WIC Local Agency Applications and State Agency Evaluations - SLT

U.S. Department of Agriculture, Food and Nutrition Service (FNS) OMB Control Number: 0584-0591

Special Supplemental Nutrition Program for Women, Infants and Children (WIC) Expiration date: xx/xx/20xx

Attachment I Gold Evaluation Instructions

Gold Award

This document works in coordination with the online evaluation site in PartnerWeb. You have completed the Step 1 online by accessing this document. Click the “SA-Reviewers” tab to return to the State Agency evaluation website.

To begin Step 2 locate the section “Applications and Evaluation Worksheets”. Click the + next to your State to expand the view of all applications submitted within your State.

The applications are located in the “name” column. Click the local Agency name to open the .zip file or right click on the drop down menu icon, select “download a copy” from the menu. Save the application packet for easy access and unzip its contents. Instructions on how to unzip can be found in the WIC Breastfeeding Awards Frequently Asked Questions. The .zip file contains the completed application forms and all of the documentation submitted by the local agency.

To score an application, you will need to open an evaluation worksheet. Scroll down to the “Applications and Evaluation Worksheets” section. To the far left, you will see a column named “edit”. This is where the evaluation worksheets are located. Each application has its own evaluation worksheet.

The Gold Award application has a total of 30 questions, each worth 1 point.

When evaluating the application, if a Gold Award question is checked “No”, or if the documentation attached for a Gold Award question does not meet the criteria listed - STOP.

The applicant is not eligible for a Gold Award. Complete the following sections of the evaluation worksheet: “State-Status”, “SA-Recommendation for Gold” (choose “No Recommendation”), “Justification for No Recommendation”, and “State Evaluator Name”. Then click save.

Prescreening
Before an applicant can apply for an award they must verify their local agency peer counseling program has been in place for at least one year, and that their peer counseling program meets all core components of WIC Breastfeeding Model for Peer Counseling listed below.

Verify the prescreening question has been answered “Yes” and the applicant meets the requirements to continue. If verified, select “Yes” on the evaluation worksheet.

If the prescreening question is checked “No” - STOP. The applicant is not eligible for a Gold Award. Complete the following sections: “State-Status”, “SA-Recommendation for Gold” (choose “No Recommendation”), “State Evaluator Name”, and “Justification for No Recommendation”. Then click save.

WIC BREASTFEEDING MODEL FOR PEER COUNSELING

REQUIRED PROGRAM COMPONENTS

Program Management

• The local agency has a designated peer counseling program manager or coordinator.

• The local agency has standardized breastfeeding peer counseling program policies in place as part of its nutrition education plan.

• Local agency staff is trained on supporting the peer counseling program.

• The local agency has a WIC designated breastfeeding expert for referrals outside of the peer counselor’s scope of practice.

• The local agency has established community partnerships to enhance the effectiveness of its peer counseling program, e.g., hospitals, health care providers, home visiting programs, etc.

Peer Counselor Staffing

• The local agency has defined job parameters and position descriptions for peer counselors.

• Peer counselors are recruited and hired from the target population served by WIC.

• Peer counselors are paraprofessionals, i.e., are not licensed or credentialed as healthcare, nutrition, or lactation consultant professionals.

• Peer counselors are available to WIC clients outside usual clinic hours and outside the WIC clinic environment.

• Peer counselors receive adequate compensation and reimbursement for expenses.

Peer Counselor Training and Support

• Peer counselors are trained using FNS-developed curricula

• Ongoing continuing education is provided to peer counselors through regularly scheduled staff meetings and other educational opportunities.

• Peer counselors have timely access to breastfeeding coordinators and other lactation experts for assistance with problems outside their scope of practice.

• Peer counselors are offered opportunities to meet regularly with other peer counselors.

