To prevent the spread of Covid-19, the CDC recommended that residents at nursing facilities have meals in their rooms and that they do not have visitors. This also included having family members and friends bring in food. This had been going on since mid-march 2020. What I didn’t realize was that there were some residents whose family members regularly brought in snacks. Thus, their supply dwindled and by the time the April weights came along we had a couple of individuals present with a significant loss. Upon speaking to the resident, family and nurse, it was discovered that is was an issue with snacks. As a result, we purchased a variety of snacks, similar to what the families might bring in. A snack cart goes around daily and the units are given extra snacks for requests at other times. I actually took a few a the residents a large zip lock bag of a variety of snacks. The look on the one resident’s face was priceless. So, this veteran dietitian learned that it’s best to assess any new “normal” to see how it might affect the residents overall health and well-being.
F Tag 807 is: Drinks Available to Meet Needs/Preferences/Hydration-this blog post gives specific examples of why this tag was out of compliance at four facilities. It also stresses the importance of providing fresh water to all residents. This is a must read for students and RDNs who want to understand more about the compliance of this tag.
Ways the RDN can help meet F Tag 807
*Investigate large, unexplained weight loss-request that labs be drawn. Look at the resident do they appear to be well-hydrated? If there is no apparent reason for the weight loss, it may be dehydration.
*Visit the resident and explain the importance of adequate hydration. Offer to get them a drink-document any approaches in your progress note.
*Ask alert residents if they drink from their water pitcher daily. If yes, document this in the medical record. If no, ask if they are getting fresh water throughout the day. If they are not, discuss with the nurse on the unit or if the problem is widespread, the Director or Assistant Director of Nursing.
*Look at residents with dementia. Do they appear to be getting adequate fluids throughout the day? If not, order an extra 120 mL with each med pass or an extra 240 mL bid.
*Visit with the resident if they appear to be dehydrated or have decline in fluid intake to see if beverage preferences are up-to-date.
*Make sure that the resident gets the appropriate adaptive equipment.
*Refer to SLP or OT for issues with swallowing or need for adaptive equipment
Written by: McKenna M. Murphy, Student Dietitian
Telemedicine “healing from a distance” in healthcare professions attempts to deliver health care services and information at a distance through electronic devices to improve access, quality, and cost. Telemedicine ranges from live interactive video for consultations, mHealth or the use of mobile devices for patient self-management, electronic instruments to collect patient data in real-time for provider analysis, and the use of Health Insurance Portability and Accountability Act (HIPPA) compliant portals for providers to share electronic health records (EHR).1 Most of the research on telemedicine has been done for many health care professions as it has entered mainstream practice. The Academy of Nutrition and Dietetics recognizes telenutrition as a tool for registered dietitians as it is an included topic in their evidence analysis library (EAL); however, it has not been updated since 2012.2 Outcome measures in the literature review will include access to RDs, cost-effectiveness, quality of care, and the effects of state licensure laws on telehealth.
Access to Registered Dietitians
Rural areas in the U.S. present with the highest rates of food insecurity among the 48 million people suffering nationwide. Research shows that food insecurity is directly linked to diet, weight gain, and chronic disease. This presents a need for RDs to provide food and nutrition education related to accessing a sustainable food supply to combat hunger, obesity, and diabetes.3-6 However, RDs are unable to offer services to millions of Americans because of limited access via transportation and time. The use of Telemedicine offers a promising new opportunity for food insecure Americans; especially in rural locations to receive high quality nutrition education without the hassle of traveling to visit a dietitian. According to a study conducted by Homenko6, 74 older adults from rural areas of New York intervention program. The goal was to observe meal planning, preparation, shopping behaviors, obesity, and glycemic control in older adults with and without food insecurity to understand if the intervention program would be beneficial to reduce food insecurity and related concerns. Results showed mildly insecure patients had higher BMIs and lower household incomes than food secure patient; however, HbA1c levels and following Dietitian advice when choosing foods did not differ between both groups. Despite no participants being classified as severely food insecure, the study concluded telemedical nutrition support services have the potential to be an important adjunct for rural primary care providers whose patients have poor access to the services of dietitians. Further research needs to be conducted to locate the severely food insecure and analyze correlations with access to internet and electronic devices to understand the limitations that telemedicine still may present with uniting patients and needed nutritional support.
