Home Care — An Emerging Practice Area for Dietetics

J AM Diet Assoc. 1999;99:453-1459

As long as the field of dietetics has been in existence, the scope of dietetics practice has expanded to fill needs for nutrition services wherever they arose. In the 1980s, dietetics practice expanded to nontraditional areas such as private practice, sports nutrition, and business and industry (1). Today, home care is a new frontier for dietetics practice. Of the 7.5 million new jobs created in the United States during the first half of the 1990s, jobs in home care were among the top 10 (2).

The aging of the American population, the growth of managed care, and the increasing availability of sophisticated technologies are important factors favoring the growth of home care (3),(4). The need for nutrition services in home care is also expected to grow. In part, this growth is expected because the Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO) 1999-2000 standards for home care require a home care provider to perform nutrition screening of all home care patients at moderate to high risk (5).

The growth of managed health care also encourages attention to provision of nutrition services in home care. In the capitated home care environment, the struggle to control costs and maintain quality of care increases the appeal of providing proactive nutrition services to reduce or prevent nutrition-related complications and costs.

A number of dietitians are already practicing in home care today. The American Dietetic Association (ADA) 1997 Membership Database Update showed that 1.4% of respondents (n=399) listed home care as their primary employment setting (6). A 1992 survey of home care dietitians found that 70% worked for home infusion companies, 12% worked for home health agencies, 8% were self-employed, 7% were employed by private physicians or outpatient clinics, and 3% were employed by hospitals (7).

Because home care is a burgeoning addition to the scope of dietetics practice, a panel of 6 dietitians currently practicing in the field was convened to create this resource for other dietetics professionals who are interested in home care. This article uses available information from the literature and the home care experience and knowledge of the panelists to accomplish the following objectives:

To describe home care organizations and related reimbursement factors;
To describe opportunities for dietetics professionals in home care along with suggested skills and characteristics that are likely to contribute to success in this emerging practice area; and
To recommend actions that individual dietetics professionals can take, individually and collectively, to improve the quantity, quality, and access to nutrition services in home care.

Aspects of Home Care
The home care industry provides a diverse array of temporary and ongoing services to frail or disabled people of all ages, ranging from premature infants to pediatric clients to young adults to the elderly. An important goal of home care is to enable these people to remain in their own homes instead of in health care institutions. Experts say that home care has a number of other advantages as well. First, there may be financial benefits, especially if home care prevents or delays a patient's transfer to a nursing home or hospital. A home care visit can cost as little as 19% of the cost of a day of care in a nursing home and about 4% of the cost of a day of hospitalization (8). Home care may also be preferred because it may reinforce and supplement care provided by family and friends and, therefore, help maintain the recipient's dignity and independence. Quality of life may be better for people when they are cared for in their usual environment where they can maintain their usual lifestyle surrounded by loved ones and familiar foods and other things (9).

Types of Home Care Organizations
The home care industry is a dynamic one, and is composed of a variety of entities known collectively as home care organiza-tions.Broadly speaking, home care organizations are defined as an operational unit that provides one or more home care program to individuals in their residence. Following is a list of typical categories of home care programs. The most common, home health agencies and hospices, will be discussed in greater detail in the next section.

Home health care Professional services provided in a patient's place of residence on either a part-time, intermittent, hourly, or shift basis.
Hospice: An organized program of interdisciplinary services for terminally ill patients and their families to provide palliative medical care and supportive social, emotional, and spiritual services.
Support Care: Supportive services related to assistance with the instrumental activities of daily living provided on a part-time, intermittent, shift, or hourly basis.
Personal Care: Personal care related to assistance with activities of daily living provided on a part-time, intermittent, hourly, or shift basis.
Home Infusion Therapy: Provision of both pharmaceuticals and skilled nursing services.
Home Medical Equipment/Durable Medical Equipment: Companies that provide equipment in the home care setting.

Home Health Agencies and Hospices
The number of agencies providing home health and hospice services rose from 8,000 in 1992 to 13,500 in 1996 (10). Home care agencies and hospices are differentiated by the types of services they provide. Home care agencies provide services to individuals and families in their homes for the purpose of promoting, maintaining, or restoring health or for the purpose of maximizing independence while minimizing the effects of disability and illness. Home care agencies that provide skilled services (eg, nursing services) make up the largest segment of the home care industry. Some agencies providing skilled services have specialty areas such as pediatrics, rehabilitation medicine, high-risk pregnancy, oncology, or maternal and child health. They may also provide personal care services to assist clients with the activities of daily living, such as meal preparation, bathing, dressing, and housekeeping.

