WIC State Agency Evaluations

U.S. Department of Agriculture, Food and Nutrition Service (FNS),

OMB Control Number: 0584-0591 Expiration date: xx/xx/xxxx

Special Supplemental Nutrition Program for Women, Infants and Children (WIC)

There are 3 Award Levels: Gold, Gold Premiere, and Gold Elite.

Gold Award Questions: In order to be eligible for any level of award applicants must fulfill the criteria for all the Gold Award questions.

The Gold Award application has a total of 30 questions. The Gold Award questions, worth 1 point each, are criteria identified as best practices, which demonstrate excellence in breastfeeding practices and support, and relate to practices beyond the core components of Loving Support^© Model.

Gold Premiere and Gold Elite Award Questions: The Gold Premiere and Gold Elite application has 16 questions. The Gold Premiere and Gold Elite questions are each worth 2 or 3 points. The questions for these higher level awards are criteria identified as exemplary practices that are deserving of the highest recognition of excellence. An applicant may fill out only the Gold award application and choose not to complete the combined application for the Gold Premiere and Gold Elite awards.

Performance data: Applicant does not submit performance data. The performance data considered is the rate of exclusively breastfed infants reported by local WIC agencies and published annually on the FNS website. Performance data is considered for the Gold Premiere and Gold Elite Awards. Evaluators will use the most recent data posted on the FNS website.

GOLD AWARD

• All Gold Award application questions (30 points) must be answered “yes” to be eligible.

• Seven of the 30 questions require you to add additional documentation to support your response.

• Performance data is not considered.

GOLD PREMIERE AWARD

• Applicants must meet the criteria for the Gold Award (30 points) and

• Additional 18 points from the Gold Premiere and Gold Elite application questions such that

additional points are awarded in each of the 3 sections:

• a minimum of 11 points from the Peer Counseling section,

• a minimum of 4 points from the Partnership section,

• a minimum of 5 points from the Other Criteria section.

Public reporting burden for this collection of information is estimated to average 2 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Research and Analysis, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-0591). Do not return the completed form to this address.

• and Performance data of either:

  • the rate of exclusively breastfed infants is at least 15 % or higher in the

previous year of published data, and the most recently published year of data shows an increase over the previous year OR

• the rate of exclusively breastfed infants is at least 25 % or higher in the most recently published year of data

GOLD ELITE AWARD (highest level)

• Applicants must meet the criteria for the Gold Award (30 points) and

• ALL of the Gold Premiere and Gold Elite application questions are answered “yes” (37 points) and

• Performance data that demonstrates 40% or higher of the infants are exclusively breastfed

Documentation

Some questions in this application require additional documents. There are two types of document requests, a unique narrative and/or supportive documentation.

Narrative refers to a document with explanatory statements that have been written exclusively for the purpose of this application. The narrative should describe how your agency meets the criteria of a specific question as noted in the instructions. Narratives are not to exceed 500 words.

Supportive documentation refers to documents that already exist. An example may be, but is not limited to, a policy/ procedure from the state manual that your local agency follows or a locally developed MOU. You may submit these documents to demonstrate your agency meets the criteria of a specific question as noted in the instructions for that question. When attaching documentation, indicate the page number(s) where the specific information can be found in response to the question.

Each document you attach to the application must have a unique name/title entered into the application. The title should reflect the content of the document. If you submit the same document for more than one question, enter the same document title again, and indicate the page number(s) that corresponds to the specific question.

Do not submit entire policy and procedure manuals

Download and save the application to your computer before entering ANY information. Work completed on the application prior to being downloaded and saved will be lost.

In order to be eligible to apply for a Gold Premiere or Gold Elite award, you must have applied and met the criteria for a Gold Award for this application period.

PEER COUNSELING

Question 1. (2 points)

Do you have established guidelines for how many hours of observation/shadowing are required as part of

peer counseling training/continuing education?

Check the appropriate box (Yes/No) in response to the question.

Question 2. (2 points)

Do you have an IBCLC on staff or do you contract with an IBCLC to serve as a referral source for peer

counselors?

Check the appropriate box (Yes/No) in response to the question.

Loving Support Award of Excellence

Gold Premiere/Elite Award Application Instructions - 2

Question 3. (2 points)

Do you have a referral process in place between hospitals and the WIC Program to facilitate peer counselor

follow-up for WIC mothers shortly after discharge?

Check the appropriate box (Yes/No) in response to the question.

Question 4. (2 points)

Do you have a system that electronically documents and tracks peer counseling referrals and contacts?

Check the appropriate box (Yes/No) in response to the question.

