Providing Nutrition Services Research Articles

Evolution: From Private Practice to Independent Practice Association and Home Health Care Agency

LEARNING OUTCOME: To identify our changing roles and opportunities in the rapidly changing patient consulting arena.For many years dietitians have been working predominately in hospital settings. As the health care environment moves to alternate site care, fewer opportunities are available in hospital settings but more opportunities are available for dietitians to work in out-patient settings and in home health care. In 1994, two dietitians took note of the changing health care environment and the effects this was having on their own practice settings - one at a large home health care agency, the other in a wellness oriented private practice. This realization led to the development of an independent practice association and home health care agency to provide nutrition services by dietitians in alternate site care: at home, in the physician's office, in the dietitian's office. This organization was the first dietitian-owned and -operated home health care agency to be awarded a home health care license by their state. This unique opportunity created by these dietitians has an organized approach to providing services by dietitians on an “as needed” basis. Because of this organization, they have been able to market their services and obtain contracts with major insurance providers and home health care providers, including two contracts which identify them as preferred providers nationwide. This organization has allowed dietitians' services to be acknowledged by the payers, alternative referral sources, as well as providing new opportunities for dietitians in the evolving health care environment The evolution, current structure and business materials will be presented so that dietitians can view their possibilities of the future.

Dialysis survival in a large inner-city facility

Impoverished patients may represent a high-risk population with poor survival. With 1993 U.S. Renal Data System survival tables (to adjust the risk of death for differences in age, race, and ESRD diagnosis), the mortality rates of patients over 3 yr in a large inner-city dialysis facility using high-flux technique were compared with national averages. At least 93.7% of patients were African-American, 50% had incomes below $7,000 per year, and employment was 5% or less. Observed and expected deaths (the latter derived from the U.S. Renal Data System tables) were used to calculate a standardized mortality ratio (observed deaths/expected deaths); the U.S. average is 1.0. The standardized mortality ratio at this facility for each year was < 0.600 and was significantly lower than the U.S. average in 1991, in 1992 (P < 0.05), and for all 3 yr (P < .001). Over all 3 yr, it was lower for females (0.540, P < 0.05), males (0.620, P < 0.05), patients with diabetes (0.593, P < 0.05), and glomerulonephritis (0.318, P < 0.05). For the 3 yr, a Cox regression analysis revealed independent associations between mortality and age (P = 0.004), serum albumin (P = 0.02), Kt/V (P = 0.02), and dialysis for more than 2 yr (P = 0.01). Patients with economic hardship can attain survival significantly better than the national average with the provision of adequate dialysis, nutrition, and support services.

Computer and Nutrition Education Training in School Nutrition Service

Schools are an important setting for provision of nutrition services and education to school age children. Today's emphasis on healthier school foodservice menus and requirements to provide meals to children with special needs necessitates a high level of nutrition expertise from school food service management. Well-trained dietetic professionals have the necessary skills to move into positions as managers and directors of School Food Operations, and will ensure quality, economical, nutritious meal service. A pilot project was initiated to facilitate improvement in dietetic student's knowledge and aptitude in this area of practice. Enhancement to the Coordinated Program (CP) in dietetics included training on and application of new computer software (Nutrikids) for school foodservice operations, and presentation of nutrition education topics for school age children. 12 first year CP dietetic students received a 2 1/2 hour lecture on school foodservice management in their initial Food Systems Management course and spent a total of 16–20 hours in the school foodservice setting, where they were oriented to school foodservice systems, and received introductory training on use of the computer. In their 2nd year, 5 CP students participated in a 24 hour/week management rotation at one of 4 school districts for a total of 240 hours in school foodservice. All 12 2nd year students attended a Nutrikids software training seminar in our computer lab and used it to complete assignments in school internship settings. They also developed and presented at least one nutrition education session at each clinical site. This project has provided dietetic students with the skills and knowledge to pursue careers as school nutrition service managers.

