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

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Presentation on theme: "Nutrition Care Process: Role of CDM Mary D. Litchford PhD, RD, LDN www.casesoftware.com."— Presentation transcript:

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

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 gain in 90 days and increase in serum cholesterol to 230 mg/dl

14 Does every Resident/Patient have a Nutrition Diagnosis?

15 Role of CDM in Nutrition 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 of Nutrition 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 % 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/patients 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. shtmlwww.dmaonline.org/Resources/DMAResources/standard02. shtml Documenting Fluid Intake –www.dmaonline.org/Resources/DMAResources/standard08. shtmlwww.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 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 residents quality of life The role of the CDM in the nutritional care of the resident is determined by his/her competence


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