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
To define specific steps the Dietitian uses when providing Nutrition Therapy
Not to standardize the Nutrition Care of each resident

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?
No longer putting residents in categories of low, medium and high risk.

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
Planned actions to positively change nutrition-related behavior or condition

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
RD will determine Nutrition Care Indicators (what is being measured)
RD will determine Nutrition Care Criteria (what it is compared against)

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
Planned actions to positively change nutrition-related behavior or condition

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/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
Documenting Fluid Intake
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
Nutrition Screening outside NCP
No references to Low, Medium or High Risk
Patients/Residents either have a Nutrition Diagnosis or do not
Facilities may define risk levels though Policies & Procedures

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
RD is ultimately responsible for nutrition care
SOP are used by lawyers
ADA cannot include CDM in Standards of Practice

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)
Review knowledge and skills to assess competence
Assign tasks based on the individual's competence
Re-assess competencies

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