Documentation
Some questions in the application require additional documents. There are two types of document requests, a 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 the 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. The preferred source of documentation are locally developed policies, procedures, MOU’s, etc.; however, State and Federal documentation are acceptable. These documents are submitted to demonstrate how the agency meets the criteria of a specific question as noted in the instructions for that question. The attached documentation should indicate the page number(s) where the specific information can be found in response to the question.

Entire policy and procedure manuals are not acceptable forms of documentation.

Prior Gold Awardees
Prior Gold Awardee Applicants were instructed to leave Questions 1-30 unanswered and complete the Cover Page, Prescreening Questions, and Application Checklist (page 6 of the Gold Application).

Verify the year the Local agency received an Award by going to: https://www.fns.usda.gov/wic/loving-support-award-excellence-awardees. If the local agency received a Gold award in the past 4 years, proceed to page 12 of the Gold Evaluation Instructions (this document).

Next, go to Page 12 of this document to finish the Gold Evaluation for Prior Awardees.

New Gold Applicants

Continue to the next page to start the Gold Evaluation at Question 1a on the online Evaluation Worksheet.

Note: To save and finish the evaluation later, scroll to the section “State-Status” and select “not finished”. Then click “Save” to save your work. You can now exit the website.

PEER COUNSELING

Question 1. (1 point)

Does your local agency conduct an annual needs assessment that identifies each of the following:

1. the top 2 priorities for your target audience;

2. where gaps exist in breastfeeding services and resources within your target audience that can be addressed through peer counseling; and

3. where improvements in your program are needed?

Successful peer counseling programs occur through careful planning to address identified needs. Information gathered during needs assessment helps local agencies identify strengths as well as areas of breastfeeding services that can be modified or improved through peer counseling. A needs assessment helps local agencies set priorities to maximize the effectiveness of peer counselors. Without a needs assessment, planning is just a best guess.

Acceptable documentation:
The narrative should describe the top 2 priorities determined by the needs assessment, how your local agency is addressing those needs through peer counseling, and where improvements in your program can be made. Narrative not to exceed 500 words.

Verify the applicant response. Select Yes or No based on applicant’s response. Verify if the documentation meets all of the requirements listed above.

Check Yes or No based on your documentation review.

Question 2. (1 point)

Do you have a protocol that describes how peer counselors address a mother’s concerns and needs outside of usual clinic hours, including how peer counselors make after-hour referrals?

The key to success in peer counseling is being available to mothers when they need it most. Breastfeeding problems often occur outside usual business hours, and peer counselors provide important support beyond usual WIC services. The WIC Breastfeeding Model for Peer Counseling requires that peer counselors be available to mothers outside of usual clinic hours, i.e., evenings and weekends. Exemplary peer counseling programs develop strategies to ensure that peer counselors are available to address a mother’s concerns and needs in a timely manner (via phone, hotline, or face-to-face) and that referral and follow-up are provided.

Examples of Acceptable Supportive Documentation: Policies and procedures or protocols, Training materials, Position descriptions / Roles and Responsibilities

Documentation attached includes all of the following:

• Your agency’s written procedure of the PC after hours referral process

• Describes how peer counselors address a mother’s concerns and needs outside usual clinic hours.

• Describes at least one of the following: telephone calls, hotline, or face-to-face.

• Describes how after-hour referrals are made to the peer counselor or Designated Breastfeeding Expert.

Verify the applicant response. Check Yes or No based on applicant’s response. Verify if the documentation meets all of the requirements listed above.

Check Yes or No based on your documentation review.

Question 3. (1 point)

Do you have opportunities for peer counselors to observe and shadow experienced lactation experts and more experienced peer counselors?

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

Question 4. (1 point)

Do you routinely monitor the work of peer counselors through spot checks, chart reviews or contact forms?

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

Question 5. (1 point)

Do you routinely observe newly trained peer counselors during contacts with mothers to provide guidance and affirmation?

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

Question 6. (1 point)

Do you schedule routine meetings to discuss case studies with your peer counselors?

