Nutrition Care Process: Role of CDM

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Nutrition Care Process Role of CDM

• Mary D. Litchford PhD, RD, LDN
• www.casesoftware.com

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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

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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

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Steps in NCP

• Nutrition Assessment
• Nutrition Diagnosis
• Nutrition Intervention
• Nutrition Monitoring Evaluation

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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

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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

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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

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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

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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

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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

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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

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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)

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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

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Does every Resident/Patient have a Nutrition
Diagnosis?
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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

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Step 3 Nutrition Intervention

• Specific to Nutrition Diagnoses
• 4 categories Intervention Strategies
• Food /or Nutrient Delivery
• Nutrition Ed
• Nutrition Counseling
• Coordination of Nutrition Care

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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

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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

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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.

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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

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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

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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

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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

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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

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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

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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)

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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

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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

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Practice Standards vs. Regulations
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Who Sets Practice Standards? Dietary Managers

• DMA Developed Practice Standards
• Documenting in Medical Record
• www.dmaonline.org/Resources/DMAResources/standard0
  2.shtml
• Documenting Fluid Intake
• www.dmaonline.org/Resources/DMAResources/standard0
  8.shtml
• CDMs certified by CBDM

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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

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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

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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.

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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.

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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

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

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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)

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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