Cost of RD services has also been a barrier in connecting patients to needed nutritional support in rural and urban settings. Two studies offered a 12-month weight management program that looked at the cost-effectiveness of telemedicine vs. face-to-face nutrition intervention and found that costs were less expensive for telemedicine services for the RD and patient.7,8 The 1-year prospective randomized controlled clinical trial resulted in the face-to-face group having a fixed cost of $420 a patient and the telephone counseling group to be $268 a participant. The mail/control group was $42 less expensive than the telephone counseling group at $226 a patient, but average weight regain after intervention was 3.1kg as opposed to face-to-face of 1.7kg and telephone format of 2.1kg.7 Results show that a face-to-face intervention may have superior outcomes as opposed to telephone interventions, but weight regain was only an 0.4kg difference; however, price of administration was a substantial $152 difference.7 The second study by Rollo showed in-person nutrition intervention costs to be about $560.59/patient and eHealth nutrition intervention costs to be about $389.78/patient. One key addition of Rollo’s study was the examination of establishment costs for dietitians and patients of $90.05 for in-person delivery and $1394.21 for eHealth. This offers one barrier in the use of telemedicine nutrition programs as start-up costs to dietitians are far higher for equipment than for in-person programs. However, if a dietitian is willing to make the investment on average the dietitian will save $42.56 per patient as compared to in-person services. This means a dietitian will only need to see about 31 patients using eHealth technology to offset the establishment costs of telemedical delivery and in the long run make/save more money than if in-person services were utilized.8
The price of telemedicine nutrition services offers the opportunity to increase access for low-income patients with only mild differences in quality of treatment, but at about half the cost of administration.6-8 The use of a telephone intervention program may also affect weight regain results as compared to videoconferencing or more personal technological use as seen in Homenko’s research, which had equal results in HbA1c and food choice to face-to-face vs. telemedicine nutrition intervention.6,7 However, the use of telephone interventions may offer an ideal opportunity for the severely food insecure to gain access to RD intervention nutrition programs that may not have access to a camera for videoconferencing. According to Rollo’s study 83% of Australians have access to the internet with 7.5 million using the internet through their mobile phone.8 This leaves 17% of the Australian population in need of internet access, but for a wide section of the population telemedicine offers a promising solution to connect RDs to food insecure populations.
Quality of Care
Although Telemedicine offers the opportunity to increase access between RDs and patients by reducing cost and negating distance concerns, the access would be insignificant if services did not generate similar or better intervention results than face-to-face contact with patients.6-8
A 12-month parallel randomized controlled trial looked at 415 patients with uncontrolled type 2 diabetes mellitus in an online disease management system. The primary outcome was HbA1c levels and at 6 months the intervention group had better diabetes control than the usual care group, but at 12 months results from HbA1c scores showed no significant difference between the usual care and intervention group. Tang’s study concluded that usual care and telemedicine intervention resulted in similar quality of care for patient treatment of diabetes.9 In comparison, Radcliff’s 1-year prospective randomized controlled clinical trial resulted in a face-to-face weight management group as having a slightly better median weight regain primary outcome of 0.4kg than the telephone weight management group.7
Tang’s and Radcliff’s studies could have had conflicting results because of the type of nutritional intervention programs implemented, telemedical equipment utilized, and personnel leading the programs. Tang’s study used a more in-depth online disease management program with an interdisciplinary health care team which included nurses and dietitians to gain results compared to Radcliff’s telephone consultations with group leaders who underwent diabetic prevention program training with degrees in nutrition, exercise science, or psychology.Tang incorporated personalized text and video educational information from the health care team, nutrition and exercise logs, wirelessly uploaded home glucometer readings with graphical feedback, insulin records, online instant messaging with a patient’s health care team, and comprehensive patient-specific diabetes summary status reports. Overall Tang’s experiment was far more in-depth and utilized far more avenues for telemedical intervention than Radcliff’s research and may have accounted for similar outcomes compared to face-to-face nutritional interventions. However, Radcliff targeted the food insecure and the use of a telephone model may be more realistic to help patients living in rural areas with limited access to telemedical equipment, so the small difference in quality of care may be insignificant as results still show significant improvement in administration of nutritional interventions compared to controls. More research needs to be done to explore the most practical applications and equipment of telemedicine intervention.7,9
Also, Tang obtained results that participants whose HbA1c improved the most in the intervention group had significantly more glucose readings and uploaded more information compared with patients that did not improve.9 It may be that the use of more technology offers more patient and provider engagement to enhance patient motivation and quality of care, but more research needs to be done to understand the motivations for patient involvement in any nutrition intervention program.
