Section IV
Providers and Costs of Nutrition Services



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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population Section IV Providers and Costs of Nutrition Services

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population 13 Providers of Nutrition Services The congressional language that initiated this study requested not only an analysis of the extent to which nutrition services might be of benefit to Medicare beneficiaries but also “an examination of nutritional services provided by registered dietitians.” The committee decided to broaden the scope and include the provision of nutrition services by other health professionals as well. In order to accomplish this, the committee systematically reviewed available evidence regarding the education and training of registered dietitians as well as other health professionals necessary to adequately provide nutrition services. TERMS AND DEFINITIONS In reviewing specific providers, it must be recognized that terms such as “nutritionist,” “dietitian,” and “nutrition professional” can have varied definitions, however all refer to professionals who practice in the field of nutrition. In 1963, the Council on Foods and Nutrition of the American Medical Association defined the field of nutrition in the following manner: Nutrition is the science of food, the nutrients, and other substances therein, their action, interaction, and balance in relation to health and disease and the processes by which the organism ingests, digests, absorbs, transports, utilizes, and excretes food substances. In addition, nutrition must be concerned with certain social, economic, cultural, and psychological implications of food and eating. (Council on Foods and Nutrition, 1963).

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population The practice of dietetics/nutrition has been defined by the American Dietetic Association (ADA, 1991) as “the integration and application of the principles derived from the sciences of nutrition, biochemistry, food, physiology, management, and behavioral and social sciences to achieve and maintain the health of individuals through the provision of nutrition care services.” They have further defined nutrition care services to include: assessing the nutrition needs of individuals and groups and determining resources and constraints in the practice setting; establishing priorities, goals, and objectives that meet nutrition needs and are consistent with available resources and constraints; providing nutrition counseling in health and disease; developing, implementing, and managing nutrition care systems; and evaluating, making changes in, and maintaining appropriate standards of quality in food and nutrition care services. Nutrition assessment is defined as “the evaluation of the nutrition needs of individuals and groups based upon appropriate biochemical, anthropometric, physical, and dietary data to determine nutrient needs and recommend appropriate nutrition intake, including parenteral and enteral nutrition.” Nutrition counseling is defined as “advising and assisting individuals and groups on appropriate nutrition intake by integrating information from the nutrition assessment with information on food and other sources of nutrients and meal preparation consistent with cultural background and socioeconomic status” (ADA, 1991). TIERS OF NUTRITION SERVICES Nutrition services are provided throughout the continuum of care: in acute and ambulatory care, in skilled nursing and long-term care, in home health agencies, and in community-based nutrition programs. The committee differentiated between nutrition-related activities. Some activities are more general, such as educating individuals on basic principles of a healthy diet, screening individuals to identify needs for more complex nutrition services, and reinforcing essential aspects of counseling provided by the nutrition professional. These basic nutrition services can be provided by a multitude of health care professionals with a small amount of training in nutrition. Other nutrition services are more complex and are referred to in this document as “nutrition therapy.” Nutrition therapy is defined as including nutrition assessment, evaluation of nutrition requirements, counseling geared towards the nutrition management of specific conditions, and follow-up care as appropriate to

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population ensure patient compliance and success of the nutrition intervention. The provision of nutrition therapy as defined here requires health professionals who have a broad base of nutrition knowledge and experience. They need to be able to define who should receive nutrition therapy, when nutrition therapy is most likely to be effective, what the specific intervention should be, and the nature of follow-up needed. For example, in the case of enteral and parenteral nutrition, specific knowledge is necessary to judge when feedings should begin and end as well as what and how much should be provided. EDUCATION AND SKILLS NECESSARY FOR THE PROVISION OF NUTRITION THERAPY When determining who is qualified to be a nutrition professional, both academic background and supervised practice or experience are required (Glanz, 1985). Nutrition professionals must have in-depth knowledge about the role of food and nutrition in the prevention, treatment, and progression of acute and chronic disease and, likewise, how disease and treatment affect food and nutrition needs. They must also have knowledge about nutrient composition and preparation of food; alternate feeding modalities; and the socioeconomic, psychological, and educational factors that affect the food and nutrition behavior of people across the lifespan. Lastly, they must have skills to translate scientific information into laymen’s terms and assist individuals in gaining knowledge, self-understanding, and improved decision making and behavior change skills (Snetselaar, 1983). In 1972, the Study Commission on Dietetics was formed at the request of the ADA and the Governing Board of the ADA Foundation. The Commission was asked to study all aspects of dietetic practice and education (Study Commission on Dietetics, 1972). The Commission evaluated knowledge necessary and sufficient for the practice of dietetics and determined that the educational background to practice dietetics needs to be in line with that of other health professionals. It requires mastering professional knowledge as well as acquiring necessary professional skills. The knowledge base needed can be described by two areas: nutrition science and food science. Nutrition science requires components of biochemistry, biology, medicine, behavioral health, human physiology, genetics, anatomy, psychology, sociology, economics, and anthropology. Food science requires knowledge of food chemistry, food selection, food preparation, food processing, and food economics. Professional skills required for the practice of dietetics include “therapy of disease, the maintenance of health, management, teaching and communication, research and

