Nutrition Care Process: Role of CDM

1. Nutrition Care Process: Role of CDM Mary D. Litchford PhD, RD, LDN www.casesoftware.com

2. Points to Ponder • What is the Nutrition Care Process (NCP)? • What is my role in the NCP? • What is the collaborative role of the CDM and the RD? • Practice standards vs. regulations for CDMs & RDs

3. What is the Nutrition Care Process (NCP)? • Developed by ADA for use by RDs • Standardized process for providing care • Standardized language • Systemic problem solving method for RDs to use to: • Think critically • Make decisions to address nutrition problems • Provide high quality nutrition care

4. Steps in NCP • Nutrition Assessment • Nutrition Diagnosis • Nutrition Intervention • Nutrition Monitoring & Evaluation

5. Step 1. Nutrition Assessment • Review data collected for factors that affect nutritional & health status • Cluster data to identify nutrition diagnosis • Identify standards by which the data will be compared

6. Role of the CDM in Nutrition Assessment Step • Data collection of Nutrition Care Indicators- Markers that can be observed or measured • Data that is in the medical record • New data which is added to medical record

7. Role of the CDM in Nutrition Assessment Step Collect Data from Medical Record • Personal data • Anthropometric • Lab test results • Medical diagnosis • Nutrition-orientated medical history • Results of nutrition-related medical procedures • Nutrition-focused physical findings

8. Role of the CDM in Nutrition Assessment Step • Add New data to Medical Record • Data collected from interview with resident/patient i.e. food preferences, meal & snack patterns, preferred eating environment • Food Intake vs Estimated Needs • Mealtime Behavior • Food & Nutrition Knowledge (food beliefs) • BMI • Percentage of Weight Change

9. Role of the CDM in Nutrition Assessment Step • Complete facility approved forms • Use the assessment data to complete the MDS • Check state licensure laws for dietitians to be sure this does not encroach on LD scope of practice • Check p/p for your facility

10. Role of the RD in Nutrition Assessment Step • Cluster Nutrition Care Indicators to identify Nutrition Diagnoses • Identify Nutrition Care Criteria by which the data will be compared

11. Step 2: Nutrition Diagnosis • Different from medical diagnosis • Identification of a specific nutrition problem that dietetic practitioners will treat • Categories of Nutrition Diagnoses • Intake • Clinical • Behavioral

12. Role of RD in Nutrition Diagnosis Step • RD uses ADA standardized language • Summarized as PES Statement • P: problem • E: etiology • S: signs/symptoms (S/S)

13. Example of PES Statement Problem: Excessive fat intake related to Etiology: consumption of fast foods provided by family members 2-3 times/wk as evidenced by S/S: 10% weight gainin 90 days and increase in serum cholesterol to 230 mg/dl

14. Does every Resident/Patient have a Nutrition Diagnosis?

15. Role of CDM inNutrition Diagnosis Step • Be familiar with the Nutrition Diagnoses for each patient/resident • Alert RD if any patient/resident has a change in medical condition, new medical data, new labs etc. • Follow facility p/p in contacting RD

16. Step 3: Nutrition Intervention Specific to Nutrition Diagnoses • 4 categories Intervention Strategies • Food &/or Nutrient Delivery • Nutrition Ed • Nutrition Counseling • Coordination of Nutrition Care

17. Step 3:Nutrition Intervention • Nutrition intervention is primarily aimed at etiology of nutrition dx • Nutrition intervention may be directed at s/s to minimize their impact • Uses ADA standardized intervention terms

18. Role of RD in Nutrition Intervention Step Write interventions that are specific to each Nutrition Diagnosis Includes: • Nutrition Prescription- i.e. Diet Order, recommendations for energy, protein, fluid intake, etc. • Goals/ expected outcomes • Actions to be taken • Collaboration with other colleagues

19. Example:Nutrition Intervention • PES- Inadequate protein intake related to dysphagia, dementia and muscle wasting as evidenced by leaving more than 25% of protein rich foods served at lunch and supper on 25 out of 30 days, albumin 2.6 mg/dl & stage 2 pressure ulcer on sacrum.

