Revised Medical Documentation Form for Special Needs Food Packages

1. Revision of Medical Documentation Form for Special Needs Food Packages March 9, 2017 Presenting To WIC Partners Alan Brown, MS, RDN

3. What should the name of the new prescription form be? • Responses: • Like the new name (Formula & Food Prescription) = 4 • Want to call it Formula & Food Request = 4 • Action taken: • Name Changed to Formula & Food Request.

4. Should sections (1,2,10, and 11) be requirements for a completed prescription (new AZ state policy would indicate that the form would be incomplete without this information and a new Rx form would be required)? • Responses: • All required = 2 • None required = 4 • Some required = 2 • Action taken • Changed top line simply to “PLEASE COMPLETE ALL SECTIONS”. Further discussion is necessary to determine state policy on required sections.

5. Should Baby / Boy Girl be an acceptable thing for the prescriptive authority to write for the patient’s name? • Responses: • Yes = 4 • No = 1 • Yes, but keep the statement on the form = 2 • Other idea = 1 • Action taken • Removed the statement (Baby Boy/Girl is “NOT acceptable) from the form.

6. Should Section 3 (Caregiver’s Name) be included as an optional section on this form? • Responses: • Yes = 1 • No = 7 • Action taken • Removed the “Caregiver’s Name” section from the form.

7. Should the “FOR WIC USE ONLY” box be included as an optional section on this form? • Responses: • Yes = 1 • No = 5 • Other idea = 2 • Action taken • Removed the “FOR WIC USE ONLY” boxfrom the form.

8. What do you think of the “Other Diagnosis” section requiring the prescriptive authority to write in a ICD 10 Name and Code if they write in another Diagnosis (Dx)? • Responses: • Love it = 1 • Don’t love it = 5 • Other idea = 4 • 2 groups asked for removal of healthy patient, underweight, obese Dx to be removed. One group asked for addition of “oral sensory dx” to be added • Action taken • Removed the “ICD 10 Name and Code”, and changed it to “Other Diagnosis”. • Healthy Patient, Underweight, Overweight, and Obese diagnoses removed from the Dx section. • Added “Developmental Disorder” to Dx section (closest Dx to oral sensory dx found”

9. What do you think about the “Milk Alternatives” section? • Responses: • Love it = 1 • Don’t love it = 6 • Other idea = 2 • Action taken • Changed “Milk Alternatives” section to more closely resemble old form

10. Other changes made based on other comments from WIC partners • Removed phrase “Check only 1 box” from “Type of Formula Requested Section” • Added phrase “Check this box to NOT GIVE ANY WIC Foods to this patient” in WIC Foods section • Changed the comments box to read: “Comments / Healthcare Provider's Stamp:”

11. Other changes made based on other comments from WIC partners • Bolded Titles, and web address • Removed the ICD 10 codes next to each of the diagnoses • Moved the “Today’s Date” field into the “Healthcare Provider’s Information” section • Created more “white space”

12. Other changes made based on other comments from ADHS staff • Moved Dx for 19 kcal/oz formulas to end of list of diagnoses • Changed phrase “Please check this box to refer to Registered Dietitian / Nutritionist” to “Please check this box to deferto Registered Dietitian / Nutritionist” and moved check boxes to the left of this and the following phrase, “Check this box to NOT GIVE ANY WIC Foods to this patient”.

14. Next Steps • Any other necessary content changes will be made to the form, which will then be submitted to the AZ state office communications team for professional formatting and creation of fillable PDF document.

15. Questions

16. THANK YOU! Alan Brown, MS, RDN | WIC Training Manager Alan.brown@azdhs.gov | 602-542-2814 azhealth.gov @azdhs facebook.com/azdhs azwic.gov

19. USDA Requirements • The name of the authorized WIC formula prescribed (Section 5) • Amount of formula needed per day (Section 7) • The authorized supplemental food(s) appropriate for the qualifying condition(s) and their prescribed amounts (Section 9) • Length of time the prescribed WIC formula and/or supplemental food is required by the participant (Section 8)

20. USDA Requirements (continued) • The qualifying condition(s) for issuance of the authorized supplemental food(s) requiring medical documentation, as described in paragraphs (e)(1) through (e)(7) of this section (Section 6) • Signature (Section 12), date (Section 4) and contact information (Sections13) (or name, date and contact information), if the initial medical documentation was received by telephone and the signed document is forthcoming, of the health care professional licensed by the State to write prescriptions in accordance with State laws.

