LARD Jan 10 Meeting Minutes - Public Health

Local Agency Registered Dietitians Meeting Minutes
January 26, 2010
29 Participants on the call:
Name County Name County
Susan Gerig Baker Nora Miller Blackwell Salud
Mari Brooker Clackamas Cheryl Alto State
Julie Aalbers Clackamas Susan Greathouse State
Janet Harris Deschutes Beth Lanham State
Sherri Tobin Deschutes Kim McGee State
Elizabeth Binkley Douglas Vernita Reyna State
Judy Harvey Jackson Nancy Ludwig Tillamook
Jackie Lucas Lane Sarah Fife Washington
Amanda Claxton Lincoln Stephanie Kohler Washington
Lindsay Grosvenor Malheur Tiare Sanna Washington
Dale Erickson Marion Jan Apland Curtis Washington
Ai-Lan Whitson Marion Angie Treadwell Umatilla Morrow
Sandra Farley Marion
Suzanne Bruels Multnomah
Heidi Suess Multnomah
Joy McNeal Multnomah
Mary Kay Diloreto Multnomah
Meeting Topics:
• Announcements
• Manager’s update
• Formula updates
• Providence medical formula update
• Medical documentation update
• LARD survey
• Guest speaker, Vernita Reyna: Growth charts & TWIST
Handouts sent prior to the call:
• Agenda
• Providence HME procedures (7/09)
• Providence HME order form (7/09)
• LARD survey results
Announcements:
• New staff/new positions:
o Sarah Fife, Washington County, has accepted position at CDRC
feeding clinic.
o Washington County has a bilingual nutritionist position, full time.
o Lindsey Grosvenor has agreed to contract with Harney County, 1 full
day quarterly.
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• Conferences:
o Next meeting will be May 25, 2010 1-4pm.
o CaCoon webinar April 14 th 8:30-12:30pm. Topics to include medical
formulas, Medicaid 101, cleft lip & palate nipples/adaptive equipment
and understanding FTT from an ethical perspective.
o Deschutes county will be hosting an ADA teleseminar: Motivational
Interviewing for Health Behavior Change Tuesday, February 23, 2010
11:00 a.m. to 12:30 p.m. (Pacific) for more information go to
http://www.eatright.org/pd-motivationalinterviewing/ or contact
Janet Harris.
Manager’s update (Susan Greathouse):
o Food package comments due February 1 st .
o National WIC association board meeting update:
March leadership conference will include a one day breastfeeding
summit. Tiare Sanna and Sue Woodbury will be attending.
o Meredith company:
California/New York WIC is working with Meredith publishing
company (Better Homes & Garden) to create a series of six topics
with the next one, Bringing Home Baby, scheduled to be done in 2
weeks, Meredith supplies a pdf in English/Spanish and we can
choose to print. There will be no formula advertising.
Susan will be working on a committee to create the 4 th publication in
the series, Feeding Your Baby. More updates to come.
o NSA funding- additional funding will be sent to local agencies. In
addition, there could be additional funding for training. This is an
opportunity for RDs in WIC for additional training and/or additional
resources for local agencies. Submit ideas to Cheryl. Timeline: prior
to September, 2010.
o National WIC Association meeting will be held in Portland May 2011
at the Hilton downtown. This is Oregon’s first time hosting the
national meeting and it will be our next statewide meeting. Will be
looking for local agency input regarding themes, speakers, ideas.
Questions for Susan:
1. Budget freeze (Tiare):
Freezing of domestic spending-freezing will be at current appropriations
levels so no changes, no cuts anticipated.
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2. Peer counseling funding (Mary Kay)
Kelly Sibley and Julie Reeder will be contacting local agencies with peer
counseling programs in early February to obtain input on evidenced based,
best practice models.
Misc:
• The Oregon WIC advisory board has been reinstated and meets
quarterly. Joy McNeal represents OWCA at the board meetings and
is willing to share any relevant information to the LARD group.
• Information on becoming certified as an IBCLC was sent by Bonnie
Ranno. Goal is to have an IBCLC at each agency.
Formula updates:
o Nestle:
Nestle Good Start will become Gerber Good Start in February 2010.
Oregon WIC will only carry the Good Start Gentle Plus. We do not
have any plans to adopt Good Start Soy. The only soy infant formula
Oregon WIC provides is Similac Isomil.
o Mead Johnson:
Nutramigen: Seeing a reduction of the number of participants on
both types. Group reported that participants are returning to the clinic
and asking for the smaller can. The market is driving the transition.