20. Example :Nutrition Intervention • Selected Interventions: • Nutrition Prescription: Mechanical Soft diet with ground meats & gravies with fortified foods & protein supplement to provide 1800 Kcal, 90 gm protein, 1500 ml fluid • Serve double portion of eggs at breakfast • Fortify breakfast cereal with Brand A protein supplement to provide 20 gm complete protein • Fortify HS milkshake with Brand A protein supplement to provide 20 gm complete protein • Collaborate with nursing on dining room seating assignment & mealtime assistance

21. Role of CDM in Nutrition Intervention Step • Collaborate with RD & nursing to develop nutrition intervention strategies • Confirm that the Nutrition Prescription is being served • Order & keep adequate stock of the products required in nutrition care interventions • Confirm that recipes for fortified menu items are being followed and prepared as ordered

22. Role of CDM in Nutrition Intervention Step • Confirm that protein or oral supplements are being served as ordered • Confirm that all other interventions are implemented i.e. adaptive equipment, dining environment • Collaborate with healthcare team to determine obstacles to interventions

23. Role of CDM in Nutrition Intervention Step • Use the nutrition interventions in developing RAI/care plan • Check state licensure laws for dietitians to be sure this does not encroach on LD scope of practice • Check p/p for your facility • Notify the RD if significant changes occur that affect nutrition status • Follow your facility p/p

24. Step 4:Nutrition Monitoring & Evaluation • Goal: to monitor, measure & evaluate progress in achieving goals/expected outcomes • 4 Categories of Nutrition Care Outcomes: • Food/nutrition related history • Biochemical data, medical tests & procedure • Anthropometric measurement • Nutrition-focused physical assessment findings

25. Examples ofNutrition Care Outcomes Examples of 4 categories of Outcomes • Food/Nutrition Hx:dietary & herbal intake, beliefs, knowledge, physical activity, nutrition quality of life • Biochemical & Medical Tests:labs, tests (gastric emptying time, RMR) • Anthropometric: ht, wt, BMI, wt history • Nutrition-Focused Physical Findings: physical appearance, muscle & fat wasting, swallowing function, appetite, nails, tongue

26. Role of CDM in Nutrition Monitoring & Evaluation Step • Collect/summarize monitoring data for RD to evaluate • Notify the RD if significant changes occur that affect nutrition status (follow your facility p/p)

27. Examples of Monitoring Data • Weight changes- 5% wt gain in 30 days • Summarize Intake Data- refused breakfast 10/30 days, eats 50-75% of meals 20/30 days, consumed 75-100% protein supplement 20/30 days, refused thicken liquids 25/30 days • Summarize V/M Supplement Intake- took folate supplement 25/30 days, refused iron supplement 20/30 days • Summarize Behavior- accepted feeding assistance at evening meal 15/30 days

28. Role of RD in Nutrition Monitoring & Evaluation Step • Determine & document progress toward meeting nutrition care outcomes • Examples: • improvement in labs • improvement in resident/patient’s ability to self feed • reduction in use of supplements • stabilization of weight • Identify new nutrition diagnosis

29. Practice Standards vs. Regulations

30. Who Sets Practice Standards? Dietary Managers DMA Developed Practice Standards • Documenting in Medical Record • www.dmaonline.org/Resources/DMAResources/standard02.shtml • Documenting Fluid Intake • www.dmaonline.org/Resources/DMAResources/standard08.shtml CDMs certified by CBDM

31. Who Sets Practice Standards? RDs/LDs • Dietitians Licensed or Certified by State Agency in 48 states • Rationale of License - to prevent harm • Scope of Practice varies by state

32. Who Sets Practice Standards? RDs/DTRs • Developed by ADA • Describes the minimum level of competency for the RD and DTR who provide direct resident care • Defines Supervision of the DTR • Role of RD & DTR in NCP

33. CMS Regulations • CMS RAI Version 2.0 does not mandate the RD complete any part of the RAI • It states, “A facility may assign responsibility for completing the RAI to a number of qualified staff members. • Staff members MUST have knowledge & skill to do so. 483.20 Accuracy of Assessment (F278) • In most cases participants are. . . licensed health professionals.”

34. CMS Regulations • F279 A Comprehensive Care Plan must be. . . • “Periodically reviewed and revised by a team of qualified persons after each assessment” • Qualified is not defined • CDM may write care plan, initiate such care, & write quarterly assessments as long as the assessments are signed by RN responsible for conducting & coordinating assessment.

35. CMS Regulations • Is the RD required to sign RAI document prepared by CDM? • CMS does not require RD to sign RAI • State licensure laws may or may not require the RD to sign the RAI • Facility p/p may or may not require the RD to sign the RAI

36. Who is ultimately responsible for the nutrition care of their patients/residents

37. Remember that…. • RD Supervision • RD is accountable for the nutrition care of the residents • The RD must answer to residents, employers, licensure boards, and the legal system is resident care is compromised • RD does not delegate duties, he/she assigns them

38. Remember that… • RD verifies Credentials • DTR • CDM • RD Establishes & Verifies Competence • CDM Nutrition Care Self-Assessment Tool (5/2009) • Nutrition Documentation Readiness for CDM, CFPP's (5 hr online CE)

39. Bottom Line • The RD & CDM will continue to work together, as a team, to enhance the resident’s quality of life • The role of the CDM in the nutritional care of the resident is determined by his/her competence