Jeanne Blankenship, MS RD CLE Vice President, Policy and Advocacy American Dietetic Association

1. The Role of Public Health Nutrition in the new Maternal, Childhood, and Early Childhood Home Visiting Program Jeanne Blankenship, MS RD CLE Vice President, Policy and Advocacy American Dietetic Association

2. Objectives • What the home visiting models must include • Examples of home visiting models • Examples of different roles for public health nutritionists • How to advocate for the RD/public health nutritionist in your state plan • Questions and discussion

3. Secretary Sebelius “Through the Maternal, Infant, and Early Childhood Home Visiting Program, nurses, social workers, or other professionals meet with at-risk families in their homes, evaluate the families’ circumstances, and connect families to the kinds of help that can make a real difference in a child’s health, development, and ability to learn - such as health care, developmental services for children, early education, parenting skills, child abuse prevention, and nutrition education or assistance. ”

4. 5 model programs identified • Nurse Family Partnerships • Parents as Teachers • Healthy Families America • Parent Child Home Program • Home Instruction for Parents of Preschool Youngsters

5. Major Themes: 5 Home Visiting Models Target Population: • Low income • High risk • Currently pregnant or recently gave birth • First time mothers • Low education level

6. Major Themes: 5 Home Visiting Models • Service Onset: • Pregnancy • 2 weeks old – 4 years • Service Duration: • Until child is enrolled in school (preschool/kindergarten) • 2 – 2 ½ years

7. Major Themes: 5 Home Visiting Models • Visit Intensity (30-60 minute sessions): • Once a week • Monthly, bimonthly • Combination of home visits and group meetings • “Program year” considered a minimum of 23 visits

8. Major Themes: 5 Home Visiting Models • Goals and Services Provided: • Role playing (curriculum) • Developmental screenings • Link to resources • Interaction (verbal, sensory, motor, connection between child and parent) • Encompass 4 out of 6 benchmarks

9. Major Themes: 5 Home Visiting Models • Staff Training: • Train-the-trainer approach • 4 – 5 day trainings with wrap-around and follow-up trainings

10. Major Themes: 5 Home Visiting Models • Evaluation: • Program plan which includes evaluation plan, site development guide • Annual Program Report submitted with recertification materials • Evaluate family outcomes, track progress • Online database (Home Visitor responsible to impute data) • Site visits, technical and training support

11. The Role of the RD • The evidence for inclusion of nutrition services • USPSTF “B” recommendation • Setting versus content • Abstract and summaries have been posted on the website

12. The Role of the RD • Program development and oversight • Defining protocols for delivery of care • Provision of MNT and/or nutrition education • High risk indicators • Training of professionals and paraprofessionals • Development of nutrition education tools • Data analysis and interpretation • Ensures validity and reliability of data

13. RD’s Role in Positive Maternal/Child Health Outcomes Nutrition Assessment: • Prenatal nutrition, reduce LBW risk • Infant and Pediatric Nutrition • School readiness (anemia, attention) • Physical growth, biochemical indices 1-6 • Feeding practices with infants and toddlers (feeding and elimination) 3, 7, 8 • Symptom/disease management 3, 9 • Resources, source of referrals 10, 11

14. RD’s Role with Direct Patient Contact in the Home • Tube feeding of child • Special healthcare needs • Failure to thrive • Not showing up for prenatal appointments in clinic • Gestational diabetes; blood glucose monitoring • Excessive weight gain or weight loss • Preeclampsia • Pantry evaluation- especially for newly arrived immigrant families with young children • All other maternal, infant, and child entities on a therapeutic diet; knowledge of disease-specific nutrient requirements • Breastfeeding support • Preterm birth

15. Direct Referral Indicators • Risk indicators defined in other programs • Increased acuity • Aggressive intervention opportunity • Direct involvement with primary care • Cross linkage with other programs when stable

16. Example: Anemia • Pregnant women – Ferritin 6, Hgb 9 during first TM • Review • History and diagnoses • Labs • Diet (iron intake, inhibitors) • Supplementation • Competitive nutrients • Compliance • Medications • Clinical signs and symptoms of deficiency • Hair, skin, nails, pagophagia, fatigue, decreased memory , concentration, tacchycardia, etc

17. Example: Anemia • Food resources and quality • Assessment and Diagnosis • Altered nutrition related labs r/t xx as evidenced by xxx. • Intervention • Supplementation • Behavioral – increased adherence • Nutrition education – high iron foods • Monitoring and Evaluation • Lab improvement • Decreased clinical symptoms • Servings of high iron foods • Increased adherence

18. Training and Education • Examples of training programs are available for several key areas

19. Nutrition Education Materials • For use by • professionals • Paraprofessionals • RDs • Integration of materials available by other collaborative programs

20. Accurate data analysis: 24 hour dietary recalls, food diaries, BMI charting, biochemical indices, review of household food inventories • Accurate interpretations and recommendations • Classification of available foods • Use of food resources and programs • Portion sizes • Data for 24 hour recalls greatly influenced by method of collection • Visual and verbal cues • Food environment • Candy and other snack foods • Pantry and Refrigerator • Physical environment • Resource allocation (ie TV’s in each room) • Lack of furniture and appliances

21. Example of Effective Program • Colorado’s Prenatal Plus Program25 • Participants: high-risk childbearing and postpartum women on Medicaid • Goals: reduce incidence LBW/improve nutritional health • 5 nutrition contacts in the home with RD: assist in developing and maintaining healthy lifestyle & self-efficacy to appropriately use existing resources

22. Example of Effective Program • n= 3567 Medicaid-eligible women • 80% of those who received full package of services (All R.D., mental health, and care coordinator) decreased some or all risk factors for LBW vs. 68% who didn’t receive full package • 6.7% LBW infants compared to 17.2% when inadequate weight gain was resolved

23. How to Advocate for RD Involvement in Your State • Acknowledge scope of services and resources • Identify cost-effective strategies to address gaps in services • Highlight evidence of home visits and of nutrition intervention with similar populations • Take advantage of 25% of funding for new programs • Work with local dietetic association in each state • ADA will provide a contact list for each state • ADA can assist with outcome measure development for RDs

24. Questions and Discussion

25. Jeanne Blankenship, MS RDVice President, Policy Initiatives and Advocacyjblankenship@eatright.org 202-775-8507 Ext. 6004