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population development, organization and administration” (Study Commission on Dietetics, 1972). The Commission also highlighted continuing education as essential to the practice of dietetics. The knowledge of medicine and nutrition science are constantly expanding. Without continuing education, the professional can not meet the dynamic needs of patients. The practitioner must be a “constant learner.” If not, “knowledge becomes obsolete and his/her skill less than it can be. Worse, he/she cannot even be a truly professional practitioner given that the basic characteristic of the professional is that he/she personally and continuously translates knowledge into judgment and then action” (Study Commission on Dietetics, 1972). LICENSURE IN THE PRACTICE OF DIETETICS For many health professionals, state licensure can be relied on to identify individuals who meet minimum knowledge and skill requirements within a particular field. In the case of the nutrition professional, requirements for licensure vary among states and in the case of some states, licensure for nutrition professionals does not yet exist. At the time of this report, twenty-seven states had licensure requirements that provide an explicit scope of practice for dietitians; thirteen states had certification that limits the use of a particular title, yet individuals who are not certified can still practice; one state had an entitlement law that protects the use of the title registered dietitian; and nine states had not yet passed legislation for licensure, certification, or recognition of nutrition professionals. For additional information regarding the status of licensure in individual states, see Appendix D. In states that have licensure or certification for a nutrition professional, the requirements vary, however the credential of a “Registered Dietitian” is commonly accepted as meeting the requirements for licensure. In addition, some states license other professionals who may, as part of their practice, provide some nutrition services. HEALTH CARE PROFESSIONALS SPECIALIZING IN NUTRITION The following section describes the background of various health care professionals and their role in providing nutrition services.

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population Registered Dietitian The most commonly identified credential that constitutes a qualified nutrition professional is the registered dietitian (RD; referred to as dietitian in the rest of this chapter). The Commission on Dietetic Registration (CDR) confers the RD credential on an individual who has a minimum of a bachelor’s degree from a regionally accredited college, meets specific academic and clinical requirements set by the ADA, and passes a national registration examination (CDR, 1999). These academic and clinical requirements include extensive coursework and experience in nutrition sciences, including the role of nutrition in the prevention and treatment of disease; food science, including the effects of processing and preparation on nutrient composition; alternate feeding modalities; and counseling techniques needed to elicit behavior change. The Commission on Accreditation for Dietetics Education (CADE) accredits programs that provide the required academic courses and clinical experience (ADA, 1999). An overview of the academic preparation for dietitians is described in Table 13.1. A more detailed view of the knowledge, skills and competency requirements for entry-level dietitians can be found in Appendix E. All dietitians are required to maintain 75 hours of continuing education every 5 years. Beginning in 2001, requirements for continuation of registration will also include a periodic assessment of learning needs and a plan to update needed knowledge and skills (Duyff, 1999). The dietitian is the designated professional to oversee food and nutrition services in acute and long-term care settings by both the Health Care Financing Administration (CFR, 1998) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, 1996). There are several types of advanced-level credentials that certify dietitians with additional training and skill level in particular areas of practice. These are the certified specialist in pediatrics, certified specialist in renal disease, certified nutrition support dietitian, and certified diabetes educator. Other health professionals can also be certified in areas of nutrition support and diabetes education and are discussed later in this chapter. Various certifications are also described in Appendix F. Certified Nutrition Specialist The certified nutrition specialist certification can be earned by an individual with a graduate degree (M.S. or Ph.D.) in nutrition and either 1,000 hours of supervised practice or 4,000 hours of unsupervised practice as well as passing a certification examination given by the Certification Board associated with the American College of Nutrition. Requirements for academic and clinical preparation for this credential are not as specific

