Nutrition Care Process: Role of CDM Mary D. Litchford PhD, RD, LDN www.casesoftware.com

Points to Ponder What is the Nutrition Care Process (NCP)? What is my role in the NCP? What is the collaborative role of the CDM and the RD? Practice standards vs. regulations for CDMs & RDs

What is the Nutrition Care Process (NCP)? Developed by ADA for use by RDs Standardized process for providing care Standardized language Systemic problem solving method for RDs to use to: Think critically Make decisions to address nutrition problems Provide high quality nutrition care To define specific steps the Dietitian uses when providing Nutrition Therapy Not to standardize the Nutrition Care of each resident

Steps in NCP Nutrition Assessment Nutrition Diagnosis Nutrition Intervention Nutrition Monitoring & Evaluation

Step 1. Nutrition Assessment Review data collected for factors that affect nutritional & health status Cluster data to identify nutrition diagnosis Identify standards by which the data will be compared

Role of the CDM in Nutrition Assessment Step Data collection of Nutrition Care Indicators- Markers that can be observed or measured Data that is in the medical record New data which is added to medical record

Role of the CDM in Nutrition Assessment Step Collect Data from Medical Record Personal data Anthropometric Lab test results Medical diagnosis Nutrition-orientated medical history Results of nutrition-related medical procedures Nutrition-focused physical findings

Role of the CDM in Nutrition Assessment Step Add New data to Medical Record Data collected from interview with resident/patient i.e. food preferences, meal & snack patterns, preferred eating environment Food Intake vs Estimated Needs Mealtime Behavior Food & Nutrition Knowledge (food beliefs) BMI Percentage of Weight Change

Role of the CDM in Nutrition Assessment Step Complete facility approved forms Use the assessment data to complete the MDS Check state licensure laws for dietitians to be sure this does not encroach on LD scope of practice Check p/p for your facility

Role of the RD in Nutrition Assessment Step Cluster Nutrition Care Indicators to identify Nutrition Diagnoses Identify Nutrition Care Criteria by which the data will be compared

Step 2: Nutrition Diagnosis Different from medical diagnosis Identification of a specific nutrition problem that dietetic practitioners will treat Categories of Nutrition Diagnoses Intake Clinical Behavioral

Role of RD in Nutrition Diagnosis Step RD uses ADA standardized language Summarized as PES Statement P: problem E: etiology S: signs/symptoms (S/S)

Example of PES Statement Problem: Excessive fat intake related to Etiology: consumption of fast foods provided by family members 2-3 times/wk as evidenced by S/S: 10% weight gain in 90 days and increase in serum cholesterol to 230 mg/dl

Does every Resident/Patient have a Nutrition Diagnosis? No longer putting residents in categories of low, medium and high risk.

Role of CDM in Nutrition Diagnosis Step Be familiar with the Nutrition Diagnoses for each patient/resident Alert RD if any patient/resident has a change in medical condition, new medical data, new labs etc. Follow facility p/p in contacting RD

Step 3: Nutrition Intervention Specific to Nutrition Diagnoses 4 categories Intervention Strategies Food &/or Nutrient Delivery Nutrition Ed Nutrition Counseling Coordination of Nutrition Care Planned actions to positively change nutrition-related behavior or condition

Step 3: Nutrition Intervention Nutrition intervention is primarily aimed at etiology of nutrition dx Nutrition intervention may be directed at s/s to minimize their impact Uses ADA standardized intervention terms RD will determine Nutrition Care Indicators (what is being measured) RD will determine Nutrition Care Criteria (what it is compared against)

Role of RD in Nutrition Intervention Step Write interventions that are specific to each Nutrition Diagnosis Includes: Nutrition Prescription- i.e. Diet Order, recommendations for energy, protein, fluid intake, etc. Goals/ expected outcomes Actions to be taken Collaboration with other colleagues Planned actions to positively change nutrition-related behavior or condition

Example: Nutrition Intervention PES- Inadequate protein intake related to dysphagia, dementia and muscle wasting as evidenced by leaving more than 25% of protein rich foods served at lunch and supper on 25 out of 30 days, albumin 2.6 mg/dl & stage 2 pressure ulcer on sacrum.