By comparison, hospices provide palliative and supportive services for people in their final stages of disease (=6 months of life expected), their families, and other loved ones. Hospices provide organized, interdisciplinary programs to provide physical, psychological, social, and spiritual care (10). Aggressive therapies such as chemotherapy and parenteral and enteral nutrition are generally not considered consistent with the hospice philosophy as nutrition care is considered to be palliative. In this environment, dietetics professionals play important roles as information resources and educators.

Medicare added hospice benefits in October 1983. Hospices certified by Medicare must meet specific participation requirements (11). Some hospice services, however, can be provided by home care agencies.

Infusion Therapy
Organizations designed to deliver infusion therapy represent another type of home care structure. These organizations specialize in the delivery of intravenous drugs, blood and blood products, other intravenous solutions, equipment, and professional services for people receiving intravenous medications, nutrition support, or other systemic therapies.

Some of these companies are associated with Medicare-certified home care agencies, allowing them to provide skilled nursing services to Medicare recipients and to bill Medicare for these services. Infusion companies not associated with a certified home care agency may provide and bill Medicare and Medicaid for pharmacy services if they are licensed as a Medicare or Medicaid provider. They may not, however, bill for nursing services.

Home Medical Equipment/Durable Medical Equipment
Also included among home care organizations are companies providing home medical equipment or durable medical equipment. This includes products such as ventilators and respiratory therapy services, wheelchairs, hospital beds, commodes, enteral tube feeding formulas and feeding devices, and catheter and wound care supplies. Some equipment vendors are affiliated with home care organizations that provide infusion and skilled nursing services. Others restrict their services only to delivering and installing equipment and supplies and teaching clients the rudiments of in-home use.

Although many of these home care organizations may not receive Medicare or Medicaid payment, other public funding sources include Medicaid, the Older Americans Act, Title XX Social Services Block Grants, the Veterans Administration, and Civilian Health. Other reimbursement options include indemnity insurance plans, workers’ compensation, public and private grants, United Way funds, Medicaid waivers, and private pay (14).

Structure of Home Care Organizations
Home care organizations currently operate under a variety of structures:

Not-for-profit: a voluntary agency with a charitable mission, exempt from federal income tax;
Proprietary: a private, profit-making agency;
Public: an agency operated by state or local government;
Subdivision: a component of a multi-functional entity, such as a hospital or managed care organization.

Of the 13,500 home care agencies and hospices providing services in 1996,34% were owned by voluntary, not-for-profit organizations, 54% were proprietary or privately owned agencies, and 11% were owned by government or other agencies (10). Many of these home care organizations have an administrator or director (often a health care executive, a nurse, social worker, or physician) who is responsible for managing the business. In a small organization, the director may also be responsible for patient services, which entails recruitment, supervision, and management of the caregiver staff. Employees of small home care organizations often have cross-functional responsibilities. In larger agencies, business volume is more likely to justify a separate director of patient services, a medical director, inservice educators and trainers, quality assurance-utilization review coordinators, invoice processors, and medical information specialists.

Reimbursement and Home Care
Regardless of their affiliation or operating structure, home care agencies can be classified as Medicare-certified or noncertified. This categorization reflects the influence of Medicare, which, when it was enacted in 1965, greatly accelerated growth of the home care industry by covering costs of services, primarily skilled nursing and therapy of a curative or restorative nature, for Medicare beneficiaries.

Before passage of the Balanced Budget Act of 1997 (15), Medicare-certified home care agencies were paid on a cost-per-visit basis for all visits, up to cost caps, as long as the client met Medicare home health criteria. Under this system, each allowable home visit produced revenue for the home care agency. The current system, the Interim Payment System (IPS), changes that scenario. Under IPS, payments to agencies are capitated; reimbursement to home care agencies managing Medicare patients has per-visit, per-beneficiary cost limits. The next iteration, the Prospective Payment System (PPS), will go into effect in October 2000. Under PPS, capitated payments will be made for each 120-day episode of illness. The IPS and PPS for home care are similar to the diagnosis-related-group system by which hospitals are reimbursed capitated amounts for care of Medicare recipients. The goals of the capitated payment systems are similar—to encourage focus on cost effectiveness and outcomes (12).