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population TABLE 13.1 Nutrition Related Academic and Clinical Requirements for Various Health Care Professionals Professional Group Accrediting Body Academic and Clinical Requirementsa Aspects of Practice that Include Nutrition Acupuncturist (licensed in some states) Accreditation Commission for Acupuncture and Oriental Medicine May include basic nutrition. May use botanicals in practice. Doctor of Chiropractic (state licensure) Council on Chiropractic Education Some coursework on nutrition and dietetics, public health, geriatrics. Clinical experience may include psychological counseling and dietetics. May employ the use of vitamins, food supplements, and foods for special dietary use. The use of these substances in the treatment of illness or injury must be within the scope of the practice of chiropractic. Doctor of Medicine (MD) (state licensure) Liaison Committee on Medical Education of the Association of American Medical Colleges Coursework in nutrition reviewed during accreditation. May be separate course or part of other courses. Can prescribe and provide all nutrition services. Doctor of Naturopathic Medicine (licensed in some states) Council on Naturopathic Medical Education Some coursework in basic foods, dietary assessment, therapeutic diets. Courses in botanical medicine. Diagnoses, treats, and cares for patients, using a system of practice that bases its treatment of all physiological functions and abnormal conditions on natural laws governing the body. Utilizes physiological, psychological and mechanical methods, such as air, water, heat, earth, phytotherapy (treatment by use of plants), electrotherapy, physiotherapy, minor or orificial surgery,

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population       mechanotherapy, naturopathic corrections and manipulation, and all natural methods or modalities, together with natural medicines, natural processed foods, herbs, and natural remedies. Excludes major surgery, therapeutic use of x-ray and radium, and use of drugs, except those assimilable substances containing elements or compounds which are compounds of body tissues and are physiologically compatible to body processes for maintenance of life. Pharmacists (state licensure) American Council on Pharmaceutical Education Accrediting body reviews curriculum for issues important to pharmacists. Nutrition would be one of these areas. Oversight of manufacturing and monitoring of parenteral nutrition support. Counseling patients about drug–food and drug–nutrient interactions, particularly as they may affect drug bioavailability. Working with other health professionals to integrate pharmaceutical treatment with dietary treatment. Counseling patients about non-prescription nutrition products, such as vitamins and minerals, liquid dietary supplements, and botanicals. On nutrition support committees, they may be involved in choice of drugs and nutrition-related formularies.

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population Professional Group Accrediting Body Academic and Clinical Requirementsa Aspects of Practice that Include Nutrition Physician Assistant (state licensure) Commission on Accreditation of Allied Health Education Programs May be included in concepts of clinical medicine and surgery. Can prescribe and provide nutrition services that are delegated in writing by MD who is responsible for patient. Registered Dietitian (RD) (licensed, certified or recognized in some states; registered nationally) Commission on Accreditation of Dietetics Education Extensive coursework in food science, nutrition science, nutrition in prevention and treatment of disease (minimum of bachelor’s degree with nationally recognized standards for academic preparation). Extensive clinical experience in application of concepts of food and nutrition (minimum of 900 hours and nationally recognized standards for supervised practice). Primary job in health care is to assess nutritional status, intervene when nutrition problems are identified and evaluate effect of intervention. Interventions include all aspects of nutrition therapy, including provision of alternate feeding modalities and counseling to prevent chronic disease, disease progression, or disease complications. The RD works in all areas of health care: acute care, outpatient clinics, skilled nursing and long-term care facilities, home health agencies, and in community-based nutrition programs.     Accrediting body reviews curriculum for issues important to nurses. 2–3 credit hours in basic nutrition (essential nutrients, Specific nursing diagnoses, interventions and care outcomes include nutrition (under and over-nutrition, constipation, diarrhea, fatigue, altered oral mucous membranes, self-

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population     criteria for adequate diet, nutrition in health promotion, nutrition assessment, ethical, social and political considerations of nutrition care, drug/nutrient interactions, nutrition management of selected health problems. Nutrition content also integrated throughout curriculum related to health promotion, symptom management, and disease management. Basic human nutrition may be prerequisite or part of curriculum. (Cover basics of diet therapy as part of other coursework.) feeding deficit, impaired swallowing, knowledge deficit, body image disturbance). Nursing interventions may include feeding, eating disorders management, nutrition counseling, nutrition and nutrition support monitoring, swallowing therapy, teaching about prescribed diets, tube care, weight gain and reduction assistance. aMay be expressed as outcome expectations or course requirements.

