1. Accommodating Special Diets: The Team Approach
CSNA Summer Conference
Wednesday, June 12, 2018
1 p.m. – 2 p.m.

2. Colorado Department of Education Vision
Together We Can
Colorado Department of Education Vision
All students in Colorado will become educated and productive citizens capable of succeeding in society, the workforce, and life.
CDE Office of School Nutrition Mission
The Office of School Nutrition is committed to ensuring all school-aged children have equal access to healthy meals by supporting, training, and connecting Colorado’s child nutrition community.

3. Objectives
Understand special meal accommodations regulations
Identify best practices in working parents and school nurses in accommodating special dietary needs

4. Introduction to Special Meal Accommodations
Kristi Rolfsen, MS, RD
Nutrition Programs Senior Consultant
CDE Office of School Nutrition

5. Background ADA Amendments Act of 2008 USDA Memo SP 59-2016
Simplified the question of whether a child has a disability
USDA Memo SP
Definition of a disability expanded
Almost all medical needs require an accommodation
Medical statements are not required if request falls within meal pattern
Utilization of team approach
The ADA Amendments Act of 2008 expanded the definition of a disability, simplifying the question of whether a child has a disability. The changes in accommodating special dietary needs began when the USDA released memo SP last September. This memo aligned special meal accommodations with the ADA Amendments Act of 2008 by broadening the definition of a disability. LEAs and SFAs no longer need to spend time determining if a medical need meets the definition of a disability as most physical and mental impairments will constitute a disability.

6. Examples of Disabilities
Food allergies
Food intolerances
Autism and/or other mental impairments
Phenylketonuria
Diabetes
Celiac Disease
Obesity
“Categories and conditions” in the ADA is not all inclusive.
According to the definition of disability in the ADA, a food allergy does not need to be life-threatening or cause anaphylaxis in order to be considered a disability.
If a food intolerance substantially limits a major life activity, including digestive impairments, it is considered a disability regardless of whether or not it causes severe distress.
Autism is considered a disability as it may disrupt the activity of eating. For example, some autistic children will only eat certain foods due to ritualistic behavior patterns. Any physical or mental impairment that prevents a child from consuming a meal is considered a disability.
If obesity substantially limits a major life activity, it can be considered a major life activity.
If a child’s medical condition is not listed under “categories and conditions” in the ADA, a SFA cannot refuse an accommodation as these are not all inclusive.

7. SFAs must have a policy in place to accommodate special dietary needs
Meal Modifications
SFAs must have a policy in place to accommodate special dietary needs
Reimbursement based on child’s eligibility
Additional costs may be paid from the nonprofit food service account
There are numerous dietary requests that could occur due to a child’s disability. It is recommended that SFAs have a policy in place for accommodating special dietary needs, including the process for requesting meal modifications and the person responsible for coordinating modifications. This information is required to be available to the public and is recommended the information is posted on the school district’s website.
SFAs will be reimbursed based on the child’s eligibility for free, reduced price, or paid meals. Modifications for disabilities that can be made within the meal pattern will be reimbursed regardless of whether a medical statement is obtained. If a modification request falls outside of the meal pattern, reimbursement is provided when supported by a medical statement signed by a licensed healthcare professional. Any additional costs in providing modifications may be paid using the nonprofit food service account. If funds from the nonprofit food service account are not available, the general fund or special education fund, if specified in a child’s IEP, may be used. The SFA should work with the school health team in determining the funds.
The SFA will not receive additional reimbursement for special meal accommodations.

8. Meal Modifications within the Meal Pattern
Do not require a medical statement
Strongly encouraged to have a Dietary Preference Form or other documentation
Should note actions to accommodate the child’s disability
Safeguards the child
SFAs may choose to require a medical statement for modifications within the meal pattern
Modifications for a disability that can be made within the meal pattern can be made without a medical statement on file. This eases the burden of obtaining a medical statement for the parent or legal guardian. SFAs will be reimbursed for these meal modifications.
In Colorado, a Dietary Preference Form is available for disability accommodations within the meal pattern. SFAs have the option to utilize this form when they do not require a medical statement. The form outlines the information that is necessary to safely accommodate a child. This form is not required, however some form of documentation is strongly recommended. This safeguards the child and ensures a safe meal is provided. It also protects the staff members preparing the meals by ensuring they have adequate information to feel confident in preparing the modified meal. Enough information should be obtained to where a substitute staff could prepare the meal with confidence. The SFA should never assume how to handle a meal accommodation.
SFAs may choose to require a medical statement for all disabilities, including those within the meal pattern. The decision to do so is left at the local level and should be established in the policy. We’ll look at examples of the forms later in this presentation.

