Testimony of Ann Gallagher, President
The American Dietetic Association
Prepared for the Senate Special Committee on Aging
Wednesday, November 3, 1999

The American Dietetic Association (ADA) is the world's largest organization of food and nutrition professionals. Our 70,000 members work in every facet of nutrition and are dedicated to serving the public through the promotion of optimal nutritional health and well-being. I am Ann Gallagher, president of ADA.

We commend the Committee for its work on behalf of the elderly. My testimony focuses on the role of the nutrition professional in assuring the highest quality of care for nursing home residents. This is the area of dietetics that I practice and I testify from personal experience about staffing needs in nursing homes.

The importance of good nutritional status in the elderly is without question. According to the 1996 edition of the US Preventive Services Task Force Report, diseases associated with dietary excess and imbalance rank among the leading causes of illness and death in the US. Major diseases in which diet plays a role are coronary heart disease, some types of cancer, stroke, hypertension, diabetes and obesity. Nutritional factors have also been linked to osteoporosis, constipation, diverticular disease, iron deficiency anemia, oral disease and malnutrition. Poorly nourished adults have higher morbidity and mortality rates. In addition, functional status is diminished, rates of admission and readmission to institutional settings, complications rates, as well as length of stay are increased in poorly nourished adults.

To address the nutritional care needs of the elderly, ADA has aggressively advocated for Medicare Part B coverage of medical nutrition therapy provided by registered dietitians and other nutrition professionals. ADA is pleased that Chairman Grassley is one of the 28 Senators and 227 members of the House who have recognized the importance of this service and cosponsored the legislation. We know that enactment of this legislation will go a long way toward helping our nation's seniors manage diseases such as diabetes, cardiovascular disease and kidney disease and prevent costly complications and treatments. We look forward to working with the members of this Committee to see this important coverage included in Medicare reform next year. We believe that access to this critical service in an outpatient setting will mean that when nursing home care becomes necessary, residents will be better nourished upon admission and thus better able to manage and cope with their frailties.

ADA has been a leader throughout the years in working for the highest quality nutrition care for long term care residents as well as all of our nation's elderly. In fact, in the summer of 1998 when President Clinton announced his nursing home initiative to improve the quality of care for nursing home residents, ADA responded to the challenge. ADA convened a task force of experts in nutritional care of the elderly and immediately began working with other organizations in the field to develop a set of tools for use by nutrition professionals in providing the best care to nursing home residents. Our tools include a nutrition risk assessment form to be completed by the nutrition professional such as the registered dietitian. Linked to HCFA's Minimum Data Set, the form contains eight risk factors -- such as unintended weight loss or gain, dehydration and pressure ulcers -- which must be evaluated by the registered dietitian. Once a resident is identified as at risk for one of these factors, strategies and interventions to address the problem are provided. The nutrition assessment and intervention tools are being widely distributed throughout our association and other related organizations.

In addition, ADA has worked in partnership with the American Academy of Family Physicians and the National Council on Aging -- as part of the Nutrition Screening Initiative -- to develop a set of nutrition care alerts targeted at nursing assistants, other members of the interdisciplinary care team and consumers. The Alerts, which are being widely disseminated to nursing homes and will be part of HCFA's Nutrition and Hydration Awareness Campaign, identify warning signs and action steps for unintended weight loss, dehydration, pressure ulcers and residents who are tube fed.

The members of The American Dietetic Association are dedicated to providing the highest quality of care and equipping our members, other health care professionals and the consumer with tools to promote optimum nutritional care. However, even the most comprehensive care plan cannot guarantee that residents are getting the best care if nursing homes are inadequately staffed. In particular, we must have a sufficient number of nursing assistants, licensed nurses and registered nurses, and dietitians if the residents are to receive quality care -- particularly nutrition care.

Nursing homes are required by HCFA to have a dietitian either as a full-time employee, part-time employee or consultant. However, many states have set a minimum number of hours for dietitians to be in a facility each week -- in some cases that number is as few as eight hours per month. Unfortunately some facilities perceive the minimum -- and often inadequate -- number as the maximum number of hours needed. That is simply not enough time for the nutrition professional to do all that is required to ensure that quality nutritional care is provided. To address this problem, ADA has developed guidelines to help dietitians determine the appropriate number of hours necessary to complete their clinical responsibilities -- including, for example, assessment of a resident's ability to eat and feed themselves, care-planning and continuous evaluation of interventions. We see this as a positive way for nutrition professionals to address some of the staffing needs within long term care. No staffing discussion is complete, however, without consideration of staffing competencies -- especially in relation to resident dining. In addition, HCFA's existing limitations on who can assist residents during meals should be revised to meet the demanding nutritional needs of nursing home residents.

The nearly 70,000 members of The American Dietetic Association thank the Committee for its leadership on quality care in nursing homes and for its diligence in assuring that HCFA's nursing home initiative is successfully implemented. We stand ready to assist in any way and look forward to continuing to work with the Committee and staff toward the highest quality of care in each of our nation's long term care facilities.