Example : Nutrition Intervention Selected Interventions: Nutrition Prescription: Mechanical Soft diet with ground meats & gravies with fortified foods & protein supplement to provide 1800 Kcal, 90 gm protein, 1500 ml fluid Serve double portion of eggs at breakfast Fortify breakfast cereal with Brand A protein supplement to provide 20 gm complete protein Fortify HS milkshake with Brand A protein supplement to provide 20 gm complete protein Collaborate with nursing on dining room seating assignment & mealtime assistance

Role of CDM in Nutrition Intervention Step Collaborate with RD & nursing to develop nutrition intervention strategies Confirm that the Nutrition Prescription is being served Order & keep adequate stock of the products required in nutrition care interventions Confirm that recipes for fortified menu items are being followed and prepared as ordered

Role of CDM in Nutrition Intervention Step Confirm that protein or oral supplements are being served as ordered Confirm that all other interventions are implemented i.e. adaptive equipment, dining environment Collaborate with healthcare team to determine obstacles to interventions

Role of CDM in Nutrition Intervention Step Use the nutrition interventions in developing RAI/care plan Check state licensure laws for dietitians to be sure this does not encroach on LD scope of practice Check p/p for your facility Notify the RD if significant changes occur that affect nutrition status Follow your facility p/p

Step 4: Nutrition Monitoring & Evaluation Goal: to monitor, measure & evaluate progress in achieving goals/expected outcomes 4 Categories of Nutrition Care Outcomes: Food/nutrition related history Biochemical data, medical tests & procedure Anthropometric measurement Nutrition-focused physical assessment findings

Examples of Nutrition Care Outcomes Examples of 4 categories of Outcomes Food/Nutrition Hx: dietary & herbal intake, beliefs, knowledge, physical activity, nutrition quality of life Biochemical & Medical Tests: labs, tests (gastric emptying time, RMR) Anthropometric: ht, wt, BMI, wt history Nutrition-Focused Physical Findings: physical appearance, muscle & fat wasting, swallowing function, appetite, nails, tongue

Role of CDM in Nutrition Monitoring & Evaluation Step Collect/summarize monitoring data for RD to evaluate Notify the RD if significant changes occur that affect nutrition status (follow your facility p/p)

Examples of Monitoring Data Weight changes- 5% wt gain in 30 days Summarize Intake Data- refused breakfast 10/30 days, eats 50-75% of meals 20/30 days, consumed 75-100% protein supplement 20/30 days, refused thicken liquids 25/30 days Summarize V/M Supplement Intake- took folate supplement 25/30 days, refused iron supplement 20/30 days Summarize Behavior- accepted feeding assistance at evening meal 15/30 days

Role of RD in Nutrition Monitoring & Evaluation Step Determine & document progress toward meeting nutrition care outcomes Examples: improvement in labs improvement in resident/patient’s ability to self feed reduction in use of supplements stabilization of weight Identify new nutrition diagnosis

Practice Standards vs. Regulations

Who Sets Practice Standards? Dietary Managers DMA Developed Practice Standards Documenting in Medical Record www.dmaonline.org/Resources/DMAResources/standard02.shtml Documenting Fluid Intake www.dmaonline.org/Resources/DMAResources/standard08.shtml CDMs certified by CBDM

Who Sets Practice Standards? RDs/LDs Dietitians Licensed or Certified by State Agency in 48 states Rationale of License - to prevent harm Scope of Practice varies by state

Who Sets Practice Standards? RDs/DTRs Developed by ADA Describes the minimum level of competency for the RD and DTR who provide direct resident care Defines Supervision of the DTR Role of RD & DTR in NCP Nutrition Screening outside NCP No references to Low, Medium or High Risk Patients/Residents either have a Nutrition Diagnosis or do not Facilities may define risk levels though Policies & Procedures

CMS Regulations CMS RAI Version 2.0 does not mandate the RD complete any part of the RAI It states, “A facility may assign responsibility for completing the RAI to a number of qualified staff members. Staff members MUST have knowledge & skill to do so. 483.20 Accuracy of Assessment (F278) In most cases participants are. . . licensed health professionals.”

CMS Regulations F279 A Comprehensive Care Plan must be. . . “Periodically reviewed and revised by a team of qualified persons after each assessment” Qualified is not defined CDM may write care plan, initiate such care, & write quarterly assessments as long as the assessments are signed by RN responsible for conducting & coordinating assessment.

CMS Regulations Is the RD required to sign RAI document prepared by CDM? CMS does not require RD to sign RAI State licensure laws may or may not require the RD to sign the RAI Facility p/p may or may not require the RD to sign the RAI

Who is ultimately responsible for the nutrition care of their patients/residents RD is ultimately responsible for nutrition care SOP are used by lawyers ADA cannot include CDM in Standards of Practice

Remember that…. RD Supervision RD is accountable for the nutrition care of the residents The RD must answer to residents, employers, licensure boards, and the legal system is resident care is compromised RD does not delegate duties, he/she assigns them

Remember that… RD verifies Credentials DTR CDM RD Establishes & Verifies Competence CDM Nutrition Care Self-Assessment Tool (5/2009) Nutrition Documentation Readiness for CDM, CFPP's (5 hr online CE) Review knowledge and skills to assess competence Assign tasks based on the individual's competence Re-assess competencies

Bottom Line The RD & CDM will continue to work together, as a team, to enhance the resident’s quality of life The role of the CDM in the nutritional care of the resident is determined by his/her competence