9. Meal Modifications Outside the Meal Pattern
Medical statement signed by a licensed healthcare professional is required
Medical statement must include:
Information on the child’s disability and dietary restrictions
Explanation of dietary modifications
Food(s) or beverage(s) to be omitted and substituted
If information is written into IEP or 504 plan, a medical statement is not required
There are times in which a disability may require an accommodation that cannot be made within the meal pattern. For these physical or mental impairments, a medical statement signed by a state licensed healthcare professional is required for reimbursement. In Colorado, a medical statement can be signed by a licensed physician (MD or DO), advanced practice nurse (APN) with prescriptive authority (RXN), or a physician assistant (PA).
A medical statement must include information about the child’s disability sufficient enough to understand how the impairment restricts the child’s diet, an explanation of what must be done for accommodations, the food(s) and/or beverage(s) to be omitted, and the recommended substitutes to safely accommodate the child. In some cases, more information may be required, such as specific caloric modifications. SFAs cannot require the term “disability” or “disabled” in the explanation of the child’s impairment, although it is acceptable. Information should be clear enough to provide a safe meal modification. If any of the required information is missing, SFAs should call the parent or healthcare professional who signed the statement for additional information. It is acceptable to call for clarification if the SFA does not feel they have enough information to provide a safe accommodation.
Some students with a disability may have a IEP or 504 plan on file with the district. If the required information from the medical statement is written into either of these plans, the student does not need to obtain a separate medical statement. This could reduce the burden for the parent or guardian in obtaining the same information twice.

10. Modifications for dietary preferences are not required
General health concerns (i.e. preference for gluten-free diet)
Cultural, religious and ethical preferences
Modifications must be within the meal pattern
Dietary Preference Form is encouraged
SFAs are not required to accommodate dietary preferences. This includes general health concerns. For example, if a parent feels a gluten-free diet is healthier, the SFA is not required to accommodate this request. Dietary preferences also includes cultural, religious, and ethical issues. Though SFAs are not required to accommodate, they are encouraged to consider these preferences. Modifications must be made within meal pattern requirements in order to receive reimbursement for the meal. SFAs will not receive additional reimbursement and must cover any additional costs associated with these modifications.
It is strongly encouraged the SFA has a Dietary Preference Form or other documentation completed prior to making substitutions for dietary preferences.

11. Reasonable Modifications
A change or alteration in policies, practices, and/or procedures in order to accommodate
Must be related to disabling condition
Must be made on a case-by-case basis
When a SFA receives a request for a disability, it is the responsibility of the SFA to provide reasonable modifications in order to prevent discrimination on the basis of a disability. A reasonable modification can be defined as a change or alteration in policies, practices, and/or procedures to accommodate the disability. The modifications made must be related to the disability or limitations triggered by the disability. Reasonable modifications will vary depending on the child and disability, and all requests must be considered on a case-by-case basis.