Effects of State Licensure Laws on Telehealth
Telemedicine incorporation in all health care practices and professions is continuing to grow as 42% of hospitals in 2012 had adopted telehealth.10 This would make sense from the past analysis as access to care, reduced cost to practitioner and patient, and similar quality of care has been shown.1-9 As telemedicine incorporation continues to increase policy makers need to understand the research behind implementation of telemedicine to make optimal decisions for the future of telemedicine in health care practice. This has been shown with the implementation of the Affordable Care Act as home health care monitoring usage has increased to reduce rates of readmission to prevent penalization features of the act from readmissions and increase incentive collection through lack of readmission.10
A study by Adler-Milstein sent surveys to 2,891 hospitals across the U.S. with a 63% response rate to understand several factors that influence adoption of telehealth in hospital settings. Interesting factors found to increase acceptance were teaching hospitals, those already equipped with advanced medical equipment, nonprofit organizations, and hospitals that were in business with larger systems. However, state policy seems to lead to and how hospitals adopt telemedicine more than any other factor and accounts for variations in hospital adoption of telemedicine by state. State policies that promote private payer reimbursement for telehealth increase likelihood of adoption, but policies that require out-of-state providers to have a special license reduces chances of incorporation of telemedicine.10
The Adler-Milstein findings are relevant to the adoption of telenutrition in the United States of America because the current policy for Registered Dietitians in 47 states have statutory provisions regulating the dietetic profession. For example, in Florida, a state with strict RD state licensure laws, an RD could only offer medical nutrition therapy (MNT) and nutritional counseling to patients living in that state or states like California that do not have strict licensure laws for nutrition counseling. This limits access to the RD to treat patients outside of the state of Florida unless the RD payed an annual fee to treat patients in each other individual state that has state licensure laws.11 This decreases the likelihood of an RD treating patients outside of their state which an RD with a strong telemedical practice could easily perform.10 As the demand for RDs increases with the increase of baby boomers, limitations on RD access to potential patients hurts the consumer and provider.11 Possible solutions could be to create a federal licensure law to allow RDs to practice in all 50 states of the U.S.A. or to get rid of the state licensure law entirely saving the RD an annual fee, but not protecting the RD credentials.
Telemedicine offers an alternative to standard in-person nutrition services through administration by RDs and interdisciplinary health care teams. As benefits abound for practitioners and patients through access and cost with similar outcomes it seems apparent that telemedicine is the future of healthcare.1-9
Food insecurity has been shown to be one of the key problems that could be positively impacted with the implementation of nutrition intervention programs that utilize telemedicine instead of in-person services. For the severely food insecure problems may still arise with limited access to internet, but overall use of telemedicine by RDs could reach far more persons in need of nutrition support especially related to diabetes and obesity as opposed to in-person services.3-7
Optimal nutrition intervention programs that are face-to-face or via eHealth services are still being perfected. The use of telemedicine offers opportunities to improve nutritional interventions for all populations because of immediate and accurate results to health care workers by real time appliances like wireless glucose monitors and enhanced communication between providers through EHR applications.1,9 However, patient activity in a nutrition program seems to be the number one factor for program success and telemedicine implementation seems to neither discourage or motivate program incorporation that appears to be at the mercy of the individual program formats and leaders.7,9 This should offer RDs comfort that jobs will not be lost to digital devices as participants still need encouragement to engage in nutrition intervention programs for healthier lifestyle outcomes.