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population nor are the requirements for clinical preparation as rigorous as those for a dietitian. Dietetic Technician, Registered The dietetic technician, registered (DTR) provides support for the dietitian in all health care settings (Arena and Walters, 1997). The DTR credential is conferred by the CDR on a person who has successfully completed an associate of science degree or a bachelor’s degree in dietetics that meets the requirements of the ADA and has specific clinical experience from a program that is accredited by the CADE. The DTR works under the supervision of the dietitian and may provide the following services: screening for nutrition risk, intervention for patients with less complex nutrition problems, and preventive nutrition services. Certified Dietary Manager The certified dietary manager (CDM) most commonly works in a skilled nursing or long-term care facility under the supervision of a dietitian, who may work part- or full-time. In the absence of the dietitian, the CDM directs food and nutrition services. A dietary manager is trained in a certificate program, usually in a community college and is certified through a credentialing exam offered by the Certifying Board for Dietary Managers. OTHER HEALTH CARE PROFESSIONALS Most health professionals can impart basic nutrition advice and contribute significantly to the provision of nutrition services. Many health professionals have varying amounts of academic and clinical preparation in the field of nutrition. Most, however, do not include concentrated preparation in the fields of nutrition science and food composition to be able to translate medical nutrition concepts into attainable dietary changes for the layperson. In most cases, standards are not available for nutrition education and counseling skills in the curriculum of the health care provider; therefore, it is difficult to generalize the reliability of the information provided to patients. The academic and clinical preparation in nutrition and the roles of various health professionals in providing nutrition services are described in Table 13.1.

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population Physicians The physician is responsible for prescribing nutrition therapy and may also provide and bill for this service under Part B of Medicare. Physicians with advanced-level training in nutrition, including fellowships or graduate degrees, can be certified as a certified nutrition specialist by the American College of Nutrition (see Appendix F). Patients generally consider their physician to be a highly credible source of health and dietary information (Hiddink et al., 1997); however, the debate over whether physicians have the time or the skills to provide nutrition counseling has been a long one. In a 1994 Connecticut Behavioral Risk Factor Surveillance System survey, only 29 percent of all overweight adults and fewer than half with additional cardiovascular risk factors reported receiving counseling from physicians about weight loss (Nawaz et al., 1999). A survey of 1,030 physicians reported that they felt lack of time and patient compliance were barriers to diet counseling (Kushner, 1995). This study, however, noted that dietitians had the knowledge and skills to complement the physician and proposed a physiciandietitian team. In 1985, a report of the National Research Council described inadequacies in the curricula of medical schools and in physicians’ knowledge, attitudes, and health care practices related to nutrition (NRC, 1985). Others have since described a modest growth in physicians’ training in applied nutrition, but continue to acknowledge discrepancies between knowledge and actual practice (Glanz and Gilboy, 1992). Additional barriers to physicians providing nutrition services are lack of time, staff, or insurance coverage (Glanz et al., 1995). In 1995, the U.S. Preventive Services Task Force found that “although physicians can often provide general guidelines on proper nutrition, many lack the time and skills to obtain a thorough dietary history, to address potential barriers to changes in eating habits, and to offer specific guidance on food selection” (USPSTF, 1995). In addition, the Task Force rated the quality and strength of evidence regarding the effectiveness of both primary care clinicians and specially trained educators in counseling to change dietary habits. The Task Force reported the effectiveness of counseling by a trained educator such as a dietitian as “fair” based on evidence from at least one properly randomized controlled trial. However, the Task Force found there was “insufficient” evidence to recommend for or against dietary counseling when performed by a primary care clinician, based on level III evidence. Hence, this report rates dietary counseling performed by a trained educator such as a dietitian as more effective than by a primary care clinician (see Appendix G).