Increase referrals with quality service management

Organizations that value high-quality customer service grow twice as fast while improving their market share and have more loyal customers than comparable organizations that do not ( 1. Heskett JL Sasser Jr, WE Hart CW Service Breakthrough. Macmillan Publishing, New York, NY1990 Google Scholar ). Quality service means operating with a consistently high level of personal attention and concern in meeting the needs of the customer. Quality service organizations focus on results achieved for the customer as the customer sees them, rather than on the services performed ( 2. Albrecht K Zemke F Service America!. Dow-Jones Irwin, Homewood, Ill1985 Google Scholar ). Quality service management (QSM), which enables organizations to provide high-quality customer service, offers dietitians who provide services in ambulatory and other settings a fresh approach to evaluating and providing nutrition services.

Nutrition services for children with developmental disabilities and chronic illnesses in education programs

Objective To determine the number of children attending school who require special nutrition services, types of nutrition services provided to children, involvement of registered dietitians in provision of nutrition services in the school setting, and continuing education needs of school nutrition personnel. Design/sample Pretested questionnaires were mailed to a national, systematic random sample of 600 school nutrition managers, 600 district school nutrition directors/supervisors, and 600 district special education program directors. Response rates were 32.7%, 46.2%, and 32.8%, respectively. Statistical analysis performed Descriptive statistics were used to summarize data, including means, standard deviations, frequencies, and percentages. Results A large percentage of school nutrition managers (46%) reported that they served no children with special food and nutrition needs. Special food and nutrition needs most frequently encountered by all groups included food allergy, food intolerance, diabetes, and conditions with which feeding problems are associated. The skills of dietitians were used by 23% of school nutrition managers, 21% of district school nutriion directors/supervisors, and 15% of special education program directors. Continuing education needs were greatest for the areas of assessing liability, calculating macronutrient content of menus, modifying menus, and understanding the physical and emotional needs of children with special needs. Applications/conclusions Communication between nutrition service providers and special education providers needs to be strengthened. A need exists to include nutrition in Individualized Education Programs for children in special education. Many opportunities are available for registered dietitians to provide consulting services for school nutrition programs related to special needs.

Commentary and translation: 1994 nutrition recommendations for diabetes

Commentary and translation: 1994 nutrition recommendations for diabetes

ORAL HEALTH AND NUTRITION

The relationships between oral health conditions, dietary practices and nutritional status, and general health status in the older American are complex, with many interrelating factors. Just as inadequate nutrition can affect oral health, poor oral health status affects food choices and, thus, nutritional status. It is clearly essential that the primary care practitioner and/or screening health professionals always include an evaluation of oral status in assessment of an elderly person. Effective care for the elderly dental patient requires knowledge about the disease of aging and the impact of those diseases on oral health and nutrition, pharmacology and drug interactions and their impact on oral health status, the biology of aging including sensory changes, the relationship of general medicine and systemic diseases, and psychology and sociology. The attitudes of empathy and understanding, caring and compassion, respect and a positive attitude toward the older patient, and flexibility in treatment planning are also critical elements.42 The interdisciplinary team of physicians, nurses, nutrition professionals, dentists, and social service professionals must all work together to ensure that good oral health status and adequate nutrition are maintained in older Americans. Recognizing and treating oral health and nutrition problems are important in improving the health and quality of life for the elderly population. Research that can provide more answers to health care problems in this growing group; educating professionals with respect to the relationships between oral health and nutrition; and public policy changes with regard to provision and funding of nutrition services, especially when provided by registered and/or licensed nutrition professionals, contribute to improving the health and quality of life for elders.

Oral Health and Nutrition

The relationships between oral health conditions, dietary practices and nutritional status, and general health status in the older American are complex, with many interrelating factors. Just as inadequate nutrition can affect oral health, poor oral health status affects food choices and, thus, nutritional status. It is clearly essential that the primary care practitioner and/or screening health professionals always include an evaluation of oral status in assessment of an elderly person. Effective care for the elderly dental patient requires knowledge about the disease of aging and the impact of those diseases on oral health and nutrition, pharmacology and drug interactions and their impact on oral health status, the biology of aging including sensory changes, the relationship of general medicine and systemic diseases, and psychology and sociology. The attitudes of empathy and understanding, caring and compassion, respect and a positive attitude toward the older patient, and flexibility in treatment planning are also critical elements. The interdisciplinary team of physicians, nurses, nutrition professionals, dentists, and social service professionals must all work together to ensure that good oral health status and adequate nutrition are maintained in older Americans. Recognizing and treating oral health and nutrition problems are important in improving the health and quality of life for the elderly population. Research that can provide more answers to health care problems in this growing group; educating professionals with respect to the relationships between oral health and nutrition; and public policy changes with regard to provision and funding of nutrition services, especially when provided by registered and/or licensed nutrition professionals, contribute to improving the health and quality of life for elders.