Adoption of telenutrition tends to be slow because of state licensure laws, increased start-up costs and the learning curve to new systems, but if barriers to telehealth can be overcome the benefits of telehealth outweigh the initial hassle.8,10
Starting a private practice is no easy task, but it can certainly be done! The graduate program I enrolled in was “Entrepreneurial” based, meaning I wrote a business plan and was required to take finance classes. The program I graduated from was awesome, and I learned how to be an effective, evidence-based Registered Dietitian… but I was not prepared for how much learning I had YET to do and learn as a business owner! I knew I wanted to start my own private practice before I even started grad school, so I started to learn from my family, friends, the Small Business Association, YouTube, social media, and other RDs. Let me tell you, I was not ready to start my private practice, and I did not feel 100% ready to go. I had picked a date to start, and as that date got closer I got nervous but I started anyway! You may not feel ready or fully confident, but you have to go for it! There are so many moving parts to starting a business, and there is no perfect way to do it. However, there are a TON of resources out there to set you in the right direction!
If you want to have a private practice as an RD, you really do just have to start! I suggest you utilize SCORE through the Small business association (SBA) in your area. SCORE gives you free business mentoring that will help you set up a business plan, develop a marketing plan, offers webinars and classes, and in-person business development. You can connect with the SBA and SCORE before you take the exam if you like. Once you pass the RD exam, check out what licensing you need in your state and town. You will need an NPI number. If you are a member of the Academy of Nutrition and Dietetics, there is group insurance through Mercer/Proliability that has a discounted rate for first year RDs. Once you have your licenses, NPI and insurance, you will want to do the following:
Every day I learn something new. Every day I work on at least one thing to make my business bigger, better and stronger. This is just the tip of the iceberg, but doing these things will help you move forward to owning the practice you deserve!
Jessica’s blog post can also be viewed at: https://jessicadorner.com/2019/08/starting-a-private-practice-as-a-dietitian-how-to-simply-start/
I am a RDN with over 25 years of experience in LTC. Over the past few years, I have been working with students as a preceptor. This led me to create four nutrition presentations that have proven to be helpful to student dietitians and diet technicians. In fact, I have recently updated the videos as a result of some feedback from over 200 students. One had commented, “I wished I had seen your videos at the start of my internship.” In addition, I have written an e-Book that students can purchase for practical information on completing nutrition assessments. Sample patients are included. Overall, these resources are designed to give the student practical advice on how to complete nutrition assessments and plans based on current nutrition scientific evidence.
1. Email Doreen Rodo at email@example.com. You can ask any RDN related questions. Specialty is LTC, writing and making videos for students.
2. Join the “Dietitian Mentor” Facebook group and post a question.
3. Join the Facebook group: “Dietitians on the blog” and visit their mentorship tab.
4. Volunteer to write a short article for a blog created by a RDN
5. Visit the Academy of Nutrition and Dietetics: https://www.eatrightpro.org/practice/career-development/mentoring-networking-and-volunteering
6. Attend a local dietitians meeting and network with RDNs in your area
7. Create a profile on LinkedIn and connect with RDN members
8. Comment on posts from RDNs and ask questions
9. Call a local hospital, food bank or a LTC facility and ask to shadow the dietitian
10. Participate in the RD mentorship program in Florida and Texas. Contact person-Kristen Hicks: firstname.lastname@example.org
Slide from Nutrition in LTC-video presentation by Doreen Rodo…..see digital goods page for more information.