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population Pharmacists Pharmacists are often in a unique position to provide nutrition information to patients as part of the discharge process or in outpatient pharmacies. They can integrate pharmaceutical treatment with diet, counsel patients about drug–food interactions as they relate to drug bioavailability, and advise patients about nonprescription nutrition products. Their knowledge of genetics, molecular biology, and botany will likely be important as more products marketed as “neutraceuticals” are approved. Of more immediate relevance is the role of the pharmacist as an important member of the nutrition support team (Allwood et al., 1996; Brown et al., 1997; Driscoll, 1996; Lee, 1996). Registered Nurses The registered nurse coordinates patient care, works with the dietitian and other health care team members to identify nutrition problems, and reinforces the importance of nutrition interventions. The registered nurse may also provide less complex nutrition care, such as counseling on preventing chewing and swallowing difficulties or contributing to the nutritional assessment. Most baccalaureate and some hospital diploma and associate degree nursing programs require a 2- to 3-credit hour basic nutrition course, which is usually taught by a dietitian or nurse. Nutrition content is also integrated throughout the curriculum in these programs. The baccalaureate nurse is prepared for a broader, more independent role related to patient education and patient care management, such as nurse case manager. Nurses can be certified as a Certified Nutrition Support Nurse by the National Board of Nutrition Support Certification, associated with the American Society of Parenteral and Enteral Nutrition. Advanced practice nurses (e.g., clinical nurse specialists and nurse practitioners) are registered nurses who are prepared at the graduate degree level. Clinical nurse specialists in gerontology and geriatric nurse practitioners specialize in the care of older adults. Among their clinical roles, they may conduct nutritional assessments of older adults in community or other settings; order therapeutic diets under standard protocols; counsel older patients on prescribed or healthy diets; and manage high blood pressure, diabetes, and other nutrition-related chronic problems, either independently or in collaboration with a physician or dietitian. Advanced practice nurses attain advanced nutrition knowledge and skill through graduate level coursework and clinical experiences. Depending upon their level of preparation, experience, and practice area, research indicates that nurses have variable amounts of nutrition knowledge. Wilt and colleagues (1990) studied the knowledge, attitudes,

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population treatment practices, and health behaviors of nurses regarding blood cholesterol and cardiovascular disease in a stratified, random sample of 206 registered nurses. While the nurses were convinced regarding the importance of diet in reducing heart disease risk, many had substantial knowledge gaps and were not adequately prepared to counsel patients regarding diet and medication therapy for hyperlipidemia. In another study, Mullen and colleagues (1988) surveyed a group of allied health professionals and found that dietitians had higher self-efficacy scores than certified nurse midwives, physician assistants, and dental hygienists for counseling about fat consumption. However, Peiss and colleagues (1995) compared the effect of information provided by physicians and nurses versus a dietitian on patient knowledge of coronary risk factors and diet. While physicians and nurses spent significantly less time than dietitians in nutrition counseling, all study participants benefited from the coronary risk reduction information, whether it was provided by physicians and nurses or dietitians. Multidisciplinary Team Approach Although physicians, nurses, pharmacists, or other health professionals do not always have the knowledge of nutrition and food science that a dietitian has, each profession brings unique skills to the provision of nutrition care. Several examples of interdisciplinary teams have been described in this report. In the nursing home, the evaluation and management of dysphagia require a combined effort by the occupational therapist or speech pathologist and the physician, nurse, and dietitian. In the Modification of Diet in Renal Disease trial, the best results were obtained when a team of physicians, dietitians, nurses, and patients reviewed laboratory values in relation to the diet and tailored the dietary approach to fit patients’ lifestyles (Gillis et al., 1995). In diabetes management, a team composed of a physician, nurse, and dietitian is the most effective in working with patients to make changes in diet, medications, activity, and other aspects of lifestyle (see chapter 6). The provision of nutrition support is optimally managed by a multidisciplinary team consisting of a physician, dietitian, pharmacist, and nurse who work together to recommend, initiate, and monitor enteral or parenteral forms of nutrition (see chapter 10). Advanced training and certification in the area of nutrition support or diabetes education is available for physicians, pharmacists, and nurses. These certifications, among other things, indicate that the professional has a greater knowledge and skill level in nutrition, as it relates to the particular field, and can serve as an excellent role extender for the dietitian. Other health care professionals, such as acupuncturists and doctors of