Although the Balanced Budget Act of 1997 has already reduced the amount of reimbursement for home care services, Medicare still reimburses for medically approved home care services for beneficiaries who qualify. To qualify for reimbursement of home care services under Medicare Part B, the client must be:

Homebound (ie, notable and taxing effort is needed for the person to leave home);
Under the care of a physician and in need of skilled care from at least one qualifying service—nursing, physical therapy, speech therapy—to treat the condition;
In need of services on a part-time, intermittent basis; and
Receiving services from a Medicare-certified agency (13).

Once recipients qualify for Medicare-covered home care benefits, they are also eligible for services such as medical social service, personal care, medical supplies, some durable medical equipment, and prosthetic devices.

In 1996, approximately 84% of home care agencies were certified under Medicare (83% as home care agencies, 21% as hospices). Eighty-six percent were Medicaid-certified (81% as home care agencies, 19% as hospices)(10). Medicare certification requires that the home care organization adhere to federal minimum requirements for patient care and management. Adherence to these regulations may be challenging because of their complexity.

Eight percent of the nation's home care agencies are not certified by either Medicare or Medicaid (10). A home care agency may not be certified for a number of reasons. For instance, some agencies may provide services not covered by Medicare (eg, personal care services in the absence of skilled nursing care); they may operate under the umbrella of a managed care payor or they may already be affiliated with a Medicare or Medicaid-certified organization. Organizations without Medicare or Medicaid certification cannot bill Medicare or Medicaid for services provided. They may serve privately insured or private pay patients.

Rationale for Nutrition Services in Home Care
Because of the number of diagnoses that are nutrition-related, and patient populations who are at nutritional risk, the need for nutrition services in home care is great. Home care administrators already recognize that many of their patients are candidates for nutrition intervention. They estimate that more than half of their new home care patients have some degree of malnutrition (14). Regardless of the apparent need, nutrition services are still seen as a cost. In a 1996 survey, home care administrators cited lack of reimbursement as the primary reason explaining their unwillingness to employ registered dietitians( 14). While it is true that dietitian services are not specifically reimbursed by Medicare, they can be paid for as part of IPS episodic payments, as are all other home care services. For non-Medicare patients, reimbursement for dietitian services should be obtained from managed care and indemnity insurance plans, workers’ compensation, or private pay. Other options to cover costs not paid by the patient or insurance provider include public and private grants, United Way funds, Medicaid waivers, and private pay.

One of the first hurdles that dietetics professionals face is proving the value of nutrition services. A compelling argument for nutrition services is that many of the most common diagnoses in the home care population are nutrition-related. These diagnoses include:

Diseases of the circulatory system (eg, heart disease);
Endocrine, nutritional, and metabolic diseases and immunity disorders;
Hypertension;
Diseases of the musculoskeletal system and connective tissue;
Injury and fracture;
Diseases of the respiratory system;
Diabetes; and
Malignant neoplasms (10).

Several comprehensive reviews of the medical literature show that regardless of setting, nutrition intervention contributes to improved outcomes and cost savings (16),(17),(18).

Clearly, there is a strong clinical rationale for ensuring that nutrition services are provided for home care clients who need them. But there are also persuasive business reasons. Preventing or reducing the incidence of complications and morbidity is less costly than treating problems after they occur (19).

As a consequence of changes in Medicare reimbursement, and the cost-containment efforts of other payors, home care providers must become more efficient. Home care agencies are already using strategies to reduce their costs. One of these strategies is increasing use of specialists, including use of nutrition specialists and critical pathways addressing nutrition interventions, that are effective and focused on achieving good clinical outcomes (20). The case for nutrition services becomes stronger when dietetics professionals educate home care executives about the cost-effectiveness of providing these valuable services (21).