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

Question 7. (1 point)

Do you have adequate supervision of peer counselors by staff with advanced lactation training?

Adequate supervision is defined as having at least a .25 full time employee (FTE) supervisor for every 5 peer counselors. Supervisory responsibilities include mentoring, monitoring, follow-up, and spot checks.

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

Question 8. (1 point)

Do you have a written defined scope of practice for a peer counselor that describes the peer counselor’s role to provide basic breastfeeding education and support to WIC mothers?

Peer counselors supplement, but do not replace, the work of CPAs and lactation professionals. A peer counselor’s scope of practice is to provide basic information and support to new moms, and make referrals when they experience problems beyond their training. The peer counselors’ scope of practice summarizes typical situations for which peer counselors can provide services, as well as the types of information they can provide.

Examples of acceptable supportive documentation: Written Scope of Practice, Position description/ Roles and Responsibilities, Policy and Procedures, Training Manual, Referral protocol for peer counselors/list of referral topics.

Documentation attached includes all of the following:

• Scope of practice is attached.

• Scope of practice limits the peer counselor’s responsibilities to providing basic information and support to new moms, and making referrals when peer counselors experience problems beyond their training.

Verify the applicant response. Check Yes or No based on applicant’s response. Verify if the documentation meets all of the requirements listed above.

Check Yes or No based on your documentation review.

Question 9. (1 point)

Do you have a process/protocol in place that describes when the peer counselors should “yield” and refer breastfeeding concerns and conditions that are outside the scope of practice of the peer counselor to a Designated Breastfeeding Expert (DBE) AND how the DBE refers the participant back to the peer counselor?

A peer counselor’s scope of practice is limited to providing basic information and support to new moms about normal breastfeeding, and “yield” (make referrals) when they experience problems beyond their training. WIC mothers who need support outside the peer counselors scope of practice should be referred to the Designated Breastfeeding Expert to provide timely and appropriate follow-up.

Documentation attached includes all of the following:

• Process describes how peer counselors refer moms to a Designated Breastfeeding Expert as part of normal clinic operations, during both the prenatal and postpartum periods

• How the DBE follows up with the peer counselor to share the participants' care plan.

Examples of acceptable supportive documentation:
Policy and Procedures, Training Manual, Referral protocol for peer counselors/list of referral topics.

Verify the applicant response. Check Yes or No based on applicant’s response. Verify if the documentation meets all of the requirements listed above. Check Yes or No based on your documentation review.

Question 10. (1 point)

Do you have procedures in place for WIC staff to refer WIC participants to peer counselors as part of your usual WIC certification, assessment and nutrition education process?

Peer counselors should receive ongoing referrals from local clinic staff as part of the usual WIC certification, assessment and nutrition education process. This includes creating ways to connect mothers who need breastfeeding support and to peer counselors.

Acceptable narrative or documentation attached includes all of the following:

• Process describes how WIC mothers are referred to peer counselors during the prenatal period.

• Process describes how WIC mothers are referred to peer counselors during the postpartum period.

• Narrative not to exceed 500 words

Examples of acceptable supportive documentation: Policy and procedures, Staff training materials, Referral protocol for peer counselors

Verify the applicant response. Check Yes or No based on applicant’s response. Verify if the documentation meets all of the requirements listed above.

Check Yes or No based on your documentation review.

Question 11. (1 point)

Do peer counselors routinely contact mothers, at a minimum, monthly during pregnancy and weekly 2 weeks prior to a woman’s expected delivery date?

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

Question 12. (1 point)

Do peer counselors routinely contact mothers, at a minimum, every 2-3 days in the first week after delivery AND within 24 hours if the mother reports problems with breastfeeding AND weekly throughout the rest of the first month?

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

Question 13. (1 point)

Do peer counselors routinely contact mothers after a woman’s first month postpartum, at a minimum, monthly, as long as things are going well?