Question 5. (3 points)

Do you have policies and procedures for home visits as part of your peer counseling program?

The supportive documentation must include a process for making home visits and procedures which address travel, safety and confidentiality.

Examples of acceptable supportive documentation: Policy and procedures, Staff training materials Check the appropriate box (Yes/No) in response to the question.

Attach the supportive documentation; fill in the document title and indicate the page numbers where the information that answers this question can be found.

Question 6. (3 points)

Do you have policies and procedures for hospital visits as part of your peer counseling program?

The supportive documentation must include:

• a process for making hospital visits,

• describe the relationship with hospital,

• address confidentiality, supervision, liability, and

• clarify the scope of practice and the role of the peer counselor.

Examples of acceptable supportive documentation: Policy and procedures, Staff training materials, Written agreements/contracts with hospitals

Check the appropriate box (Yes/No) in response to the question.

Attach supportive documentation. Fill in the document title and indicate the page number(s)

where the information that answers this question can be found.

Question 7. (2 points)

Do you have a recognition program in place to acknowledge peer counselor accomplishments?

Check the appropriate box (Yes/No) in response to the question.

Question 8. (2 points)

Do you include career path structures for upward mobility of peer counselors?

Check the appropriate box (Yes/No) in response to the question.

Loving Support Award of Excellence

Gold Premiere/Elite Award Evaluation Instructions - 3

Question 9. (3 points)

Do you have policies and procedures for peer counselors to communicate via social media technologies, e.g.,

Facebook, text messaging, Twitter, Skype or PalTalk?

Social media is the use of web-based and mobile technologies to turn communication into interactive dialogue and build a sense of community among users. Social media represents a fundamental shift in the way people communicate in recent years. Research shows that WIC’s target population of low-income mothers use social media extensively as a means to communicate.

The narrative and/or the supportive documentation should indicate how the local agency is using social media technologies with peer counselors. It should indicate how they allow peer counselors to use social media and/or electronic communication for at least one of the following

reasons: training, communicating with mothers, communicating with supervisors, communicating with other peer counselors, communicating with referral sources.

Documentation must include information on at least one of the following that allows peer counselors opportunities to communicate via social media technologies or other electronic media: Facebook, text messaging, Twitter, Skype, PalTalk, other electronic media.

Policies and procedures must address confidentiality and privacy, proper etiquette, and follows local agency , health department or State policies for use of social media. It also must indicate supervisory monitoring of communication.

Examples of acceptable supportive documentation: Policies and procedures, Screen shots, Peer counselor documentation log

Check the appropriate box (Yes/No) in response to the question.

Please describe in a narrative how your peer counseling program is implementing social media technologies and attach supportive documentation. Narrative not to exceed 500 words.

Attach narrative and supportive documentation that indicate existing policies and procedures for peer counselors to communicate via social media technologies.

Fill in all document titles for both the narrative and supportive documentation and indicate the page number(s) that corresponds to each document.

Question 10. (2 points)

Do you ensure that peer counselors are solely dedicated to peer counselor support for breastfeeding, or, if you allow peer counselors to work in dual-role positions, do you ensure that those positions do not compromise the intent and purpose of the BFPC program?

Peer counseling programs function best when peer counselors are allowed to solely dedicate their time to peer counselor support for breastfeeding. State agencies that allow peer counselors to work in dual-role positions should consider whether such positions meet the definition of a peer counselor in the Loving Support Model, including being available to mothers outside of regular WIC hours and outside of the clinic.

Verify the applicant response. Check Yes or No based on applicant’s response.

PARTNERSHIP

Although the WIC Program can provide many of the services breastfeeding women in the community need to educate and support breastfeeding families, WIC cannot do it alone. Various community entities such as public health programs, coalitions, schools and businesses influence a mother’s ability to initiate and continue breastfeeding. Establishing meaningful partnerships among these relevant community organization/resources is critical to a mother’s breastfeeding success.

Partnership is defined as a sustainable ongoing voluntary collaborative agreement between two or more parties based on mutually agreed upon objectives and a shared vision, generally within a formal structure. The partners agree to work together to achieve a common goal, undertake specific tasks, and share risks, responsibilities, resources, competencies and benefits in order to provide breastfeeding support throughout the continuum of care.

Question 11. (2 points)

Does the partnership have a written agreement or a Memorandum of Understanding?

Examples of acceptable supportive documentation: Memorandum of Understanding, Written agreement

Documentation attached includes all of the following:

• Description of the role of each partner

• Description of the goals and outcomes.

• Description of the types of activities planned.

Check the appropriate box (Yes/No) in response to the question.

