1. Renee Walker, MS, RD, LD, CNSC, FAND June 2015 Therapeutic Diet Order Writing: the road to implementation

2. Disclosure 2 None

3. Objectives 3 Understand the CMS rule on diet order writing Identify obstacles to diet order implementation Review supporting Academy resources

4. Food and Dietetic Services §482.28 Old RuleRevision effective July 2014 Required therapeutic diet be prescribed by the practitioner responsible for the pt’s care All diets, including therapeutic diets, must be ordered by a practitioner responsible for the pt’s care, or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff and in accordance with state law 4 What is a qualified dietitian or qualified nutrition professional? Meets determined education, experience, training, licensure or registration, and professional SOP.

5. More about this rule 5 Response to President’s Executive Order 13563 -reduce or revise/streamline Reduced burden on MDs/PAs, NPs Saved HC $$ for hospitals

6. The Basics of the New Rule Centers for Medicare and Medicaid Services (CMS) * Allows RDNs to become privileged to independently 1) Order diets 2) Order lab tests to monitor nutritional efficacy Ordering privileges are determined by hospitals, their medical staff and state laws, including scope of practice laws Ruling effective July 11, 2014 6

7. Reasons for Change ↑ Efficiency ↑Efficacy Free time of MDs or other HC providers $$$$Cost Savings$$$$ $459 million in annual hospital costs 7

8. Support for Ordering Privileges StudyOutcomes 2010 Retrospective Cohort ( N=1965) Peterson et al RD ordering PN in a 613 bed hospital ↓ Inappropriate PN usage Savings $135K annually ~$169K in 2014 Smaller hospitals ~ 164 bed save $45,641 w/ inflation adjustment 2008 Clinical Manager Survey (N=1500) Weil et al RD level of prescriptive authority and barriers to obtaining Independent ordering would not be CMS accepted = significant barrier to obtaining privileges 2007 PN complications ( N=190) Duffy et al PN ordered by RD  fewer days hyperglycemia (57 vs 23 %) fewer electrolyte abnormalities ( 72 vs 39%) 8

9. Who’s implementing? Prior to ruling ~ 5% (245 hospitals) are already granting RD ordering privileges After ruling Initially estimate 75% (3,674 inpatient hospitals) 3674 hospitals x $45,641 in reduced PN usage=$167,730,675 annually 9

10. Cost savings $69/hr cost diff RD ( $57/hr) MD, PA, NP( $126/hr) 7,000 inpatient stays per hospital per year at least one dietary plan/order per stay avg 5 days 8 min per stay non-complex diet, lab ordering, diet modifications, and discharge orders 18 minutes complex orders i.e. PN, TF 10

11. Health Care Dollars Saved 11 Time HC$: ((3,675 hospitals x 5600 inpt hospital staysx0.13 hrs of staff time x$69/hr staff cost difference)+(3,675 hospitals x 1400 inpt hospital stays x 0.30 hr of staff time x$69 staff cost difference))

12. What does therapeutic diet include? 12 Scope of practice may include/not limited to Enteral nutrition Parenteral nutrition Oral nutrition supplements Medical Nutrition foods Dietary supplements Vitamins Minerals Diet textures  No definition in CoP(Condition of Participation)  Academy definition adopted  Intervention by HC provider to treat disease by adjusting substances in diet (ie. Na, k+)

13. Impediments/Obstacles 13  Changes to regulations or statutes to align with prior CMS definition  Review state licensure/practice acts/regulatory impediments

14. Therapeutic Diet Orders: State Status and Regulation 14 States are color coded in a stoplight fashion to indicate: Green: No apparent obstacles Yellow: Certain statutory or regulatory language exists, Affiliates should work with state regulators to ensure the language used in the interpretation will enable qualified RDNs to see privileges for therapeutic diet. Red: Significant statutory or regulatory impediments exist Source:http://www.eatright.org/dietorders/statestatus/ assessed on October 4, 2014

15. Academy Resources 15 Look to Academy resources for 1) Suggestions on how to discuss this issue 2) Strategies for obtaining privileges 3) Sample of policy and procedures Examples of current resources: Practice Tips: Hospital regulation-Ordering Privileges for the RDN Practice Tips: Implementation Steps- Ordering Privileges for the RDN FAQs-CMS Final Rule Related to Therapeutic Diet Ordering Therapeutic Diet Orders: State Status and Regulation http://www.eatright.org/dietorders/

16. Conclusion 16 Hospitals now have authority to grant diet ordering privileges to RDNs Before pursing, review state licensure/practice acts and associated regulatory impediments Valuable resources are available from the Academy

17. References 17 Department of Health and Human Services for Medicare & Medicaid Services 42 CFR Parts 413, 4416, 440, 442, 482, 483, 485, 486, 488, 491, and 493 [CMS-3267-F] RIN 0938-AR49. Medicare and Medicaid Programs;Regulatory Provisions to Promote Efficiency, Transparency and Burden Reduction; Part II. AGENCY: Centers for Medicare & Medicaid Aservices (CMS), HHS. ACTION: Final Rule. Federal Register/Vol 79, No. 91/Monday, May 12, 2014/ Rules and Regulations. Academy FAQs. www.eatrightpro.org/resource/advocacy/quality-health-care/consumer-protection-and-licensure..accessed 4/2/15. Duffy J, Gray RL, Roberts S, et al. Independent Nutrition Order Writing by Registered Dietitians Improves Patient Outcomes. 2007; 107(suppl 3):A86. Kinn TJ. Clinical Order Writing Privileges. Support Line. 2011;33:4;3-10 Peterson SJ, Chen Y, Sullivan CA, et al. Assessing the Influence of Registered Dietitian Order-Writing Privleges on Parenteral Nutrition. 2010;110:1703-1711. PRACTICE TIPS: Hospital Regulation ‐ Ordering Privileges for the RDN http://www.eatrightpro.org/~/media/eatrightpro%20files/advocacy/practice-tips-hospital-regulation-ordering-privileges-for-the- rdn.ashx PRACTICE TIPS: Implementation Steps – Ordering Privileges for the RDN http://www.eatrightpro.org/~/media/eatrightpro%20files/advocacy/practice-tips-implementation-steps-ordering-privileges-for- the-rdn.ashx Weil SD, Lafferty L, Keim KS, et al. Registered Dietitians Prescriptive Practices in Hospitals. J Am Diet Assoc. 2008;108:1688-1692..

18. Does this rule do anything else in addition to making this change to Diet ordering? 18 From the Academy FAQs Yes. The Final Rule clarifies that RDNs may be included on the medical staff, as they “have equally important roles to play on a medical staff and on the quality of medical care provided to patients in the hospital.” In addition, the final rule reviewed suggestions that would enable RDNs and other practitioners to furnish and bill for site telehealth services through rural health clinics (RHC) in a way that will not result in duplicate payment(once through the Medicare RHC cost report and again through the Medicare Part B physician fee schedule payment)

19. What does it mean to have hospital privileges? 19 From Academy FAQs “ Privileging is the process by which a hospital’s medical staff individually evaluates each practitioner and determines that he or she has the qualifications and demonstrated competence to perform all of the specific tasks for which privileges are granted.” How does this apply to RDNs in long term facilities? “This rule would apply only to RDNs privileged by hospitals. The Academy continues to work with CMS to urge a separate regulatory change that would apply to RDNs practicing in long-term care or other facilities and it hopeful for success in the future.”

20. Questions????????????????????????????? 20 Renee.Walker2@va.gov