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

Question 14. (1 point)

Do peer counselors routinely contact mothers after a woman’s first month postpartum, at a minimum, 1-2 weeks before the mother plans to return to work or school AND 1-2 days after she returns to work or school?

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

PARTNERSHIP

Question 15. (1 point)

Was the partnership developed to solve an existing problem or gap in breastfeeding support services?

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

Question 16. (1 point)

Are the resources each partner brings to the partnership clearly delineated?

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

Question 17. (1 point)

Does the partnership have goals that have been agreed upon by the members of the partnership?

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

Question 18. (1 point)

Are the roles and responsibilities clearly identified and understood by all members of the partnership?

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

Question 19. (1 point)

Does the partnership have activities that have been agreed upon by the members of the partnership?

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

Question 20. (1 point)

Has the partnership produced results that provide an ongoing benefit?

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

OTHER CRITERIA

Question 21. (1 point)

Do you have a supportive clinic environment for breastfeeding that visibly endorses breastfeeding as the preferred method of infant feeding?

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

Question 22. (1 point)

Do you have policies that support a clinic environment where participants feel comfortable breastfeeding?

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

Question 23. (1 point)

Do you have policies and procedures that encourage and support exclusive breastfeeding among prenatal and postpartum WIC participants?

Examples of acceptable supportive documentation: Policies and procedures, Staff training materials

Documentation attached includes all of the following:

• Encouragement is provided to mothers to exclusively breastfeed for 6 months and continue to breastfeed for at least the first year of life and thereafter as long as desired

• Staff provide anticipatory guidance on what mothers should expect and strategies for breastfeeding success

• Efforts are made to contact mothers who intend to breastfeed as soon after delivery as possible to provide timely breastfeeding support during the early postpartum period

• No routine issuance of infant formula in the first month

• Minimal infant formula amounts are provided only when medically necessary or requested.

• If formula is provided it is based on the infants assessed needs

• Education is provided to mothers on the effects of early formula supplementation of breastfeeding

• Staff promotes the fully breastfed food package, making participants aware of the greater quantity and variety of food included in this package

• Prohibits the promotion of infant formula

Verify the applicant response. Check Yes or No based on applicant’s response. Verify if the documentation meets all of the requirements listed above.

Check Yes or No based on your documentation review.

Question 24. (1 point)

Do you ensure that all staff are trained to support the goal of exclusive breastfeeding with WIC participants using the FNS-developed competency-based breastfeeding curriculum?

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

Question 25. (1 point)

Do you have policies and procedures that require staff to assess, and individually tailor food packages to all breastfeeding dyads when infant formula is requested?

Examples of acceptable supportive documentation: Policies and procedures, Staff training materials

Documentation attached includes all of the following:

• Indicates individually tailored food packages to all breastfeeding dyads based on a complete breastfeeding assessment

• Routine issuance of infant formula to breastfeeding infants is prohibited.

Verify the applicant response. Check Yes or No based on applicant’s response. Verify if the documentation meets all of the requirements listed above.

Check Yes or No based on your documentation review.

Question 26. (1 point)

Does new clinic staff orientation include breastfeeding policies and procedures especially related to supporting exclusive breastfeeding?

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

Question 27. (1 point)

Do you provide ongoing training to all WIC staff using the FNS-developed competency-based breastfeeding curriculum, or similar State-developed training based on FNS-developed competency-based breastfeeding curriculum?

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

Question 28. (1 point)

Do you have ongoing continuing education on breastfeeding for all staff through regularly scheduled staff trainings and other educational opportunities?

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

Question 29. (1 point)

Do you have policies and procedures that require support for breastfeeding mothers, especially during the early postpartum period, that assist mothers in continuing exclusive breastfeeding for as long as possible?

WIC staff has an important role in encouraging mothers to breastfeed exclusively for 6 months and providing the support necessary for them to feel confident in their ability to do so.