Attach supportive documentation. Fill in the document title and indicate the page number(s) where the information that answers this question can be found.

Question 12. (2 points)

Have new policies or procedures been developed because of the partnership?

Describe the new procedures developed as a result of the partnership in a brief narrative or attach supportive documentation that indicates policies or procedures have been developed as a result of the partnership. Narrative not to exceed 500 words.

Acceptable documentation: Narrative or Supportive Documentation. Examples of acceptable supportive documentation: Policy and procedures

Check the appropriate box (Yes/No) in response to the question.

Attach narrative or supportive documentation. Fill in the document title and indicate the page number(s) where the information that answers this question can be found if using supportive documentation.

Question 13. (2 points)

Does the partnership have a plan for sustainability?

Check the appropriate box (Yes/No) in response to the question.

OTHER CRITERIA

SUPPORT OF EXCLUSIVE BREASTFEEDING

Exclusive breastfeeding, feeding only breastmilk and nothing else except drops or syrups consisting

of vitamins, minerals or medications, is recognized as the optimal feeding practice for

infants. It confers the most health benefits for babies and mothers and contributes to a longer duration of breastfeeding. Although women are aware that breastfeeding is the best source of nutrition for their infants, many are uncertain about what to expect and how to actually carry it out (Surgeon General’s Call to Action). WIC staff have an important role in educating mothers about exclusive breastfeeding, encouraging new mothers to breastfeed exclusively for 6 months and providing the support necessary for them to feel confident in their ability to do so. The local agency must have policies and procedures in place that ensure benefits and services (support and assistance) are provided which support exclusive breastfeeding.

Staff provide realistic strategies to mothers on how to feed their baby only breast milk and provide appropriate support and/or referrals as needed.

Question 14. (2 points)

Do you have a supportive clinic environment that implements breastfeeding-friendly workplace polices for

WIC staff?

The supportive documentation should indicate workplace polices that are breastfeeding-friendly for WIC staff and should include adequate time and an appropriate place to express milk and a program such as a “Bring your baby to work” program for staff who are breastfeeding.

Examples of acceptable supportive documentation: Policies and procedures Check the appropriate box (Yes/No) in response to the question.

Attach the supportive documentation; fill in the document title and indicate the page number(s) where the information that answers this question can be found.

Question 15. (2 points)

Do you partner with stakeholders such as the American Hospital Association to support the Baby-Friendly

Hospital Initiative in your community?

Check the appropriate box (Yes/No) in response to the question.

STAFF TRAINING

Breastfeeding promotion and support has always been a key part of the WIC Program’s mission to

improve the health of its target population. However, as the focus on breastfeeding has increased, it has become essential for all staff to have knowledge and skills needed to encourage and support breastfeeding mothers. All local agency staff who interact with WIC participants should be trained to have a level of competence in breastfeeding promotion and support relevant to their tasks and responsibilities.

OTHER CRITERIA

Question 16. (3 points)

Do you provide funding or work hours for education and training for staff to pursue certifications and

advanced credentials in breastfeeding? (e.g. CLC, CLE, IBCLC)

The supportive documentation should indicate funding or staff working hours are provided for education and training for staff in pursuit of certifications and advanced credentials in breastfeeding.

Examples of acceptable supportive documentation: Policy and procedures, Nutrition education plan.

Check the appropriate box (Yes/No) in response to the question.

Attach the supportive documentation; fill in the document title and indicate the page number(s)

where the information that answers this question can be found.

PRENATAL/EARLY POSTPARTUM SUPPORT

The third trimester of pregnancy and the early postpartum period are critical times in encouraging

and supporting mothers who express intention to breastfeed and those who have initiated breastfeeding. These time periods are important to helping mothers establish successful breastfeeding relationships with their babies. During the prenatal period, a mother should be educated about breastfeeding and her ability to produce milk. She should be assured that her baby will get enough milk from her to thrive. During the first few weeks after delivery, mothers need assurance they are successful and support should be provided if problems arise.

Question 17. (3 points)

Do you provide around the clock assistance to assist mothers working through their breastfeeding

problems?

Please describe in a narrative how you provide assistance to breastfeeding mothers around the clock. Narrative not to exceed 500 words.

Check the appropriate box (Yes/No) in response to the question. Attach the narrative. Fill in the narrative title.

Please complete the Application Checklist on Page 5 and the Application Verification Form on page 6 of the Application.

Thank you for applying for the WIC Loving Support Award of Excellence

For more information, visit the FNS WIC Website: http://www.fns.usda.gov/wic/breastfeeding-promotion-and-support-wic