12. Reasonable Modifications- Things to Consider
Food Allergies
Offer vs. Serve
Portion Sizes
Brand Name Requests
Tracking Dietary Intake
Fluid Milk Substitutions
Food allergies - As previously mentioned, a child’s food allergy does not need to be life threatening or cause anaphylaxis to be considered a disability. When providing modifications for a child with a food allergy, the request extends to items and ingredients in the meal. No item offered can contain traces of the substance or substances that cause the allergic reaction. It is the responsibility of the SFA to check food labels to ensure all items offered to the child are safe. Reasonable modifications also extends to the kitchen environment. The SFA should be cautious of food preparation areas, storage of ingredients and food items, and cleaning techniques.
Offer vs. Serve – offer vs. serve allows students to decline some food components or items. Schools participating in offer vs. serve are required to make all food components available for students with disabilities. A SFA cannot accommodate disability by having the child exclude a certain food component. A meal that mirrors the main entrée does not need to be provided. For example, if a child is gluten-free and the entrée for the day is a hamburger, a gluten-free bun does not need to be provided. The SFA only needs to ensure the grain item offered does not contain gluten.
Portion Sizes – Some disabilities may require portion sizes that are larger than the maximum quantity or smaller than the minimum quantity requirements of the meal pattern. The SFA must follow the prescribed portion sizes in these instances and must be supported by a medical statement. Specific caloric needs or portion sizes should be written into the medical statement so the SFA has clear information. The SFA should follow up to obtain any information that is unclear.
Brand Name Requests - Some medical statements may request a specific brand name for a substitution. In most cases, the specific brand name does not need to be provided if a generic brand is sufficient. Unless a particular brand is deemed medically necessary, a generic brand is acceptable. The SFA should work with the parent or legal guardian in making these determinations. For example, if a medical statement requests a specific brand of gluten-free bread and the SFA utilizes another brand, the SFA could check with the parents to see if the option offered is a safe and appropriate substitute.
Tracking Dietary Intake - For disabilities that require the tracking of dietary intake for a child. A common example of this is a child with diabetes where the child’s carbohydrate intake must be tracked. SFAs are required to provide nutritional information for a child that needs to track their dietary intake. The SFA is required to provide nutritional information, but is not required to track dietary intake. In the example of diabetes, food service personnel are not responsible for weighing or measuring leftover food or determining the proper amount of carbohydrates consumed. This is the responsibility of the school nurse or other designated personnel.
Fluid Milk Substitutions - One of the most popular requests an SFA receives might be a fluid milk substitution. If the request is not a disability or the disability is not supported by a medical statement, milk substitutes must meet nutrient requirements outlined by the USDA. Low-fat or fat-free lactose-free milk or low-fat or fat free reduced-lactose milk would meet the nutrient requirements. Non-dairy milks, such as almond milk or soy milk, would need to meet these requirements when a medical statement is not provided. Juice and water are not appropriate substitutes unless listed on a medical statement.

13. A team approach should be used for meal modifications
The Team Approach
A team approach should be used for meal modifications
The 504 coordinator is responsible for addressing disability requests
LEAs are encouraged to develop a team
SFAs are encouraged to work with school nurses and parents
Accommodating special diets can be tricky and sensitive for all parties. In order to ensure accommodations are right for the child, the team approach is strongly encouraged. This means working with a school health team, parents or legal guardians, or school nurses when determining a meal modification. LEAs employing 15 or more employees are required to have at least one person to coordinate compliance with disabilities. This position is known as the 504 coordinator. The 504 coordinator is responsible for addressing disability requests that come into the district, which may include requests for meal modifications. This is a great person to start connections with for some requests received.
LEAs are encouraged to develop a 504/ADA team or school health team to develop best practices and create a safe learning environment for all children. The team approach encourages different departments that may be working with the same child to share information and provide the best accommodation, both inside and out of the cafeteria.
SFAs are encouraged to work with school nurses and parents when determining appropriate meal modifications. School nurses are often familiar with the child and parents. It is important that they understand meal accommodation requirements. Involving parents or legal guardians in the process allows the SFA to develop a good rapport with the family and may help prevent misunderstandings and miscommunications with the family.
Now Becky and Amy are doing some great work in their districts with nurses and parents. I’ll turn it over to them to discuss best practices when working with these groups.

14. Accommodating Special Diets: Building Relationships and Working with Parents
Becky Wiggins, RD
Nutrition Coordinator
Poudre School District

15. Overview
Step by Step Process
Conference Meetings
Special Menus
Maintaining relationship
Benefits
Good and Bad Examples

16. Step by Step Process – Step #1
The Phone Call
Create a rapport with the family 
Gain a clear understanding of the foods needing to be omitted and substitution options
Provide clear instructions on how student’s meal modification needs will be met
When I receive a meal modification form into my office, the first thing I do is call the family. My goal is to create a relationship with the family, so that the whole special diet process goes smoothly. The most important aspect of any healthy relationship is effective communication. During the phone call, I will ask any clarifying questions on foods to omit and substitution options. For example, if “milk” is listed in the omit section, I will ensure that means all items including milk (yogurt, cheese, etc) or just fluid cow’s milk. I then will take the time to explain to the parent the instructions on how the student’s meal modification needs will be met.