Providing nutrition services to children with special needs in a community setting

Lichtenwalter, Lee MPH, RD, LDN; Freeman, Rebecca MPH, RD, LDN; Lee, Mary DrPH, RD, LDN; Cialone, Josephine MS, RD, LDN Author Information

Nutrition concerns in children with special health care needs: Preliminary screening data

California Children Services (CCS), California's program for children with special health care needs (CSHCN), funds tertiary center-based Special Care Centers (SCC). Some of these are mandated to provide nutrition services as part of their interdisciplinary care because of a suspected high frequency of nutrition problems. They include: GI, Pulmonary, and Infectious Disease/Immunology. Twenty-eight of these SCCs, located throughout California, were targeted by CCS to participate in this screening initiative, undertaken as a collaboration between CCS and the federal Maternal and Child Health-funded project “Strengthening the Nutrition Component of Community-based Services for CSHCN in California” ∗ Funded by MCJ-065057 ∗Funded by MCJ-065057. The purpose was to describe the existing nutrition problems, both quantitatively and qualitatively. The project staff, with input from the clinics, modified a nutrition screening tool and computerized database previously developed for use by CSHCN programs in the states in Region IX (AZ, CA, HI, NV). To date, greater than 500 children have been randomly screened in 23 clinics. A majority of the children represent ethnic minorities; 47% are caucasian. Preliminary data confirm a high prevalence of nutrition concerns eg. daily medication use (44%), need for special diet/formula/supplement (20%), picky eater (24%), feeding difficulty (20%), tube feeder (12%), constipation (15%). One-third of the population was underweight for age (< 5th %ile, NCHS), 35% had short stature (< 5th %ile for age, NCHS); 20% were underweight for height (< 5th %ile, NCHS). The data suggest that nutrition problems play a role in the etiology of the higher than normal prevalence of growth failure.

White paper on health care reform

It is the position of The American Dietetic Association that provision of nutrition services be included in any health care reform legislation. The dietetics professional (qualified dietitian) should be identified as a qualified provider of reimbursable nutrition services.

Volunteer Labor Contribution in Nutrition Programs for the Elderly

Using the productivity ratio, labor min/meal, this study analyzed the contribution of volunteer as well as paid staff in the congregate and home delivered meal services of eight nutrition programs for the elderly. A simple monitoring instrument was used to record volunteer and paid staff work activities. The contribution by volunteers was substantial and varied significantly among the centers and by number of meals served. Volunteer time was greater than paid staff time for the service and cleaning components of congregate service and for the transportation component of home delivered service. Understanding the volunteer contribution in elderly nutrition programs is important to program administrators as they make decisions for the provision of nutrition services to an expanding clientele with limited federal funding.

Quality assurance in nutrition and dietetic service provision

This paper reviews published work on quality assurance, gives an outline of the methods that can be used in implementing and monitoring a quality assurance programme and assesses the implications for nutrition and dietetic departments and dietetic practitioners.

Entry-level practice: Challenges, obligations, and opportunities

Each of us has a unique and varied set of experiences, ideas, and skills that we bring to dietetic practice. This diversity is the strength of the profession. With a strong commitment to provide nutrition services to the public, entry-level practitioners can successfully meet the challenges, fulfill the obligations, and maximize opportunities in a way that will make the vision of the future a reality for the profession of dietetics.