RD/RDNs in all fields in Texas and Florida to mentor dietetics students in Fall 2019-Spring 2020! Apply by 7/24/19.
Click the link below for more details or contact the program coordinators at RDmentorshipprogram@gmail.com.
Student link to follow when available
5/20/17-Resident has experienced a decline in meal intake the past week r/t UTI with ABT therapy. She denies any difficulty chewing or swallowing. Currently eating 25-50% of meals, which is down from her usual 50-100%. Weight taken on 5/3/17 was 136# and was stable between 133-138# for 180 days. IBW is 100#. BS range from 125-200. Labs-5/18/17: Na 146H; K 3.7; Cl 110; Hgb 11.2L; Hct 38L; BUN 25H; Creat 1.0; GFR >60; Glu 137H. Skin is intact. Needs: 1545-1854 Kcals (BWx25-30) and 49-62 grams of protein (BWx.8-1.0) and 1854 mL in 24 hours (BWx30); Meals provide approx. 700-800 Kcals and 22-27 grams of protein. Would benefit from nutrition supplement. Spoke with resident and she agreed to try our Diet House supplement.
Nutrition Diagnosis: Inadequate meal intake related to recent infection and ABT therapy as evidenced by leaving 50% or more of meals
Recommend: 1) 120 mL SF House Supplement tid-following each meal. 2) Weekly weights 3) Encourage fluids-give an extra 120 mL q shift. Follow prn.
This is an excerpt from: The Top Fifty Questions from Student RDNs about Long-Term Care, an e-book created by Doreen Rodo, M.Ed, RDN
$6.99 Kindle Edition on Amazon
Afshan Hussain Ali, MSc, RDN, CDE
Though summer may bring to mind picnics and chips and delicious chocolate desserts, dietitians believe that it is easiest to ‘eat healthy’ during this time.
With a healthy meal and proper exercise routine, you are sure to shed all the unwanted weight you carry around. Following are the few points to remember during summers-
Summer may be an excellent time for us to get into the process of detox as when it is warm, it is easier for our body to be in a detox process naturally.
What you eat on daily basis matters, as habits add up and the bad ones take a toll on your health. So, if you want a quick way to ramp up your energy, clear your mind, and lighten the toxic load on your body, food-based detox can make a big difference on how you look and feel. It’s time to flush out the toxins from our bodies and get rid of the excessive chemicals, sugar, processed foods and alcohol too.
The liver produces its own antioxidants, but it also needs other antioxidants from food sources in order to remain healthy. So, eat foods that support the liver and the digestive system. Increasing antioxidant-rich foods can also help counter the free radicals in the body. Mentioned below are four wonder foods, which help to clean out our bodies and make us feel healthy, light & refreshed.
It is the number one food for a summer detox. It is extremely alkaline-forming in the body and contains high amounts of citrulline. This helps to create arginine, which removes ammonia and other toxins from the body. Also, watermelon is a good source of potassium, which balances the high amounts of sodium in our diets, which supports your kidneys and is great when cleansing.
Cucumbers are great as in sandwiches or when eaten raw. Cucumbers help flush toxins from the body. The high water content in cucumbers benefits your urinary system. A half-cup of sliced cucumber has hardly around 8 calories.
Squeeze some lemon in your drink for a bout of freshness. Your liver loves lemons. The lemon is a marvelous liver stimulant and is a dissolvent of uric acid and other poisons. It alkalizes the body and hence helps restore balance to the body’s pH.
Think mint, think coolness! Mint leaves are great for summer cooling. It helps you digest your food more effectively and improves the flow of bile from the liver, to the gallbladder, to the small intestine, where it breaks down dietary fats.
So, remember melons and lemons when garnished with mint leaves are one of the best foods to beat the summer heat!
Afshan Hussain Ali, is a RDN and certified diabetes educator who lives in Nagpur, Maharashtra India
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