RD if
w/l @ 10%ile or below.
ITCA WIC Accepted Abbreviations
Word
Adjusted
Blood Sugar Content (g/dl)
Breastfeeding
Calories
Carbohydrates
Complaining of
Cups
Diabetes
Abbreviation
adj
Bs
bf
Kcal
Carbs
c/o
c
DM
Diagnosis
Due to
Failure to Thrive
Fetal Alcohol Effects
Fetal Alcohol Syndrome
Follow uo
Gestational Diabetes
Height
Hemoglobin
High Blood Pressure
History
Length
Liquid
Low birth weight
Measurements
Nausea and vomiting
Number of times per
Ounces
Percentile
Pounds
Powdered
Pregnancy
Prescription
Primary Care Provider
Protein
Special Formula Authroization
Tablespoons
Weight
Within normal limits
dx
dt
FTT
FAE
FAS
f/u
GDM
ht
Hgb
HBP
hx
l or ln
liq
lbw
m/s
n/v
X/(day, week, etc.)
oz.
%ile
lb or #
pwd
pg
rx
pcp
P
sfa
Tbsp
wt
wnl
Registered Dietitian?
Who or What is a
Registered Dietitian?
The Academy of Nutrition and Dietetics
(formerly known as the American Dietetics
Association)
stated definition
A Registered Dietitian…
is a food and nutrition expert who
has met the minimum academic
and professional requirements to
qualify for the credential R.D.
Qualifications of a Registered
Dietitian
Earned a bachelor’s degree with course work
approved by the Academy of Nutrition and
Dietetics Accreditation Council for Education in
Nutrition and Dietetics (ACEND).
Qualifications of a Registered
Dietitian
• Completed an accredited, supervised practice
program at a health-care facility, community
agency or foodservice corporation.
• Passed a national examination administered by
the Commission on Dietetic Registration.
• Completes continuing professional educational
requirements to maintain registration.
Those are the basics
Now we will look at more specifics
Assessment of Risk
Factors
Automatic vs
Selected
Guidelines for Assigning Risks
• Policy
• Each applicant will be assigned all of the
nutritional risk(s) that apply according to the
definition in the Nutritional Risk Factors
Manual at all certification and midcertification
visits. Some nutritional risks will be
automatically determined by the STARS
system.
Automatically Assigned HR
• From Measurements- Underweight, low
maternal weight gain, short stature, low birth
weight
• From Age- pregnancy at a young age
• From Gestational age- prematurity
High Risk Factors
• Must open Risk screen after inputting data
• HR on top bar in Red
• Risk factors that are high risk appear in pink
A. My doctor told me
I have high blood
pressure?
B. I feel like I my
blood pressure
is too high.
Self Reporting
• Self reporting of Medical Diagnosis
• Self-reporting of a diagnosis by a medical professional
should not be confused with self-diagnosis, where a
person simply claims to have or to have had a medical
condition without any reference to professional
diagnosis. A self-reported medical diagnosis “My
doctor says that I have/my son or daughter has…”
Should prompt the CNW to validate the presence of the
condition by asking more pointed questions related to
that diagnosis.
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Self Reporting VS Self-Diagnosis
• Self-reporting for “History of…”conditions
should be treated in the same manner as selfreporting for current conditions requiring a
physicians diagnosis, i.e., the applicant may
report to the CNW that s/he was diagnosed by
a physician with a given condition at some
point in the past. As with current conditions,
self-diagnosis of a past condition should never
be confused with self-reporting.
Professional Discretion
Occasionally you may feel that a client should be seen
by the nutritionist even though they do not have a risk
that is designated as high risk. You can indicate this by
checking the Professional Discretion High Risk.
Check box on the Risk
Screen in STARS. You also need to write a short note
indicating why you feel the client needs to be seen by
the nutritionist. This will help the R.D. provide the
best care.
What is the role of the CNW in High
Risk Referral?
Assess risk correctly including good
measurements.
Check risk status by opening risk screen
Schedule HR appointment with RD
Read notes written about RD visit
Follow plan written by the RD for client care
What is the role of the WIC LA
Director?
• To determine if all HR clients are being seen
by RD within the 60 days
• To evaluated if system for referral is effective
• To determine if the RD care plan is observed
and completed by CNW’s.
What is the Administrative
Assistant’s role in HR
• Check for HR status when scheduling a family
• Reschedule with RD when clients with HR/RD
cancel if possible
• Read notes to see if RD has already seen and
signed-off on HR client or still needs to be
seen by RD
Questions?