17. Step by Step Process – Step #2
Allergy Pop-Up & Kitchen Communication
Meal modification forms are sent to the kitchen
Communicate meal modification information to the kitchen manager 
Pop-up allergy alert is added in the student’s meal account 
Cashiers are provided with lists of foods containing the top 8 food allergies as a quick reference
After calling the family, I will send the meal modification form to the kitchen and communicate the necessary meal modification information to the kitchen manager (ordering information on substitution items, food items to omit from students meals, any special menus to follow). We will put a pop-up allergy alert in the student’s meal account. If the student were to come through the meal line with a item on a tray they are allergic to, with this alert in place, kitchen staff would let the student know they have an item on their tray that they are allergic to and help them find a different meal option. I have created lists of our food products that contain the different top 8 food allergens (milk, eggs, wheat, soy, peanuts, tree nuts, fish, and shellfish). This is a quick reference for the cashier, as students with food allergies come through the line. For example, wheat can be in so many foods- it is helpful to have the list available, as a quick reference. I will communicate this information to the family.

18. Quick Reference Food Allergy Lists
PEANUT/ TREE NUT
Honey Nut Cheerios Cereal (Tree Nuts)
Uncrustable Peanut Butter and Jelly Sandwich (Peanuts)
Grape and Strawberry
May Contain:
Breakfast Rounds (Peanuts, Tree Nuts)
Chocolate Chip
Original (Cinnamon)
Chili Seasoning (Tree Nuts)
Chocolate Chip Cookies (Peanuts and Tree Nuts)
Hamburger Bun (Tree Nuts)
Sugar Cookies (Peanuts and Tree Nuts)
Cocoa Cherry Bar (Tree Nuts)
Garlic Powder (Tree Nuts)
Ginger Spice (Tree Nuts)
Yogurt Chips (Tree Nuts)
Here is an example of the lists I have created as a quick reference for cashier to use as students come through the line with peanut or tree nut allergies.

19. Step by Step Process – Step #3
Conference Meeting
Offer conference meeting to all families
Provides opportunity to get all parties on the same page and create a relationship

20. Student, if age appropriate Nutrition Coordinator
Conference Meeting
Parents
Student, if age appropriate 
Nutrition Coordinator
Kitchen manager and kitchen staff
Child Nutrition Area Supervisor
School Nurse
Conference meetings will include all of the above individuals. We will go over student’s needs for meal modification (example: meals prepared separately to prevent cross contamination), go over menus & ingredient labels, answer any questions the family or kitchen may have. 

21. Step by Step Process – Step #4
Special Menus 
We have found that in most cases it is easier for the kitchens and the families if I create a special menu for students in need of meal modifications
Versus having to know which items include wheat, milk, ect. We have found that it is easier for kitchens to follow a gluten free or dairy free menu that I put together. I think we all know how chaotic school cafeterias can be, so taking away the stress of figuring out if a meal contain an allergen has been very helpful! It is also helpful for families, as we will make these menu selections in the conference meetings and they will feel comfortable in knowing that their child will be eating a safe meal.

22. Special Menus
Special gluten free, dairy free, allergen free menus are created for the kitchens to follow, based on family/student preferences 
Monthly the special menus are sent to the parents
We request that they let the kitchen manager know what days their students will eat, so we can provide the proper meals

23. Special Menus
Here is an example of a special menu that I created for our gluten free students

24. Maintaining Relationships
Special menus are sent monthly to parents
This also provides an opportunity to touch base with them and ensure everything is still going smoothly 
Additional conference meetings are offered, whenever changes occur 
Menu cycle change
Kitchen Manager change 
Student changes school

25. Benefits of Building Relationships
Allows us to control substitution requests
 Helps financially 
Provides clear instructions on how best to accommodate student
Eliminates stress for kitchens 
Satisfied parents 
Allows parents to have an understanding of realistic requests for our department

