July 27, 1998

Introduction

The American Dietetic Association would like to thank you, Senator Grassley, for this opportunity to submit our views for the hearing record on the issue of the quality of care in California nursing homes. Like so many others, we are deeply disturbed by the heartbreaking reports of the thousands of nursing home residents suffering from malnutrition, dehydration, pressure sores and other forms of neglect in these facilities. Everyone should be shocked by the findings of the General Accounting Office (GAO) report that as many as a third of all California nursing homes have been cited for "serious or potentially life-threatening" care problems. While your hearings focus on California, our members indicate that similar problems can be found in states throughout the country, where inconsistent enforcement of health and safety regulations leads to much of this suffering.

While it is clear that measures to curb malnutrition in nursing homes are badly needed, we urge you to view this problem as part of a larger complex of issues related to senior citizens' overall nutritional health. Unfortunately, the antecedents of nursing home malnutrition are often established long before residents enter these facilities. Nutrition services across the continuum of care--not merely in the nursing home setting--must be addressed if progress is to be made in this area.

We applaud the committee's efforts to uncover instances of nursing home neglect and to address them before they become even more severe. We stand ready to lend our expertise as nutrition professionals to assist you in finding ways to end these problems and hope that our statement will be of assistance to you in this regard.

The Role of the ADA and Dietetic Professionals

The ADA, with nearly 70,000 members, is the world's largest organization of food and nutrition professionals with members serving in every facet of nutritional science. Our members serve the public through the promotion of optimal nutritional health and well-being and are uniquely educated, trained, and qualified to provide nutrition services in a variety of health care settings. With a minimum of five years of education and training specifically devoted to the science of nutrition, registered dietitians (RDs) can boast of a higher degree of expertise in this field than an other class of health care provider.

The vast majority of RDs work in the treatment and prevention of disease in an array of health care settings. RDs are found in hospitals, clinics, physicians offices, home health agencies, retirement communities, nursing homes and other health care facilities. Today, nearly 7,000 ADA members work in long term care facilities where they are on the front lines in the battle against malnutrition among the elderly. As experts in the field of geriatric nutrition, these highly trained health professionals represent an invaluable source of advice and practical experience that should be highly regarded as policymakers seek to eradicate malnutrition in nursing homes.

Federal policies have long recognized the indispensable role of the RD in the area of nutrition assessment and intervention. For years, Medicare regulations have ensured that dietitians are an integral part of the health care teams serving patients in hospitals, hospices, home health agencies, end stage renal disease programs and nursing facilities. In fact, under Medicare's "conditions of participation" rules, these entities are required to utilize the services of "qualified dietitians." This policy helps ensure that all of a Medicare beneficiary's relevant health care needs are addressed, including their nutritional requirements. The result has been improved health and quality of life for millions of elderly Americans over the last few decades.

We are proud of the fact that our role as leaders in health and nutrition policy continues to be recognized at the highest levels. The Clinton administration, in announcing its recent nursing home initiative, named the ADA as the sole private organization with which it will consult in developing "best practices" in the prevention of pressure ulcers, malnutrition and dehydration. This was among the issues the ADA discussed with the Health Care Financing Administration in a meeting earlier this year, and we are delighted the administration has chosen to continue to seek our help.

Combating Malnutrition in Nursing Homes

As the committee knows, malnutrition is a complex issue, especially among nursing home residents. These individuals are more susceptible to this condition than other groups of elderly people due to a variety of factors. Multiple medical diagnoses, advanced age, high medication use, compounding mental disabilities and problems with eating and swallowing all contribute to malnutrition among nursing home residents. The testimony provided to the committee last year at its forum on "The Risk of Malnutrition in Nursing Homes," and the new evidence brought to light through the GAO report, highlights the true complexity and extent of this problem. This evidence should make it abundantly clear that immediate and extensive policy changes are necessary if nursing home malnutrition is to be curtailed.

While many areas should be addressed, we believe the following areas require immediate action.

a.) Training Additional Staff to Feed Residents

While malnutrition in nursing homes can have many causes, one of the most common exacerbating factors is that too few staff are available to ensure residents are properly fed. Because current regulations restrict the classification of those who can participate in feeding, this critically important task is often left to overworked staff whose background and training may not prepare them for the complications that can arise related to resident feeding.

