Summary of HOD NCP Dialogue 2002

Consolidation of Dialogue Books and Flip Chart Notes

October 18, 2002


MEGA ISSUE QUESTIONS:

  • How effectively does the proposed process reflect the dietetic professional as the provider of nutrition care?
  • What are the strengths of the proposed model and what needs to be added or further refined in order to create the right model for a standardized nutrition care process?

PROPOSED CRITERIA FOR THE NUTRITION CARE PROCESS

1. Is this the right set of criteria upon which to base a nutrition care model?

  • Yes, with revisions based on the dialogue.
Criteria Numbers of Table that Agreed with Criteria
1. Used in a variety of settings 14
2. Includes nutrition diagnosis, education and outcomes 10
3. Easily recognizable 12
4. Visualizes entire process/context 13
5. Already established common language 12
6. Impacts current regulatory standard 12
7. Specific to nutrition/dietetics professionals 11
8. Electronically friendly 13
9. Suitable for field testing/validation 16
10. Supported by CADE’s educational competencies 14
11. Includes DTR 11
12. Can validate nutrition care 14
13. Usable at all levels 15
14. Supports teamwork 15
15. Depicts unique knowledge and skills 13

2. Are there other criteria that need to be clearer?

Clarifications to Proposed Criteria Original Criteria
Need assumptions — not management in addition to already in place criteria #1
Do we mean “adapted to” all settings #1
Can definition of settings be more defined to include examples such as day care/schools/management activities? #1
Does it include impact and cumulative value? #2
Need more clarity to reflect document #2
Include: nutrition dx, evaluation, plan and outcomes #2
Needs to include assessment, intervention, documentation as well as the other steps of the nutrition process mentioned in this criteria point #2
It is unclear how reimbursement coding systems (current or future) are related to DX and assessment #2
Define ‘nutrition diagnosis’ and try to increase comfort level of practitioners #2
Not clear (recognizable by whom RD/Regulatory agencies, other professions, clients and 3rd party payers) #3
Add other regulatory language #5
Does state licensure support “nutrition diagnosis”? #6
Not clear what “impact” means — content is “congruent with”? #6
Add RD and DTR #7
Ask to explain rationale below the 2 (are they the same thing?) #7, #15
Merge #7 into #15 — both cover similar areas; process should be specific but universal enough that anyone with nutrition in scope of practice would want to us this model #7, #15
Need to clarify role of interdisciplinary team and dietetics professional (“promotes” vs “support”) #8
Add focus group testing (preference for option #1 or option #2 varied) #9
Process should be flexible enough to hold up our time so don’t need to retain staff every 1-2 years. This should be looked at in field-testing #9
Question the Intent: ADA sets direction of practice which is supported by CADE #10
Define ‘CADE’ for those who don’t know — or spell out undergrad/grad education #10
Delete DTR and change it to “includes all dietetics professionals” #11
Define DTR scope of practice more clearly — criteria should define how DTR is include — data collection is RD actual assessment #11
Includes a role of DTR #11
Include with #15 #11
Clearly ID the dietetics professional #11
Criteria not needed #11
Merge #11 into #13 to demonstrate continuum from DTR to expert level; have one inclusive continuum #11, #13
Collapse into one (call all levels of nutrition profession) #11, #13
Clearly define DTR responsibilities/scope #11, #13
Need to consider time constraints #12
End statement after "validate nutrition care" #12
Needs to be more concise #12
Question the Intent: is it that all levels of practitioners do all steps? #13
Does this reflect that all components be used or that all would be using the entire process? #13, #15
Can we omit “unique”? #13, #15
Promotes (not “support”) #14
Need to expand on collaboration with others/disciplines #14
Demonstrates (not “depicts”) #15
Overall — can we improve clarity for the practitioner and consumer? #15
Need to articulate behavioral change aspect more #15

3. Are there any critical criteria that are missing?

Additional Criteria To Consider
Model should show how outcomes of the Nutrition Care Process are used as basis for research (note: this is in the text — put it in the criteria)
Model should be related to “scope pf practice” (e.g., re-define, expand, update)
Supports code of ethics
Should be science-based including physical, social and behavioral sciences
It was difficult to view if anything is missing without the mechanics of how the process will operate
Include ethical and diversity considerations
Include temporal influences
Recognize individuality of practitioner skills
Recognize the interface of the attributes of the client/practitioner partnership
Easy to recognize in practice for any healthcare professional or 3rd party payer, state agencies, JCAHO or other stakeholders that this is the way a dietetic professional practices their work
Role of or necessity of the dietetic professional includes the DTR — combine #11 and #7
Combine 11 and 13 — call all levels nutrition professionals (RD, DTR, entry level, expand)
Needs to recognize continuum of care, life cycle/life span and evolution of nutrition science and care; requires re-assessment of the model (dynamic)
Will economics impact process (i.e., rural versus urban)
What is common language of the profession should include glossary of terms
Behavioral intervention
Create mechanism to test model with existing data
Develop tools for practitioners to enter data from model for aggregate use
Legal issues to state licensure
Time limitation for adoption
Foods as a component of what (need to translate nutrition into personal food choices)
Need to add language (a criterion, i.e., ethical practice)

STEPS IN THE NUTRITION CARE PROCESS

Are these the right steps in the right order? Why or Why Not?

Screening/Assessment

  • Screening or referral should be the first step. (x13) This is important when considering the involvement of the DTR. (x2)
  • Screening is both external (on model) and internal). The internal screening is not reflected here.
  • Diagnosis would require an external referral.
  • Referral as to a possible aspect of intervention may be collaboration interdisciplinary or external referral.
  • Need to reassess — loop back.
  • Important to assess before intervention.
  • Identify questions to be asked in first step of screening.
  • DTR included in screening step.
  • Assessment and Diagnosis should be a single step.