Action: State will continue to run reports for Nutramigen 16 oz can
and the goal will be to transition to the Nutramigen Enflora.
o Nutricia:
Per report from Nutricia rep: A product replacement was initiated
12/1/09 for Neocate infant. The original Neocate contained 5% MCT.
The new "Renovated" Neocate has 33% MCT and DHA/ARA.
o Abbott:
Pediasure: A memo was sent out November 30th stating that the full
formula package would need to be Pediasure Enteral, available only
from Providence. Pediasure Enteral is the only form that Providence
offers. Pediasure Enteral has less sucrose, more corn maltodextrincan
help prevent gastrointestinal problems that can sometimes result
from the large volume of formula. Pediasure Enteral comes in vanilla
flavor only.
o TWIST growth chart reviews for participants receiving Pediasure: When
running statewide report on usage of full formula packages of Pediasure
approximately 50% of the growth charts reviewed had a BMI greater
than 50th% and in some cases the growth velocity was increasing
significantly.
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Group discussion:
-The new food packages allow for more flexibility to adjust foods/formula
amounts to meet the individual needs of the participant.
-Medical documentation is not a prescription, it is a request/sharing of
information and allows RDs to approve/not approve a formula depending
on the underlying diagnosis/growth data.
-Contacting the HCP allows the RD to negotiate/inform the HCP of the
participant’s health status, growth pattern and coordinate care.
-State NCs/Cheryl is available to support local agencies as needed
regarding medical documentation, formula usage.
Action: Recommend looking at growth rates of participants who are
receiving a full food package and a full formula package for Pediasure to
ensure appropriate weight gain.
Providence medical formula:
Discussed Providence shipping errors. Thanks to the hard work at the local
agencies to correct this situation. State staff met with Providence Home
Medical Equipment administration to discuss the problem and identify ways
to correct errors on formula orders. Providence presented data on errors
made by local agencies with the largest number of errors existing with use
of the incorrect form, incomplete data provided (missing voucher numbers,
phone numbers, and incomplete address or missing formula density –i.e.
BKE 1.0 vs. 1.5)
Group discussion:
-Separation of duties: ensure that person assigning food package is not
the same person printing vouchers.
-Remind Providence to provide notification on back order status.
-State WIC needs to be notified when a decision needs to be made
regarding adjustments on vouchers.
Action:
• Update forms for Providence Home Medical Equipment (correct
forms are dated 7/09).
• Delete any old Providence forms.
• Type information onto request forms (vs handwriting).
• Write specifics on vouchers when needed (i.e. fiber, flavor)
• Cheryl will send PHME formulary, Providence data on local agency
orders.
• Cheryl will remind Providence to notify local agencies of back order
status.
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Medical Formula brochure:
The State is creating a brochure for vendors with formula graphics to
ensure that the correct formula is sold.
Group Discussion:
-consider formatting that would allow for lamination of the material.
-Many agencies show participants images of formulas on-line.
-Reminder that it is against the WHO code to display formula information.
Materials are to be kept out of view and shown to families as needed.
-In addition to the brochure, formula descriptions on vouchers are being
updated to ensure consistency and reduce errors at the grocery/pharmacy.
Medical Documentation Workgroup:
Shared comments, suggestions from local agencies regarding medical
documentation form changes.
Recommendations from LARD members:
o Clarify length of authorization: 12 calendar months vs. 12 month age of
child
o Supplemental foods section-include wording to indicate food package
guidance when infant turns 7 months of age.
o Add family phone number in the staff section on the form.
o Add expiration date to the bottom of the form.
o Consideration: How are agencies filing the forms-by the month of
expiration, month received, by name? Identify the pros & cons of the
filing methods.
o What is stated in TWIST and on the med doc are not in the same
sequence. Prefer that the med doc form not change.
o Make small changes, not major changes as HCPs are just now
becoming familiar with the changes
Group Discussion:
• Soy beverage-lactose intolerance vs. severe lactose intolerance:
o Lactose intolerance is not a qualifying condition for soy
beverage
o Start with lactose free milk but if nothing else is working, what is
the next step?
o Some HCPs have been adamant that soy beverage be issued
for constipation.
o Others mark vegan and then issue milk and eggs.
o Local agencies are needing clarification on RD’s role for
accepting verbal order for clarification of diagnosis for issuance
of soy beverage.
• Documentation needed when taking verbal orders:
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o No specific USDA guidance but the State recommends
including your name, date and who you spoke to, and to
document in TWIST.