Environmental Interventions to Promote Healthy Eating: A Review of Models, Programs, and Evidence

Environmental interventions are an important part of efforts to improve health in populations. With respect to strategies to encourage positive nutrition behavior, environmental approaches help create opportunities for action by removing barriers to following a healthy diet. This article reviews the rationale, conceptual models, program examples, and recent empirical evidence regarding the extent and effects of environmental interventions to promote healthy eating. The state of the art is described for five types of interventions: (1) changes in the food supply; (2) point of choice nutrition information; (3) collaboration with private sector food vendors; (4) worksite nutrition policies and incentives; and (5) changes in the structure of health and medical care related to nutrition. Environmental approaches to dietary behavior change can reach large segments of the population through increased availability of nutritious foods, provision of quality nutrition services in workplace and health care settings, and accessible information about healthful food choices. Nutrition intervention can also serve as a model for other types of health promotion initiatives using multidimensional environmental and educational technologies.

Documentation of time expenditures of clinical dietitians: Results of a statewide time study in Texas

The purpose of this study was to establish a profile of the amount of time expended by clinical dietitians in providing nutrition services. One hundred twenty-seven dietitians in 49 hospitals in Texas collected time data according to nutrition care activity, diet order classification, care level, and diagnosis. Frequency, mean time, standard deviation, and percentage of time were computed for each of the variables. Data were analyzed to ascertain relationships among the variables. The dietitians expended 50.7% of their time performing client-related activities, 9.8% in administrative/managerial functions, 1.0% in professional activities, 5.1% in non-professional activities, 14.0% in delay activities, and 19.5% in transit time. The diet order classification that required the largest amount of the dietitians' time according to selected components of the nutrition care process was the calorie-controlled diabetic diet. Among the four nutrition care levels, dietitians expended the greatest percentages of time providing services for patients requiring intermediate (35.4%) and advanced intermediate care (30.4%). Dietitians expended more time providing client-related activities to patients diagnosed with diseases and disorders of the endocrine and excretory systems than to other patients. Mean times provide the clinical manager with documentation for determining staffing needs and costs of services. J Am Diet Assoc 88:38, 1988.

Provision of clinical nutrition services by diagnosis-related groups (DRGs) and major diagnostic categories (MDCs)

Provision of clinical nutrition services by diagnosis-related groups (DRGs) and major diagnostic categories (MDCs)

Preparing public health nutritionists to meet the future

Public health nutrition personnel have been defined as those specialized nutrition professionals and paraprofessionals who provide nutrition services through agencies whose mandate is health protection and promotion, disease prevention, and/or primary care to people in the community. Educators preparing graduate level nutritionists for future demands of federal, state, and local public health programs must read the scientific, technological, and societal trends, including changes in demographics, health delivery systems, communications technologies, and consumer demands. As research more clearly defines the role of nutrition and diet in human health, nutritionists should be educated to monitor trends and be proactive in seeking emerging opportunities. It is nutritionists' responsibility to assure that scientific findings in nutrition, dietetics, and food science are considered in policy formulation as well as in the technical input into agency and community programs. The nutritionist who understands the changing values and life-styles of diverse populations uses acceptable techniques to motivate any necessary behavior changes. To be effective in the community, he/she uses community assessment, epidemiological, and program planning skills basic to public health practice. In the current climate of cost containment, the public health nutritionist will successfully compete for dwindling funds by managing programs with skill and documenting cost benefits and cost-effectiveness.

Dietary Intake of Homebound Elderly Recipients and Nonrecipients of Home-Delivered Meals

Dietary intakes of 54 home-bound elderly recipients and nonrecipients of home-delivered meals were examined, utilizing the 24-hour recall. Nonrecipients had significantly greater intakes of carbohydrate, thiamin, and iron than recipients. More than 50% of all subjects consumed less than the RDA for vitamin A, riboflavin, calcium, phosphorus, and iron. Calcium intake was below the RDA for 82% of the subjects. Mean fat and saturated fat intake exceeded recommendations for both recipients and nonrecipients. Provision of nutrition services to homebound elderly appears to be lagging behind need.

The Hill-Burton Program—A way to provide nutrition services for the medically indigent

Facilities that received construction funds through the Hill-Burton Program are obligated to provide a certain amount of uncompensated care each year to the medically indigent. Since each obligated facility has the right to decide what kinds of free care it will offer, dietitians can be persuasive in encouraging increased nutrition education and counseling programs. This paper has described how one small group worked with its HSA to become knowledgeable about Hill-Burton facilities themselves and at separate sites. This effort, if repeated in other health service areas, has the potential to bring much more nutrition education and counseling to the medically indigent across the country.