In addition to ensuring that adequate numbers of staff are available, steps must be taken to appropriately train these individuals in proper feeding techniques. Last year, we recommended to your committee that training of a broader range of staff and volunteers to assist with resident feeding was needed. We continue to believe that this one change will help alleviate a great deal of this problem and are encouraged that the Clinton administration has included such a provision in its proposed legislation on nursing home improvements.

b.) Ensuring RDs are Part of the Nursing Home Care Team

As we have indicated, HCFA regulations require that long term care facilities employ qualified dietitians either full-time, part-time, or on a consultant basis [Medicare State Operations Manual (HCFA-Pub. 7)]. Despite this requirement, too little is done to ensure that RDs are given a prominent role in screening, assessing and treating patient's nutritional needs. In order for proper assessments to be performed, nourishing and appealing meals to be prepared, and effective and regular monitoring to be conducted, RDs and other nutrition professionals must be available and included as part of the interdisciplinary health care team in all long-term care settings. Within state guidelines, these facilities have a great deal of flexibility in determining the number of hours that dietetics staff are available in a facility. While some flexibility is probably warranted, too often this has resulted in cut backs in the number of hours RDs spend at these facilities. We have received numerous reports of nursing homes seeking to cut costs by delegating nutrition services to persons with minimal qualifications, a trend that is undoubtedly contributing to declines in resident nutritional status. While we are not prepared to recommend a specific number of required hours, we urge the committee, HCFA and the nursing home industry to work with us to determine an appropriate range of hours necessary to ensure adequate nutritional care.

c.) Including More RDs on Survey Teams

States should be encouraged to employ more RD surveyors. Many states have registered nurses or sanitarians completing the nutrition/food service survey. Generally, these professionals possess limited background in nutrition and dietetics, while RDs are clearly the most qualified professionals for this task. Lack of understanding of the role that nutrition and RDs play in caring for nursing home residents can result in an inadequate and inappropriate review of nutritional services. This can be avoided through the use of more RDs as nursing home surveyors.

d.) Addressing the Nutritional Health of Seniors Prior To Nursing Home Stays

We urge all who are involved in the care of the elderly to recognize malnutrition as a multifaceted problem with multiple causes that frequently occur prior to residents ever being admitted to nursing home facilities. Too often, patients treated at home, in doctors offices or in hospitals leave those settings without appropriate consideration of their nutritional status. As a result, many are admitted to nursing homes in a compromised nutritional state, making them more susceptible to a variety of illnesses and injuries.

To combat poor nutritional status among seniors, public policy should do more to prevent malnutrition and nutrition-related medical complications generally. ADA is supporting the "Medicare Medical Nutrition Therapy Act" (S.597, H.R.1375), legislation to provide seniors with access to "medical nutrition therapy" (MNT) in outpatient settings under the Medicare program. Currently, coverage for this service is virtually non-existent through the Part B portion of Medicare, even though more and more private health plans are recognizing its value. If we want to reduce the incidence of malnutrition in nursing homes, and the myriad health complications that follow, it makes sense to provide senior citizens with access to MNT services as a way of keeping them healthy. Clinical evidence indicates that MNT can improve health outcomes and reduce medical costs for patients with pressure sores, diabetes, heart disease, high cholesterol, cancer and other diseases that are frequently found among the elderly. We firmly believe that coverage for MNT will bring immediate benefits to the senior population through fewer and shorter hospital stays, a reduction in medical complications and the alleviation of the physical and emotional toll taken by malnutrition in nursing homes.

Conclusion

There are many complex and interrelated issues that lead to malnutrition in nursing homes. Solving this problem will require a comprehensive response that utilizes the expertise of all relevant experts--especially RDs. We have attempted to suggest a few ways by which the situation can be markedly improved, but we urge the committee to consider other policy changes as well. Nutrition professionals understand most clearly the causes and effects of malnutrition on the human body and ADA is committed to combating this debilitating condition. We look forward to working with Congress to take whatever steps are needed to ensure that nursing home residents enjoy the quality of life that they deserve.