Action:
• The supplemental food section of the med doc in TWIST will be
changed to be consistent with the med doc form.
• Cheryl will seek guidance regarding role of RD in obtaining
clarification of diagnosis by verbal order.
• The original medical documentation workgroup will be reconvened. If
interested in assisting, contact Cheryl.
LARD survey results:
Group Discussion: Children with Special Health Care Needs (CSCHN)
• Prevalence of CSHCN has increased while at the same time:
o Availability of public health nurses has decreased.
o RD training opportunities for CSCHN have decreased.
• Scope of practice: mixed opinions whether WIC is set up to provide
nutrition services for CSCHN.
• Recent survey reflects lack of confidence regarding RD skills/training
to provide services to CSHCN.
• System issues: WIC is not funded, set up to provide high risk nutrition
services. At the same time, there is a lack of community RD services
for CSHCN. Result: high risk participants fall through the cracks
and/or end up in feeding clinics, hospitalized (tertiary care settings).
• Need to consider payment of services, development of partnerships
to allow WIC RDs (who are trained and interested) to see participants
outside of WIC.
Action:
Development of RD training plan workgroup within LARD, let Cheryl know if
you are interested in assisting.
Referrals for High Risk Participants
• The following counties are willing to share high risk referral protocols
and they will be sent out in email: Washington, Marion, Salud,
Umatilla-Morrow
• TWIST:
• Can provide a high risk report (CP800R) client
process/reports/nutrition education/high risk participant listing
• There is no connection between assignment of risk level and the
risk associated with scheduling preferences (on the family
summary screen).
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Action:
• Cheryl will forward referral protocols received from local agencies.
• Kim McGee will send out TWIST specifics (risk assignments,
scheduling, etc.) in a future newsletter. Tiare will send screen
shots to Kim to include.
OVERVIEW OF TWIST GRAPHING FUNCTIONALITY
(Presentation provided by Vernita Reyna)
Source:
• Graphing data loaded from CDC in 2004 and populated into TWIST
base tables for weight, length/height, and BMI for children
• Prenatal weight gain grids loaded from IOM data.
• TWIST code developed to read data points and reconstruct graphs.
• A comparison of current CDC graphs and TWIST graphs show
matching curves. Note: No preterm graphing data is available at this
time from CDC.
Functionality:
• Percentiles are calculated from data entered by the user on the
medical data screen in TWIST.
• Risk assignment is based on percentile calculations from this data.
Note: if data is adjusted, risks that have been inappropriately
assigned need to be removed manually.
• Graphing uses measurements and age of client to create graph. To
determine age of client, TWIST rounds to full months.
Example: if infant’s birth date is the first of the month, any
measurements inputted up until the 15 th will round to the age at
the first of the month. Measurements inputted from the 16 th to
the end of the month will round the age to the end of the month.
Rounding of the age can shift the point by half a month which is
especially visible when reviewing charts for children under three
years of age. This variation may result in graphing that does not
match the percentiles displayed on the medical data screen
however, general trends are still clear.
• Plot points are enlarged to be visible against the percentile lines.
Large points can make viewing of specific percentiles difficult for
young infants.
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Future considerations:
• TWIST could be reprogrammed to calculate and plot exact age with a
significant amount of effort.
• Other software graphing could be accessed to provide additional
options.
• Updated prenatal weight gain grids information from IOM will be
available in TWIST with the implementation of RISC Revision 10 in
August 2010.
Requests from LARD:
• Make gestational age more specific on the medical data screen.
• Add color to the BMI graph to denote normal (green) and excess
(red) BMI levels to aid in explanation of the graph and enhance
parents understanding of the chart.
• Identify availability of Down’s syndrome growth charts to be added to
TWIST.
Addendum message from Kim McGee:
At the last LARD meeting, a question was raised regarding what to put in
the height and weight fields when no values are available. "Filling the fields
with 9's" is the standard to indicate a null value. There had been some
problems where 9's were entered and then incorrect information displayed
on the growth grid. The main reason for that is that there were not enough
nines entered (e.g. putting in 2 nines when have to put in 3). A call came in
asking what to do with the ounces and the 1/8 inches, since the system
won't allow 9's. If you leave the ounces and the fractions as zero, but fill the
pounds and inches with 9's and you will not get a plot on the grid.
Next meeting: Tuesday, May 25, 2010 1-4pm
Minutes respectively submitted by Cheryl Alto
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