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population chiropractic or naturopathic medicine, may have training in nutrition and consider nutrition to be part of their scope of practice. Nutrition interventions may involve advising about healthy lifestyles, including diet and the use of botanicals or other dietary supplements. It is important that recommendations for the use of botanicals and dietary supplements are supported by peer-reviewed, published, randomized, controlled trails. WHO IS QUALIFIED TO PROVIDE BASIC NUTRITION EDUCATION OR ADVICE? Basic nutrition education can be provided by a number of different professionals in the course of health care. It can occur during individual consultation with patients or in a group setting. This type of interaction has been defined (Murphy, 1989) as any activity intended to encourage patients to improve their dietary habits. Information is basic, can be provided verbally or in writing, and may include the importance of nutrition in relation to risk factors or known disease conditions. Recommendations should be based on sound nutrition principles, such as those specified by the Dietary Guidelines for Americans (USDA and DHHS, 1995) or the U.S. Preventive Services Task Force (USPSTF, 1995). A basic nutrition education encounter usually lasts from 1 or 2 minutes up to about 15 minutes (Peiss et al., 1995) and is often incident to normal medical care. An example would be the counseling that could take place for osteoporosis prevention. Simple questions could be asked about the intake of calcium-rich foods, advice can be given about culturally specific foods that might be added to the diet, and, if appropriate, the physician or nurse may recommend calcium and vitamin D supplementation. However, if a patient has other chronic diseases that required more complex nutrition intervention, advice about calcium and vitamin D intake could be incorporated into the overall consultation provided by the nutrition professional. In addition to basic nutrition information, it is important that each health professional reinforce the importance of nutrition therapy prior to counseling with a nutrition professional and again at any follow-up visit. Since patients perceive physicians to be highly credible sources of information, their reinforcement is an important aspect of dietary compliance. Nutrition advice needs to be based on sound scientific principles and should be accompanied by simple practical suggestions on how to incorporate changes into the diet. It is important that the nutrition professional be active in updating other professionals’ knowledge and skills in nutrition.

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population WHO IS QUALIFIED TO PROVIDE NUTRITION THERAPY? The dietitian has strong academic and clinical training in nutrition science, food science, nutrient composition of foods, and behavior change related to food intake. This health professional is also the most knowledgeable about strengths and limitations of methods used to determine nutrient composition of foods and dietary intake. Dietitians are a resource for other members of the health care team about nutrient needs and lifestyle factors revealed during diet-counseling sessions. The dietitian is the main advocate for nutrition therapy in the overall care plan and understands how nutrition therapy relates to other forms of treatment. The dietitian or another health professional with comparable academic and clinical training should provide the more advanced level of nutrition services referred to as “nutrition therapy.” SUMMARY Many health care providers have some education in nutrition. However the registered dietitian has the greatest amount of academic and clinical training in nutrition and food science. Basic nutrition education and advice can be provided by most health care providers, but should reflect sound evidence in the literature. The nutrition professional should be involved in educating other health professionals regarding nutrition interventions and practical suggestions for dietary change that he/she can use to educate patients. With appropriate training, all health professionals should be involved in reinforcing the concepts of nutrition therapy provided by the nutrition professional. The registered dietitian is currently the single identifiable group of health care professionals with the standardized education, clinical training, continuing education, and national credentialing requirements necessary to provide nutrition therapy. The importance of the interdisciplinary team is recognized. Each health professional brings a unique role to the provision of nutrition services. Multidisciplinary teams have been shown to be particularly effective in the management of chronic renal failure, diabetes, dysphagia, and the delivery of nutrition support. RECOMMENDATIONS Basic nutrition education can be provided by most health professionals. It should be evidence-based and include practical suggestions for change. The nutrition professional should be involved in educating other members of the health care team regarding nutrition interventions and

