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Nutrition Care Process: Role of CDM Mary D. Litchford PhD, RD, LDN www.casesoftware.com 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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nutrition care process role of cdm

Nutrition Care Process: Role of CDM

Mary D. Litchford PhD, RD, LDN

www.casesoftware.com

points to ponder
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
what is the nutrition care process ncp
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
steps in ncp
Steps in NCP
  • Nutrition Assessment
  • Nutrition Diagnosis
  • Nutrition Intervention
  • Nutrition Monitoring & Evaluation
step 1 nutrition assessment
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
role of the cdm in nutrition assessment step
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
role of the cdm in nutrition assessment step7
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
role of the cdm in nutrition assessment step8
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
role of the cdm in nutrition assessment step9
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
role of the rd in nutrition assessment step
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
step 2 nutrition diagnosis
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
role of rd in nutrition diagnosis step
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)
example of pes statement
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

role of cdm in nutrition diagnosis step
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
step 3 nutrition intervention
Step 3: Nutrition Intervention

Specific to Nutrition Diagnoses

  • 4 categories Intervention Strategies
    • Food &/or Nutrient Delivery
    • Nutrition Ed
    • Nutrition Counseling
    • Coordination of Nutrition Care
step 3 nutrition intervention17
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
role of rd in nutrition intervention step
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
example nutrition intervention
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.
example nutrition intervention20
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
role of cdm in nutrition intervention step
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
role of cdm in nutrition intervention step22
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
role of cdm in nutrition intervention step23
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
step 4 nutrition monitoring evaluation
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
examples of nutrition care outcomes
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
role of cdm in nutrition monitoring evaluation step
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)
examples of monitoring data
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
role of rd in nutrition monitoring evaluation step
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
who sets practice standards dietary managers
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

who sets practice standards rds lds
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
who sets practice standards rds dtrs
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
cms regulations
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.”
cms regulations34
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.
cms regulations35
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
remember that
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
remember that38
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)
bottom line
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