Examples of acceptable supportive documentation: Policies and procedures, Staff training materials

Documentation attached must include all of the following:

• Early assessment and follow-up for the breastfeeding dyad soon after delivery

• Anticipatory guidance on what to expect (e.g., growth spurts, hunger and satiety cues, signs that baby is getting enough, etc.)

• Staff provide practical strategies to address potential obstacles

• Education and support available to breastfeeding mothers who are returning to work, or school, and mothers who are breastfeeding multiple infants.

• Referral system is in place ensuring the mother is connected to the appropriate WIC staff person

• Appropriate referrals to community resources that provide breastfeeding support services

Verify the applicant response. Check Yes or No based on applicant’s response. Verify if the documentation meets all of the requirements listed above.

Question 30. (1 point)

Do you have policies that ensure all participant breastfeeding concerns are addressed according to established time frames?

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

Note: To save and finish the evaluation later, scroll to the section “State-Status” and select “not finished”. Then scroll to the bottom of the evaluation worksheet and click save to save your work. You can now exit the website.

All Gold Applicants

Saving the worksheet will bring you to the Evaluations page where you will verify the score.

If the GScore equals 30 points, go back to the evaluation worksheet by clicking the back arrow to return to the evaluation worksheet of the local agency you are evaluating. Scroll down and complete sections: “State-Status”, “SA-Recommendation for Gold” and “State Evaluator Name”. Then click save.

If the GScore is less than 30 points – STOP. An application with a GScore of less than 30 points is not eligible for a Gold award. Please click the back arrow to return to the evaluation worksheet to double check your work. Ensure all questions are answered and double check your evaluation responses. If you have verified that your evaluation is correct and the GScore remains under 30 points, complete the following sections: “State-Status”, “SA-Recommendation for Gold” (choose “No Recommendation”), “State Evaluator Name” ” and “Justification for No Recommendation”. Then click Save.

Prior Gold Awardees

After confirming the Local Agency received an Award by visiting the FNS website, go to the Evaluation worksheet in PartnerWeb.

Select the checkbox for “Prior Awardee” if the LA has received a Gold Award in the past 4 years. By selecting the checkbox, it automatically populates their Gscore to 30, the number of points in a Gold Award. Gold Q1a through Gold Q30 should be left blank.

Select the year the LA received an award using the Prior Award Year drop down menu.

Scroll down to the bottom of the page and click save. You may start the evaluation for the Local Agency’s Premiere/Elite Application.

New Gold Applicants

When questions 1 through 30 are complete, scroll down to the bottom of the evaluation worksheet page and click save.

When you click save, the website will take you to the “Evaluations” page. This page reflects scores for finished evaluations. The scoring for the 30 Gold award questions can be found in the column titled “GScore.

Find the GScore for the name of the local agency you just evaluated. A Gold award application must have a Gscore of 30 to be eligible for the Gold award.

Congratulations and thank you for completing the Gold Award evaluation!

If the applicant has not applied for a higher level award, you have finished the evaluation.

If the applicant has applied for a higher level award, click the “State Agency Review” link on the left menu and continue on with Step 3.

In accordance to Section 231 of the Healthy, Hunger-Free Kids Act of 2010 (HHFKA) (Public Law 111–296), this information is being collected to assist the Food and Nutrition Service in implementing a program to recognize exemplary breastfeeding support practices at WIC local agencies and clinics. This is a voluntary collection, but failure to provide the requested information in full will prevent applicants from being considered for recognition. FNS will use the information to improve the delivery and tailoring of WIC services and increase satisfaction of both staff and participants. This collection requests only minimal personally identifiable information (email address) which will not be used routinely to retrieve records under the Privacy Act of 1974. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-0591. The time required to complete this information collection is estimated to average 1.2 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. 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 Service, Office of Policy Support, 1320 Braddock Place, 5th floor, Alexandria, VA 22314 ATTN: PRA (0584-0591). Do not return the completed form to this address.