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population practical aspects of nutrition care. Additional time has been added to cost estimates for the nutrition professional in home and ambulatory care to provide consultation to other health professionals. It is not recommended that basic nutrition education be a separate reimbursable charge. More complex nutrition services, referred to in this report as nutrition therapy, should be provided by a nutrition professional and be a covered benefit for Medicare beneficiaries. The registered dietitian is currently the single identifiable group of health professionals qualified to provide nutrition therapy. It is recognized that other health care professionals in particular fields may be qualified to provide nutrition therapy and should be considered on an individual basis as a reimbursable provider. REFERENCES ADA (American Dietetic Association). 1991. ADA policy statement on licensure. J Am Diet Assoc 91:985. ADA (American Dietetic Association) 1999. Commission on Accreditation for Dietetics. Available at: http://www.eatright.org/caade/. Accessed August 10, 1999. Allwood MC, Hardy G, Sizer T. 1996. Roles and functions of the pharmacist in the nutrition support team. Nutrition 12:63–64. Arena J, Walters P. 1997. Do you know what a dietetic technician can do? A focus on clinical technicians and their expanded roles and responsibilities. J Am Diet Assoc 97:S139– S141. Brown RO, Dickerson RN, Hak EB, Matthews JB, Hak LJ. 1997. Impact of a pharmacist-based consult service on nutritional rehabilitation of nonambulatory patients with severe developmental disabilities. Pharmacotherapy 17:796–800. CDR (Commission on Dietetic Registration). 1999. Registered dietition (RD) certification. Available at: http://www.cdrnet.org/certifications/rddtr/rdindex.htm. Accessed May 15, 1999. CFR (Code of Federal Regulations). 1998. Requirements for long-term care facilities. 42CFR482–483. Washington, D.C.: U.S. Government Printing Office. Council on Foods and Nutrition. 1963. Nutrition teaching in medical schools. J Am Med Assoc 183:995–997. Driscoll DF. 1996. Roles and functions of the hospital pharmacist on the nutrition support team. Nutrition 12:138–139. Duyff RL. 1999. The value of lifelong learning: Key element in professional career development. J Am Diet Assoc 99:538–543. Gillis BP, Caggiula AW, Chiavacci AT, Coyne T, Doroshenko L, Milas C, Nowalk MP, Scherch LK. 1995. Nutrition intervention program of the Modification of Diet in Renal Disease Study: A self-management approach. J Am Diet Assoc 95:1288–1294. Glanz K. 1985. Nutrition education for risk factor reduction and patient education: A review. Prev Med 14:721–752. Glanz K, Gilboy MB. 1992. Physicians, preventive care, and applied nutrition: Selected literature. Acad Med 67:776–781. Glanz K, Tziraki C, Albright CL, Fernandes J. 1995. Nutrition assessment and counseling practices: Attitudes and interests of primary care physicians. J Gen Intern Med 10:89–92.

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population Hiddink GJ, Hautvast JGAJ, van Woerkum CMJ, Fieren CJ, van’t Hof MA. 1997. Consumers’ expectations about nutrition guidance: The importance of primary care physicians. Am J Clin Nutr 65:1974S–1979S. JCAHO (Joint Commission on Accreditation of Healthcare Organizations). 1996. Comprehensive Accreditation Manual for Hospitals. The Official Handbook. Oakbrook Terrace, Ill.: JCAHO. Kushner RF. 1995. Barriers to providing nutrition counseling by physicians: A survey of primary care practitioners. Prev Med 24:546–552. Lee HS. 1996. Roles and functions of the hospital pharmacist on the nutrition support team. Nutrition 12:140. Mullen PD, Holcomb JD, Fasser CE. 1988. Selected allied health professionals’ self-confidence in health promotion counseling skills and interest in continuing education programs. J Allied Health 17:123–133. Murphy PS. 1989. Effect of nutrition education on nutrition counseling practices of family physicians. Acad Med 64:98–102. Nawaz H, Adams ML, Katz DL. 1999. Weight loss counseling by health care providers. Am J Publ Health 89:764–767. NRC (National Research Council). 1985. Nutrition Education in U.S. Medical Schools. Washington, D.C.: National Academy Press. Peiss B, Kurleto B, Rubenfire M. 1995. Physicians and nurses can be effective educators in coronary risk reduction. J Gen Intern Med 10:77–81. Snetselaar LG. 1983. Nutrition Counseling Skills: Assessment, Treatment, and Evaluation. Rockville, Md.: Aspen Systems. Study Commission on Dietetics. 1972. The education of future dietitians. Pp. 55–60 in: The Profession of Dietetics: The Report. Chicago, Ill.: American Dietetic Association. USDA (U.S. Department of Agriculture) and DHHS (U.S. Department of Health and Human Services). 1995. Dietary Guidelines for Americans, 4th ed. Washington, D.C.: U.S. Government Printing Office, USPSTF (U.S. Preventive Services Task Force). 1995. Guide to Clinical Preventive Services, 2nd ed. Report of the U.S. Preventive Services Task Force. Washington, D.C.: U.S. Department of Health and Human Services, Office of Public Health, Office of Health Promotion and Disease Prevention. Wilt S, Hubbard A, Thomas A. 1990. Knowledge, attitudes, treatment practices and health behaviors of nurses regarding blood cholesterol and cardiovascular disease. Prev Med 19:466–475.