1. The Right Care at the Right Time: Integrating Nutrition Care for Diabetes into Primary Care Academy of Nutrition and Dietetics September 6th 2017
This presentation is provided free-of-charge and is supported by Grant Number 1L1CMS from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided in this webinar are solely the responsibility of the presenters and do not necessarily represent the official views of HHS or any of its agencies.

2. Amy Allen serves as a Member of the Nutrition Services Payment Committee for The Academy of Nutrition and Dietetics. She received her bachelors of Art from Kalamazoo College in Kalamazoo, MI, and completed her Registered Dietitian Internship and earned a Master’s degree of Public Health, Human Nutrition & Dietetics in Environmental Health Sciences from the University of Michigan. She has worked in this field for seven years.
Amy Allen, MPH RDN

3. Nothing to disclose Disclosure Speaker Notes: For today’s meeting:
We will go over the MACRA legislation and the two pathways within the MACRA Quality Payment Programs. How you as a provider can prepare for these alternative payment programs under MACRA with TCPI, or The Transforming Clinical Practice Initiative.
We will provide an overview of the Transforming Clinical Practice Initiative and discuss the two key components to TCPI – Support and Alignment Networks (SAN) and the Practice Transforming Networks. The TCPI is critical as it ushers in a new era of practice that shifts its focus from “volume” to “value” and what does this new payment system mean.
We will discuss the criteria for TCPI participation and the benefits to doing so.
If time allows, we will take the opportunity to address your questions.

4. Objectives
Describe how Medical Nutrition Therapy (MNT) improves outcomes in populations with diabetes
Integrate nutrition care for diabetes and related chronic conditions into various primary care models
Estimate the potential revenue streams for nutrition services provided by RDNs in primary care

5. National Diabetes Statistics Report, 2017
30.3 million people have diabetes
23.1 million diagnosed
7.2 million undiagnosed
12 million among those aged 65 years or older
132,000 children & adolescents < 18 years of age
Centers for Disease Control

6. What is Medical Nutrition Therapy (MNT)?
An evidence-based nutrition service provided by RDNs to prevent, delay or manage diseases and conditions
A personalized, in-depth assessment, nutrition diagnosis and intervention treatment plan
Provided over multiple visits to positively impact nutrition behaviors and allow for continued personalized monitoring of the patient/client

7. The Nutrition Care Process Includes
Nutrition Screen/Referral
Nutrition Assessment
Nutrition Diagnosis
Nutrition Intervention
Nutrition Monitoring and Evaluation
Nutrition Documentation
Outcomes Management

8. Alignment with National Practice Guidelines
Standards of Medical Care in Diabetes

9. MNT Improves A1c & Reduces Cost
% reduction in A1C 1st 6 months (UKPDS)
2% reduction in newly diagnosed when the A1C > 9% (LOADD study)
0.5% reduction in A1C in persons with Type 2 DM for ≥ 9 years with sub-optimal control
More cost-effective than adding a third medication (LOADD study)
9.5% reduction in hospital utilization (Lewin Group)

10. Impact of Reduced Glycemia
Lower A1C levels are associated with reduced onset or progression of microvascular complications.”
1% ↓ mean A1C levels associated with risk reductions:
21% for death related to diabetes
14% for myocardial infarction
37% for microvascular complications
= ↓ avoidable spending (saves $)

11. Risk Factors for Complications of Diabetes
Smoking
Overweight and Obesity
Physical Inactivity
High Blood Pressure
High Cholesterol (Hyperlipidemia)
High Blood Glucose (Hyperglycemia)
National Diabetes Statistics Report, 2017

12. Revenue from Services Provided by RDNs?

13. Codes for Medical Nutrition Therapy (MNT)
CPT® codes
Description
Key Information
97802
Initial assessment and intervention
Individual
face-to-face and via telehealth
Time-based code
(15 minutes/unit)
97803
Reassessment and intervention
individual
face-to-face, and via telehealth
(15 minute/unit)
97804
MNT delivered in a group setting
2 or more individuals
(30 minutes/unit)

14. When Patients Need More Care:
MNT beyond the standard benefit (3 hours/2 hours) Required: 2nd referral from treating physician Criteria: medical necessity
G0270 15
minutes
Reassessment and subsequent intervention(s) following 2nd referral in same year individual, face-to-face 
G0271 30
Same as above, but for groups of 2 or more individuals

15. Minimum Revenue Per Patient
Standard Medicare benefit for MNT
2017 CMS fee schedule national rate/unit:
3 hours of individual MNT (1st year):
97802 x 4 $29.89 = $119.56
97803 x 8 $25.93 = $207.44
= $327.00
2 hours of individual (subsequent years)
97803 x = $207.44
$ per client for 1st two years

16. Improve Access to MNT via Telehealth

17. Related Services to Improve Care & Outcomes
RDN Can Provide “Incident to” services:
Intensive Behavioral Therapy (IBT) for Obesity
Chronic Care Management Services
Annual Wellness Visit (AWV)
USPSTF Preventive Screening & Counseling

18. Integrating Nutrition- Getting Started

19. Business Relationship
Employ an RDN (PT or FT)
Independent Contractor
Consultant
Referrals to RDNs
Private practice RDN or within IPA, medical group or system

20. Operationalizing Nutrition Care
Population Management
Services
Practice Resources
Delivery
Measure outcomes/effectiveness

21. Set the Stage for Success
Share confidence in the process, person and experience
Explain what patient might expect
Warm hand-offs
Referral to an RDN to help patients live well with diabetes
“Team sport” culture

22. Implementation Do
Study
Act
Plan

23. Stories from the Field RDNs in Medical Homes
Medication adjustment per protocol
Manage registries
Monitor labs
Clinical quality targets
Self-management
Food insecurity pilot
New service delivery methods

25. Sources
UK Prospective Diabetes Study (UKPDS 7). Response of fasting plasma glucose to diet therapy in newly presenting type II diabetic patients. Metabolism. 1990; 39:
Coppell/LOADD study, cited by Franz M, Boucher J, Evert A. Evidence-based diabetes nutrition therapy recommendations are effective: the key is individualization.
Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy. 2014:7; 65-72
American Diabetes Association Standards of Medical Care in Diabetes 2017
Stratton, I et al., Association of glycaemia with macrovascular and microvascular complications of Type2 diabetes (UKPDS 35): prospective observational study, 321 The British Medical Journal. 2000;Aug 405, 409
Sheils J, Rubin R, Stapelton D. The Estimated Costs and Savings of Medical Nutrition Therapy: The Medicare Population. J Acad Nutrition and Dietetics. 1999; 99(4):

26. Q & A

27. Business Case For Nutrition Care-Academy of Nutrition and Dietetics Resource
Organizational contact for this resource is the Nutrition Services Coverage Team at the Academy of Nutrition and Dietetics : or

28. Thank you!
Amy Allen, MPH, RD Member, Nutrition Services Payment Committee Academy of Nutrition and Dietetics