26. Before Relationship Building – Example
Medical statement received for gluten and dairy substitutes
Restricted all gluten and dairy items & provided recommended substitute
Parent called kitchen manager with unreasonable requests
Requests were difficult for kitchen manager to manage
No relationship = chaos
Parent meal requests- Provide frozen gluten free/dairy meals, pizza on Fridays was ok, and requesting that we discontinue gluten restriction for a couple of weeks, and then restrict again
This situation was hard for the mother and our staff. The mom did not have a clear understanding on what we were capable of providing as substitutions. The kitchen manager needed meet her responsibilities in the kitchen, while managing the requests of the mom. This created frustration on both sides. 
The situation was resolved by having a conference meeting with the mother and the group. We explained to her that we either restrict gluten and dairy at all times not at all (it is all or nothing). At this point, she decided to discontinue the meal modifications. 

27. After Relationship Building - Example
Student with sensory eating disorder, dysphagia, and dairy allergy
Immediately called parent to schedule conference meeting
Met with mom, nurse, kitchen manager and staff, area supervisor and myself
Parent provided clear instructions on how to prepare his foods and what foods he would accept
Within 2 weeks, he started accepting new foods- which he unsuccessfully had done for years with eating therapy centers!
When student first came to PSD he had only accepted a handful of foods including protein shakes, corn dogs, chicken nuggets, tricolored rotini, and a few fruits. All other foods he would refuse to try or choke on. Slowly our kitchen staff introduced him to new foods and within two weeks the student had accepted and enjoyed chicken strips and green beans! Today the student is accepting most foods that his friends are eating at school! The parent is more than grateful for the kitchens hard work making the meal modifications.

28. Accommodating Special Diets: Collaborating with Nursing Services
Amy Faricy, RD
Manager of Menu Services
Douglas County School District

29. History of Accommodating Special Diets in DCSD
Prior to 2013
Part-time contract RD on staff
No students special diet accommodations
Part-time contract RD on staff who handled the special diets and menu, 1 additional RD
3-4 students with special diet accommodations
2015-present
Two full-time RD’s on staff
72 students with special diet accommodations
Special diets not going away. On the rise

30. Types of Meal Modifications
Diabetic- 305 in district. Most manage through

31. Communication Gaps Discuss our process and where the gap was
Three distinct stakeholders who have same mission but who were often working independently rather than cohesively
Parent/Child (504)
School Admin/District Nurse/School Health Assistant (504)
Kitchen Staff/Nutrition Services
While we were capturing a lot of students there were plenty we were unaware of
Infinite campus does not talk to POS or notify us of allergies

32. Benefits of Collaborating with Nursing Team
Shared purpose
Established point of contact
Share knowledge and ideas
Build rapport
Improved customer service
Training opportunities
Increase in meal modifications provided
Advocates for Student safety and well being. Care team that ensures healthy and happy student- Parents peace of mind, same page.
Provide regulatory information for accommodating special diets. Dual effort on streamlining the process/closing communication gap
for nurses and families
Families and RN’s Working together, being available to answer questions and help. We are the experts in nutrition and food service they have their own
In-services, RN meetings
Easier and more cost effective

33. How to Start the Collaboration Process
Outline your objectives
Identify collaborators
Be prepared
Schedule brainstorming time
Communicate and follow up
Know the regulations
Establish your policies and procedures
Outline the objectives. What is the purpose. Only increasing. Easy to go on as business as usual but collaboration can only strengthen your rapport, visibility, resources. Need allies. Win-win
Is it the RN coordinator, school health assistants, all of the above. Start at the top
Share as much information about the objectives as you can, and make it clear what they stand to gain from their involvement.
Be prepared to talk with an educated group about the requirements and what our role is.
on meal modifications and your process for notification and management
around meal modifications
Discuss process and how we can work together
Get in front of RN team- CDE present overview, then present our process
Keep an open mind

34. Questions?

35. CDE OSN Special Dietary Needs webpage
Resources
CDE OSN Special Dietary Needs webpage
Special Dietary Needs Online Training
Documentation Flowchart
Milk Substitution Flowchart
SOP Template
Medical Statement & Preference Form (English & Spanish)
Discontinuation Form
Letter to Parents Template
USDA’s Accommodating Children with Disabilities in the School Meal Programs: Guidance for School Food Service Professionals