21. AZ State Requirements • All of the federal regulations plus: • Type of formula (i.e., ready-to-feed, powder, or concentrate) (Section 5)

22. Other Proposed Required Sections • Section 1 (Patient’s Name) and Section 2 (Patient’s Date of Birth) give us specific information that allows for the clear determination of the intended recipient of the prescription. It has also been proposed that ("Baby Boy/Girl" is NOT acceptable) for section 1. • Section 10 (Healthcare Provider's Title) easily lets healthcare provider’s know who may complete the Rx, and it also lets WIC staff know that the form was completed by an approved prescriptive authority. • Section 11 (Healthcare Provider’s Name) is only a federal requirement if the medical documentation was received verbally, however, this is very useful information in the event that the prescriptive authority need to be contacted, since the “Healthcare Provider’s Signature” is rarely legible enough to determine the name of the person who completed the prescription.

23. Other Proposed Optional Sections • Section 3 (Caregiver’s Name) has been proposed as an optional section since it allows WIC employees another way to search for the client for whom the prescription has been completed for. • The “FOR WIC USE ONLY” section has been proposed as an optional section since it allows WIC employees another way to search for the client for whom the prescription has been completed for by providing a space for employees to write in the “Client ID Number”. It also lists check boxes for “Approved”, “Not Approved”, and “Follow-Up” for local agencies to use as a method for categorizing prescriptions after review.

24. Useful USDA Information • The State agency has the discretion to require medical documentation for any contract brand infant formula other than the primary contract infant formula (Similac Advance and Gerber Good Start Soy).

25. Food Package I (Infants birth through 5 months) Any contract brand infant formula that does not meet the requirements in Table 4 of paragraph (e)(12) of this section (Similac Sensitive, Similac Total Comfort, Similac for Spit-Up) may be issued in this food package only with medical documentation of the qualifying condition. A health care professional licensed by the State to write prescriptions must make a medical determination and provide medical documentation that indicates the need for the infant formula. For situations that do not require the use of an exempt infant formula, such determinations include, but are not limited to, documented formula intolerance, food allergy or inappropriate growth pattern. Medical documentation must meet the requirements described in paragraph (d) of this section.

26. Food Package III(Participants with Qualifying Conditions) This food package is reserved for issuance to women, infants and child participants who have a documented qualifying condition that requires the use of a WIC formula (infant formula, exempt infant formula or WIC-eligible nutritional) because the use of conventional foods is precluded, restricted, or inadequate to address their special nutritional needs. Medical documentation must meet the requirements described in paragraph (d) of this section. Participants who are eligible to receive this food package must have one or more qualifying conditions, as determined by a health care professional licensed to write medical prescriptions under State law. The qualifying conditions include but are not limited to premature birth, low birth weight, failure to thrive, inborn errors of metabolism and metabolic disorders, gastrointestinal disorders, malabsorption syndromes, immune system disorders, severe food allergies that require an elemental formula, and life threatening disorders, diseases and medical conditions that impair ingestion, digestion, absorption or the utilization of nutrients that could adversely affect the participant’s nutrition status. This food package may not be issued solely for the purpose of enhancing nutrient intake or managing body weight. (ii) Non-authorized issuance of Food Package III. This food package is not authorized for: (A) Infants whose only condition is: (1) A diagnosed formula intolerance or food allergy to lactose, sucrose, milk protein or soy protein that does not require the use of an exempt infant formula; or (2) A non-specific formula or food intolerance.

27. Food Package III (Continued)(Authorized categories of supplemental foods) The supplemental foods authorized in this food package require medical documentation for issuance and include WIC formula (infant formula, exempt infant formula, and WIC- eligible nutritionals), infant cereal, infant foods, milk, cheese, eggs, canned fish, fresh fruits and vegetables, breakfast cereal, whole wheat/whole grain bread, juice, legumes and/or peanut butter.

28. USDA Final Rule Regarding Supplemental Foods Due to the nature of the health conditions of participants who are issued supplemental foods in Food Package III, close medical supervision is essential for each participant’s dietary management. FNS considers it appropriate that the responsibility for this close medical supervision remain with the participant’s health care provider. Medical documentation requirements for specific supplemental foods that do not usually require a prescription were established to ensure that the participant’s healthcare professional has determined that the supplemental foods are not medically contraindicated by the participant’s condition. Therefore, FNS retains the technical requirements for medical documentation for supplemental foods in Food Package III as written in the interim rule. However, FNS recognizes that WIC registered dietitians and/or qualified nutritionists play an important role in the continuum of care of medically fragile WIC participants. Therefore, FNS would support State agency policy that allows health care providers to refer to the WIC registered dietitian and/or qualified nutritionist for identifying appropriate supplemental foods (excluding WIC formula) and their prescribed amounts, as well as the length of time the supplemental foods are required by the participant. This arrangement would be supported only in situations where the health care provider has indicated on the medical documentation form that the provider acknowledges referral to the WIC registered dietitian and/or qualified nutritionist for such determinations. This gives the health care provider medical oversight while allowing the WIC registered dietitian and/or qualified nutritionist to determine the appropriate issuance of WIC foods to participants with qualifying conditions in Food Package III.