Case Studies
Dietetics professionals should be prepared to provide cost-effectiveness success stories like the 3 cases summarized by Bryars (22). She reports a case where an 85-year-old man was admitted to a home care agency with problems including osteoarthritis, a 10-lb weight loss in the previous 2 weeks, poor appetite, and dehydration risk. After an in-home medical nutrition assessment revealed that he was consuming less than 1 L fluid daily and as little as 1,000 kcal, the dietitian provided a number of nutrition interventions. She provided diet instruction to help the client and caregivers improve the patient's intake of nutrients and fluid. She also suggested supplementing his diet with medical nutritional supplements and keeping a record of nutritional intake. On follow-up about 3 weeks later, intake records showed improved dietary intake. At the 5-week follow-up, the client had gained more than 8 Ib and was regularly consuming 2 to 3 servings of medical nutritional supplements in addition to his regular meals. As a result of this progress, the patient did not need tube feeding. In this case, provision of nutrition services resulted in a savings of as much as $250 weekly and contributed to improved quality of life for the client.

In a second case, a 79-year-old man had been seen in the emergency room twice over a period of 2 weeks. His problem list was long, including congestive heart failure, dyspnea, coronary artery disease, renal failure, and hypertension. These problems were compounded by a 40-lb weight loss in the previous 6 months. At the first emergency room visit, the patient was prescribed a 2-g sodium, high-calorie diet. Two weeks later, at the time of the second emergency room visit, a dietitian consulted with the client and his wife. She suggested modifying the diet to one providing 30g protein, 3g potassium, 2g sodium, 1.2g phosphorus, 1,500 mL fluid, and 1,800 kcal. She carefully explained the rationale for the diet—to manage the renal and cardiac dysfunction and provide enough energy to maintain his current weight. At follow-up 5 weeks later, the client's wife reported compliance with the diet, and the client reported feeling better. Additionally, he had not made an emergency room visit since the dietitian's consultation. Each 1-hour visit to the emergency room at this institution could cost as much as $2,600. The nutrition intervention provided in this case helped result in fewer emergency room visits, reduced nutrition-related complications, and improved patient satisfaction.

In a third case, a 31-year-old man was admitted to a home care agency with a diagnosis of pneumonia. He was also positive for human immunodeficiency virus (HIV). Presenting problems included respiratory failure, seizures, a recent 20-lb weight loss, and diarrhea. After completing a nutrition assessment, the dietitian discussed the option of a low-fat, high-calorie, high-protein oral diet supplemented with MCT oil and specially formulated medical nutritional supplements to prevent malabsorption and promote weight gain. She also recommended that the client consume about 1000 mL additional fluid to prevent dehydration. Both the dietitian and the client believed these dietary modifications could help the client avoid parenteral nutrition and daily tube feeding. Seven weeks later the client reported routinely consuming 2 to 3 servings of the medical nutritional supplements in addition to his usual diet, resulting in a weight gain of 10 Ib. The dietitian gained authorization from the client's managed care company for a 6-month supply of the medical nutritional supplement. At a 14-week follow-up, the client had gained a total of 20 Ib. The cost differences in this case, based on supplies alone, were $3.42 per day for the medical nutritional supplement vs $250 per day for parenteral nutrition. These savings do not include the psychological, clinical, and financial benefits gained from avoiding placement of a central line and avoiding parenteral nutrition-related complications.

Expanding Focus
Home care organizations are also focusing on diversifying and expanding their services and products to improve marketability and attract new customers. These new areas include adult day care, personal care, private-duty care, specialized disease management, and infusion therapy. Dietetics professionals should show home care executives how nutrition services can be another unique, value-added product for the agency.

Dietetics professionals are needed in home care. Nurses and other health care professionals may be able to provide basic nutrition care, but dietetics professionals are needed to develop and implement programs and protocols to address notable nutrition problems. But dietetics professionals must prove their value to the bottom line by educating home care executives about the role that nutrition services can play in generating business and revenue and improving the quality and marketability of the organization's services and products.

Roles for Dietetic Professionals in Home Care
When home care administrators ranked the value of services provided by dietetics professionals, the following services were ranked highest:

Educating/counseling patients and caregivers,
Planning and providing medical nutrition therapy for specific conditions,
Developing nutrition care plans, inservice training and communications, and
Conducting nutrition assessments (23).