Nutrition Diagnosis

  • Diagnosis and documentation as subset and separate steps.
  • Consider Nutrition Diagnosis for its applicability to other nutrition care settings and liability for dietetics professional.
  • Dietetics professionals can and do diagnose nutrition problems — word is needed along with education.

Nutrition Intervention

  • Changing intervention to nutrition plan (JCAHO and Medicare look for plan of care) — intervention would then be part of the nutrition plan.
  • Still needed as part of process.
  • This is an ACTION in part of the process — translate to outcomes.
  • Change to Nutrition Intervention/Plan and Implementation.

Nutrition Documentation

  • Eliminate documentation but make inherent in other steps.
  • Include step to identify information management.
  • Step needed.
  • Should be Nutrition Documentation/Communication.
  • Should be interwoven into each one of the steps and should not be a separate step.
  • Omit as a step because it is a process that should be taking place all during the process (4).

Nutrition Outcome Evaluation

  • Determine impact and value of the nutrition outcome and disseminate the information.
  • Follow-up is a problem — weakest link for community and acute care.

General Comments

  • Order is just fine (11).
  • Since this is Nutrition Care Process, eliminate the words “Nutrition” in each step. Should just be Assessment, Diagnosis.
  • Eliminate sequencing/ordering to allow for flexibility.
  • Consistent language with regulatory groups.
  • How will it most effectively be used by members/practitioner?
  • SIX STEP: Report the results in documentation — or add a step to go back and reassess (build in feedback loop where needed).
  • Add step: DISCHARGE — end nutrition care of client.
  • Add new step that indicates that you can return to any step in the process depending on the circumstances. (x3)
  • Suggest deleting the idea that there is a specific order. The important message is that this is a process rather than a specific sequence of actions.

NUTRITION DIAGNOSIS AS PART OF NUTRITION CARE PROCESS

How Do We Create Better Understanding of the New Definition of Nutrition Diagnosis?

  • If diagnosis codes are developed will the non-licensed, non-registered individual be able to utilize them? How will we educate them?
  • Use PDP as option to better understand and give practitioners the option.
  • Open up to grassroots members and ask which codes they may find helpful and use.
  • Use the models already out there — i.e., physicians initiative program and the model for rolling out PDP program — delegates going to districts/grassroots and teaching practitioners
  • Similar to other professions who have diagnostic codes.
  • The word “diagnosis” means something different in some settings. In community need a different term to describe diagnosis.

NUTRITION DIAGNOSIS AS PART OF NUTRITION CARE PROCESS

Advantages and Disadvantages of Including Nutrition Diagnosis in the Process

ADVANTAGES DISADVANTAGES
Makes reimbursement easier; potential for reimbursement if matches with MNT/ICD codes. Resistance from other professions.
In sync with other professions. Limitations in practice if not inclusive list—limit scope.
Training students & new employees. Limit reimbursement potential.
More standard care. Different connotations of diagnosis in different nutrition settings.
Better standards of practice. Education — reaching members and non-members.
Outcomes based research. Not appropriate in all settings.
Legally defensible. Liability risk and not following through with intervention.
Descriptive of the task. State licensure laws limit practitioners.
Typical interventions-monitoring outcomes. Practitioners not interested in changing practice.
Increase specific of problem. Price ourselves out of practice.
More credibility for the profession. May distract from overall goals and other professionals may become resistant to nutrition.
Recruit students to profession. Language seems very individual specific/MNT specific. Makes it difficult to translate the concept to a “group diagnosis”. For example “food insecurity” would be population based. Limits understanding to clinical settings.
Documentation in one place; will improve communication among health care providers. Practitioner discomfort.
Project profession forward. Money, effort, time to define, train and disseminate to membership.
Defines problems which assists in outcomes measurements. Challenge for educators to teach.
Supports identifying “best practices” — starting point. Time to implement will be long.
Creates common language. Difficult to implement in community setting.
Could tie nationwide outcomes with specific diagnosis.  
Creates accountability.  
Opportunity to clarify the problem.  

NUTRITION CARE PROCESS: ROLE OF RD AND DTR

Single Model for Dietetics Professionals: Why or Why Not

  • YES — dietetics is evolving and as we separate it will create problems.
  • YES — RDs and DTRs are both Active Members with equal membership rights.
  • YES — collaboration.
  • Single Model implies DTR can do everything in the model and have same skill sets.
  • YES — DTRs perform steps in model under supervision of the RD, especially in Long-term Care.
  • YES — community setting using non-credentialed people to perform some steps in the model — working under supervision of the RD.
  • Process is ultimately under the direction of RD — but allows for flexibility across care settings as well as geographical areas.
  • Encourage DTRs to have same level of professionalism as RD.
  • With two models RD might have to do work of DTR, if facility does not have DTRs.
  • Modeling a process not who performs the process.
  • Process/Model must be consistent — does not matter who performs the model/steps.
  • Model needs flexibility to allow for different levels of skills — both RDs and DTRs.

What Are the Advantages/Disadvantages of Having a Single Nutrition Care Model for Both RDs and DTRs?

ADVANTAGES —

  • Including screening step encompasses DTR.
  • Opportunity to advance the profession-promote teamwork concept.
  • RDs to focus on outcomes management steps of the process.
  • No need to be specific — performer does not need to be defined.
  • Already addressed in scope of practice, dependence is on utilization of process by practitioner.

DISADVANTAGES —

  • None listed

Additional Comments —

  • Scope of practice for DTR should be addressed — and relate back to the state laws pertaining to their scope.
  • DTR should be added to task force.
  • GRID: change language to dietetics professional in all steps and all settings — many steps DTR can perform.

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