Nutrition Care Process_ Role of CDM

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					Nutrition Care Process:
      Role of CDM

Mary D. Litchford PhD, RD, LDN
       Points to Ponder
 What is the Nutrition Care Process
 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
•   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
•   Nutrition Assessment
•   Nutrition Diagnosis
•   Nutrition Intervention
•   Nutrition Monitoring & Evaluation
Step 1. Nutrition Assessment
• Review data collected for factors that
  affect nutritional & health status
• Cluster data to identify nutrition
• Identify standards by which the data
  will be compared
        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 Step
Collect Data from Medical Record
– Personal data
– Anthropometric
– Lab test results
– Medical diagnosis
– Nutrition-orientated medical history
– Results of nutrition-related medical
– Nutrition-focused physical findings
        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 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
• Cluster Nutrition Care Indicators to
  identify Nutrition Diagnoses

• Identify Nutrition Care Criteria by which
  the data will be compared
  Step 2: Nutrition Diagnosis
• Different from medical diagnosis
• Identification of a specific nutrition
  problem that dietetic practitioners will
• Categories of Nutrition Diagnoses
  – Intake
  – Clinical
  – Behavioral
      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
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
Does every Resident/Patient
have a Nutrition Diagnosis?
          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
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 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
       Role of RD in Nutrition
         Intervention Step
Write interventions that are specific to
  each Nutrition Diagnosis
  – 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
• 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 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
• 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 Step
• Confirm that protein or oral supplements are
  being served as ordered
• Confirm that all other interventions are
  implemented i.e. adaptive equipment, dining
• Collaborate with healthcare team to
  determine obstacles to interventions
       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 &

• Goal: to monitor, measure & evaluate
  progress in achieving goals/expected
• 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
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

• Collect/summarize monitoring data for RD to

• Notify the RD if significant changes occur
  that affect nutrition status (follow your
  facility p/p)
   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
• 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
Practice Standards vs.
 Who Sets Practice Standards?
      Dietary Managers
DMA Developed Practice Standards
• Documenting in Medical Record

• Documenting Fluid Intake

CDMs certified by CBDM
 Who Sets Practice Standards?

• 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?
• 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 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
• In most cases participants are. . . licensed
  health professionals.”
         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 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
Who is ultimately responsible for the
       nutrition care of their
         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 that…
• RD verifies Credentials
  – DTR
  – CDM
• RD Establishes & Verifies Competence
  – CDM Nutrition Care Self-Assessment Tool
  – Nutrition Documentation Readiness for
    CDM, CFPP's (5 hr online CE)
              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

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