In addition to these services, dietitians currently practicing in home care agree with other experts who say that dietetics professionals are especially valuable to home care organizations because they can also provide a broad array of other nutrition-related functions (22),(24),(25),(26),(27),(28),(29),(30), including the following:

Providing expertise on Medicare/Medicaid guidelines to assist in gaining reimbursement for parenteral and enteral therapy;
Developing specific parameters for identifying nutrition risk;
Developing standards of quality for nutrition services including process and outcome indicators;
Conducting in-service training of home health care professionals and paraprofessionals regarding nutrition screening criteria and prescribed diets;
Developing a system for efficient nutrition referrals and consultations;
Designing nutrition monitoring procedures for high cost diagnoses and therapies (eg, cardiovascular disease, diabetes, oncology);
Planning and implementing medical nutrition therapy;
Participating in and conducting quality assurance and outcome studies;
Performing home visits for nutrition assessment, nutrition-focused physicals, and diet instructions;
Developing menus and shopping lists based on diet orders;
Establishing and standardizing enteral/parenteral formularies and administration device inventories to help control costs;
Collaborating with insurance case managers to justify home nutrition interventions;
Planning and participating in community health fairs and screening programs; and
Accessing community resources/assistance for programs such as food pantries, meals-on-wheels, and food stamps.

In addition to these nutrition-related functions, dietetics professionals are qualified to perform in a number of other high-level roles. Home care executives believe dietetics professionals can function in nontraditional roles such as quality improvement, policy and procedure development, clinical case coordination, and outcomes research (14). Our home care panelists listed the following additional examples of nontraditional roles for dietetics professionals:

General manager overseeing general day-to-day agency operations;
Case manager coordinating nutrition services;
Director of program services developing disease management programs;
Reimbursement specialist, especially in the field of nutrition support as well as general areas;
Clinical educator for internal and external staff,
Patient educator;
Nutrition specialist developing nutrition care plans for patients or setting up protocols for other health professionals to follow;
Clinical manager coordinating daily care of patients by interacting with other health care professionals (eg, pharmacists, physicians, nurses, discharge planners, insurance agency representatives);
General sales manager;
Referral coordinator for referrals between customers and home care agency through client visits, public relations, continuing education programs, and follow-up visits with referral sources; and
Clinical liaison between a referral source and home care agency (ie, actually working in the clinic performing screenings and nutrition interventions).
Consultant for food, sanitation, and food safety services for new residential programs (ie, adult foster care and residential hospice programs).

Necessary Skill Sets and Competencies for Success in Home Care
Dietitians interested in home care would benefit from previous experience in public health, clinical and/or outpatient settings. Although the home care, industry does not demand specific credentials for registered dietitians, JCAHO requires that registered dietitians employed by home care agencies have proof of their credentials and continuing education efforts. Credentials, specialty certification, and/or certificate training for specific areas of practice in home care can be a competitive advantage for dietetics professional. Specific certification that may be beneficial include the certified diabetes educator (CDE) and/or certified nutrition support dietitian (CNSD) designations.

Skills
Dietetics professionals who possess the following skill sets are likely to be successful in home care:

Two to 5 years’ clinical experience;
Excellent oral and written communication skills;
Willingness and ability to work interdependently with and respect the expertise of other disciplines;
Excellent knowledge of enteral and parenteral nutrition for the infusion market;
Effective interviewing techniques;
Ability to educate patients, family, clinicians, and caregivers;
Ability to perform cross-disciplinary functions (eg, physical assessment, venipuncture, enteral tube placement, blood glucose monitoring), that is, being “upskilled”;
Project and case/outcome management abilities;
Knowledge of finance and reimbursement practices;
Sales experience; and
Ability to negotiate with a variety of health professionals in a team setting.

Characteristics
In addition, dietetics professionals who are successful in home care will likely possess the following characteristics:

Leadership,
Self-direction,
Self-motivation,
Self-confidence,
Curiosity,
Commitment to lifetime learning,
Flexibility,
Creativity,
Cooperativeness, and
Analytical and critical thinking.

The Future of Nutrition Services in Home Care
Actions for Dietetics Professionals
The success of dietetics professionals in home care will depend on their persistence and ability to create and provide evidence of the value of their services. Successful dietetics professionals will demonstrate that provision of quality nutrition services supports regulatory and accreditation standards, drives revenues, reduces costs, and improves efficiency and efficacy of care. A unique expertise that dietetics professionals bring is their ability to help home care agencies meet the standards for nutrition services required by regulatory and accrediting bodies. For example, a number of the 1999-2000 JCAHO standards for home care refer specifically to nutrition care (see the Figure below). It is important, however, that dietitians negotiate adequate time with the home care agency to accomplish the tasks required for the agency to meet JCAHO requirements.

