Gold Application - Preview

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All questions require a yes or no response.  Additional instructions are noted where appropriate.

Peer Counseling

QUESTION 1

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

(a) the 2 top priorities for your target audience;

(b) where gaps exist in breastfeeding services and resources within your local agency and the community that can be addressed through peer counseling; and

(c) where improvements in your program are needed?

Attach narrative. Fill in narrative title.

Instructions

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.

QUESTION 2

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?

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

Instructions

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.

QUESTION 3

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

QUESTION 4

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

QUESTION 5

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

QUESTION 6

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

QUESTION 7

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.

Instructions

Supervisory responsibilities include mentoring, monitoring, follow-up, and spot checks. Check the appropriate box (Yes/No) in response to the question.

QUESTION 8

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

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

Instructions

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.

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 9

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?

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

Instructions

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 DBE 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.

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 10

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

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.

Instructions

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

Attach the 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.

QUESTION 11

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

QUESTION 12

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 rest of first month?

QUESTION 13

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

QUESTION 14

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?

Partnership

Although the WIC Program can provide many of the services breastfeeding women in the community need, WIC cannot do it alone. Various community entities such as public health programs, coalitions, schools and employers, impact 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.

A partnership is defined as a sustainable ongoing voluntary collaborative agreement between two or more parties based on mutually agreed 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 responsibilities, resources, competencies and benefits in order to provide breastfeeding support throughout the continuum of care.

QUESTION 15

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

QUESTION 16

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

QUESTION 17

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

QUESTION 18

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

QUESTION 19

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

QUESTION 20

Has the partnership produced results that provide an ongoing benefit?

Other Criteria

CLINIC ENVIRONMENT

A breastfeeding friendly clinic environment is educational and promotional materials portray breastfeeding as the best source of infant nutrition and does not display materials that feature infant formula. Positive breastfeeding posters and brochures, comfortable areas for women to breastfeed, and signs that say “Breastfeeding Welcome Here” are all ways a clinic can promote and support breastfeeding through the environment. The manner in which staff communicate and interact with participants should always be supportive of breastfeeding.

Policies should support a clinic environment where participants feel comfortable breastfeeding by providing a space in the clinic for participants to breastfeed and a private space for participants to express their milk.

QUESTION 21

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

QUESTION 22

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

QUESTION 23

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

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

Instructions

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 infant's 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

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

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 24

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?

QUESTION 25

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?

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

Instructions

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.

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 26

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

QUESTION 27

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 breastfeeding curriculum?

QUESTION 28

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

QUESTION 29

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?

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

Instructions

The supportive documentation 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 mother’s breastfeeding multiples.

• 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

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

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 30

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

 

OMB 0584-0591 EXP Date: 11/30/2023