FIG. Nutrition care standards from the Joint Commission on Accreditation of Healthcare Organizations. Source: Joint Commission: 1999-2000 Comprehensive Accreditation Manual for Home Care. Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations; 1998.

Dietetics professionals also prove their value when they develop nutrition services programs that include objective and measurable process and outcome indicators that help agencies meet quality standards. Regulatory and accrediting bodies that have quality standards include the Health Care Financing Administration's (HCFA) Outcome and Assessment Information Set (OASIS), the ORYX program from JCAHO, and the Health Plan Employee Data and information Set (HEDIS) from the National Center for Quality Assurance (NCQA). For more information on these programs visit their Web sites (the HCFA Information Clearing House at www.hcfa.gov/regs/regs.htm; JCAHO at www.jcaho.org; and NCQA at www.ncqa.org).

Before dietetics professionals can start to market to home care agencies, they must first conduct a needs assessment of the agency, then develop client-focused nutrition programs specifically tailored to help meet the agency's needs (31). The following are examples of effective approaches:

Conducting mock accreditation surveys and quality audits,
Making home visits for nutrition education and/or assessments,
Developing policies and procedures for nutrition services,
Incorporating nutrition interventions into agency pathways,
Designing and implementing nutrition risk screening tools,
Developing nutrition assessment and monitoring instruments, and
Developing and conducting inservice and patient education programs and materials.

Dietetics professionals can use other tactics to promote nutrition services in home care, including the following:

Identifying, cooperating with, and comarketing with other therapists contracted to home health care providers;
Marketing nutrition services to physicians, thus encouraging referrals to home health care providers offering nutrition services;
Advertising nutrition services in local and national home care newsletters and journals; and
Public speaking about the value of and need for nutrition services in home care.

Individual and/or group consultants can study home care market opportunities and develop business plans with targeted services and products. Clinical nutrition managers in health care systems are well positioned to develop home care contracts for high-risk intervention programs and general services. Assistance is often available through coordination with the finance and legal services departments of the organization. Malpractice insurance coverage is recommended.

Dietetics professionals should expect payment for services rendered. Often dietetics professionals are tempted to provide services at no cost, especially if they believe the services are needed but clients are unable to pay for them. However, services obtained at no cost may not be perceived as valuable. Dietetics professionals can and should charge fair market rate for their services on an hourly basis, per visit, or per service basis (eg, nutrition assessment, nutrition education, follow-up visit, monitoring enteral or parenteral therapy). Nutrition services might also be bundled into the complete clinical management fee, as long as this is clearly delineated in the home care agency's contract. An approach that might be used in the infusion industry is to include clinical monitoring provided by the dietetics professional as part of the clinical management fee similar to pharmacy monitoring, but charging additional fees for nutrition assessments, home visits, education and so forth.

Dietetics professionals must develop expertise in methods for gaining coverage for their services. This includes learning about insurance case manager relations and terminology used on Medicare forms, documenting nutrition risk, quantifying the potential negative outcomes if nutrition care is not provided, and objectively chronicling the positive outcomes that are supported by nutrition intervention.

Dietetics professionals interested in home care should avail themselves of the number of materials on nutrition that are available. The Dietitians in Nutrition Support dietetic practice group has developed a home care “kit” containing Medicare guidelines for reimbursement for parenteral and enteral nutrition, JCAHO standards for home care, and sample forms for nutrition assessment in home care. The Consultant Dietitians in Health Care Facilities dietetic practice group has produced the Practice Guide for Nutrition in Home Care. The American Society for Parenteral and Enteral Nutrition (ASPEN) has published nutrition practice guidelines for enteral and parenteral nutrition in home care (32). A variety of other publications and resources are frequently referred to in home care practice (33),(34),(35),(36),(37).

The following items are examples of materials that may still be needed or that need expansion for home care practice:

A nutrition screening device to incorporate into nursing admission assessments,
Protocols for triaging patients according to their need for nutrition services,
Nutrition care protocols that can be incorporated into agency protocols and care maps,
Protocols for initiating and monitoring enteral and parenteral feeding, and
Information on the liability of dietetics professionals practicing in home care.

Such items might be especially valuable if they are developed in collaboration or endorsed by ADA along with the National Association for Home Care (NAHC) or other influential organizations such as HCFA, the National Home Infusion Association (NHIA), ASPEN, or the National Association of Medical Equipment Suppliers (NAMES).

Future Considerations
On an organizational level, ADA and its members can address the role of dietetics professionals in home care through the ongoing strategic planning process. Individual members, dietetic practice groups, and, perhaps, a specific task force could identify opportunities in home care and position members to succeed in this market. Key linkages would include strengthened relationships with HCFA, JCAHO, NAHC, NHIA, ASPEN, NAMES, and other organizations and agencies that are influential in home care. An example of a potential project would be an insurance initiative to promote greater use of ADA reimbursement specialists whose major responsibility would be to educate home care decision makers about nutrition services. A model for this initiative is the success story of how Blue Cross Blue Shield of Massachusetts attained MNT coverage (38).

Another valuable effort would be to continue to collaborate on and expand health campaigns. Although these programs are familiar to nutrition professionals, they are new in the home care industry. These initiatives are an ideal opportunity to promote nutrition and position dietetics professionals as medical nutrition experts in home care. Models for this activity are the Partnership for Food Safety, the Nutrition Screening Initiative, the “It's All About You” Program, National Nutrition Month®, and the Physician Nutrition Education Program.

Strategic planning within ADA could support home care and could open opportunities by expanding the availability of grant monies to support cutting-edge issues in home care, such as outcomes research and evidence-based practice in home care; creating a home care track at the Annual Meeting and Exhibition; and recognizing and rewarding inter-dietetics practice group programs and initiatives that link all aspects of home care nutrition.

Finally, the ADA could consider marketing dietetics professionals in home care by advertising nutrition services in home care–related publications, developing and distributing direct mail pieces and press releases to key players in the home care industry, and funding and encouraging dietetic practice groups exhibits at national home care conventions.

Conclusions
Home care is an essential service that helps millions of people receive health care in their homes. Because of the influence of managed care, cost constraints on health care, availability of technology, and changing demographics, we expect that the home care industry will continue to grow, along with the need for nutrition services. Home care executives recognize their clients’ need for nutrition services. Unfortunately, nutrition services are more often considered an extra cost rather than a cost-effective necessity. We must take steps to demonstrate the clinical and financial benefits of nutrition services to these decision makers. Demonstrating value in objective terms requires that the dietetics profession mount an organized effort to gather outcomes data and to use these data to convince home care executives, national home care organizations, regulators, and payors.

On an individual level, dietetics professionals must be prepared to appropriately market nutrition services by learning all they can about the home care field, understanding agency needs, tailoring services to meet those needs, and collecting clinical and financial data to demonstrate the specific value to the agency.

The need for nutrition services in home care is high and the opportunities for dietetics professionals in home care will continue to grow. As Michael Rothkopf, MD, president of the American Academy of Home Care Physicians, said: “We have found that the dietitian plays a critical role in identifying patients at nutritional risk. These are patients who might have been identified if they were hospitalized, but now are more dependent than ever on an outpatient dietary evaluation. Once identified, the patients can also greatly benefit from registered dietitians who detail dietary intervention, plan for nutritional therapeutics, and monitor outcomes” (personal communication, September 23, 1999). It is up to dietetics professionals to put in the effort it will take to ensure that all clients who could benefit from nutrition services will receive them now and in the future.

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Recognition is given to the following people for their contributions in developing this practice report.

Editor: Sheila M. Campbell, PhD, RD.
Practice Report Panel: Patricia A. Anthony, MS, RD; Alison Arkin, MS, RD; Rosanna Gibbons, MS, RD; Kathy Hammond, MS, RD, RN; Carol Ireton-Jones, PhD, RD; Jody Vogelzang, MS, RD.
House of Delegates Task Force on Practice Papers: Cecilia P. Fileti, MS, RD, FADA, chair; Sara Long Anderson, PhD, RD; Myrtle Hogbin, RD; Harold Holler, RD; Kathleen Pintell, RD; Joan Schwaba, MS, RD; Margaret Tate, MS, RD.