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VOLUME 23 NUMBER 4

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THE CONSULTANT DIETITIAN

LEADERSHIP IN PRACTICE

Adequacy of Consultant Hours inLong Term Care

CD-HCF Strategy Paper - About the AuthorsJody L. Vogelzang, MS, RD, LD, FADA, is the Chair of CD-HCF and president/owner of JLV& Associates, a health care consulting firm specializing in evaluation and compliance.Pam Womack, RD is a past secretary of CD-HCF and owns Challenge Enterprises in theSeattle area. She is the author of several books on dysphagia and is a former state ofWashington surveyor.

Strategy StatementThe consulta.nt dietitian is an importantpart of the long-term care interdiscipli-nary team. In order to meet the complexnutritional needs of the resident, as wellas satisfy regulatory requirements, ade-quate hours of consultation time must benegotiated.

A consultant dietitian is a multifacetedcontributor to the health care team.Effectiveness and perceived value of theconsultant's role is directly related to res-ident and facility outcomes.Administrative personnel hire the con-sultant as an expert in food and nutrition.If there are dietary or nutrition deficien-cies cited during a survey, the consultantwould be called upon to explain theproblems. If the consultant is unaware ofthe problem or has not identified anintervention, the resident and the consul-tant's job is in jeopardy.

This paper serves as a tool, in conjunctionwith CD-HCF publication" Steps to Successfor Consultant Dietitians," to help the con-sultant calculate the number of hoursrequired to meet the unique needs of a longterm care facility.

Clinical ConsiderationsThe clinical responsibilities of a consul-tant dietitian include assessment, care-planning, and continuous evaluation ofinterventions. Each component of this

process requires reliance on facility stafffor information, a resident interview andobservation, and a medical chart review.To allow adequate time for clinicalresponsibilities consider the following:

./ General acuity level of the facility -Is the facility more of a medical modelor more social and supportive care?

./ Number of residents receiving par-enteral/ enteral-feedings

./ Number of residents with stage II orabove pr.essure ulcers

./ Prevalence of unplanned weightchange month to month

./ Admissions and discharges/month

./ Atterrdance at interdisciplinarymeetings

./ Content of recent regulatory sur-veys

./ Staff turnover of nursing personnel

./ Dietitian workspace in relation toresident care - Can you chart and workat the nurse's station or must you carrya small number of charts to anotherlocation?

./ Centralized or decentralized med-ical record - are other records such asflow charts, intake records, skin reportskept in other areas?

(continued on page 4)

PRINTINGAIIJD MAILING COURTESY OF ROSS PRODUCTS DIVISION, ABBOTT LABORATORIES, COLUMBUS, OHIO

Adequacy of Consultant Hours ...(continued from page 1)

.;' Capability and availability of existing dietary staff inassisting with preliminary assessment/nutrition screen

.;' Corporate/facility policy on what level of nutritionrisk receives a comprehensive nutritional assessment

.;' Involvement of consultant dietitian in the MDSprocess

.;' Participation in care protocol implementation andevaluation.;'

.;'

.;'

Status and philosophy of dining programs

Involvement in externally generated consult requests

Frequency and style of visit reports

Management ConsiderationsAn effective consultant dietitian must also be skilled inidentifying and solving management and administrativeissues. Many of the day to day functions of the dietarydepartment will be delegated to a full time employee.However, the consultant must be cognizant of the manymanagement problems that affect the quality of residentcare in a facility. Quick identification of administrativeproblems will yield a stronger meal delivery system andbetter nourished residents. Evaluate the status of the fol-lowing:.;' Dietary staff retention and training - is RD involve-ment required in interviewing or training?.;' Physical layout and complexity of meal delivery sys-tem.;' Food and labor budget.;' Procurement/ complexity of menu cycle.;' Existing sanitation level of dietary department.;' Percentage of modified diets.;' Extent of supplement usage.;' Resident council reports relating to food issues.;' Frequency and style of management reports includ-ing ongoing quality improvement assessments.;' Participation in outcome studies.;' Last revision of policy and procedures.;' Expected time of next regulatory survey- is RD partic-ipation required? (If so, this should be over and abovethe negotiated hours).

Education ConsiderationsThe consultant dietitian is often the most highly educatedhealth care professional in a long-term care facility. Thecommunication of nutrition information to other care-givers is essential in ensuring prompt attention to nutri-tionalissues. Education may be formal or informal innature and should be ongoing. Consider participation inthe following:

.;' Corporate/ facility policy on RD involvement in the

Page 4

inservice program.;' Participation in resident discharge education.;' Recommendation of educational materials, workshops,and courses for staff

Hours RequiredAfter careful evaluation of the special needs and require-ments of a facility, an accurate estimation of dietitian timecan be determined. This time can be affected by level ofexperience of the consultant dietitian and familiarity withexisting medical record procedures and meal delivery sys-tems.

Assessment time may also vary with subtle changes in res-ident acuity mix within the facility, proximity of dietitianworkspace to resident, length of resident observation, andavailability of resident's medical record .

Time Estimates for Clinical Functions.;' Nutrition screening -15 minutes/resident.;' Nutrition assessment for moderate and high risk - 45-60minutes/resident.;' Ongoing assessment of at risk residents (Stage II orgreater pressure ulcers, unplanned weight change, par-enteral/ enteral feeding) and routine periodic updates - 20minutes / resident.;' Completion of the MDS - 10 minutes/resident.;' Attendance at interdisciplinary meetings - Highlyvariable depending on facility policy and practice.Determine if this is a valuable use of dietitian time. .".;' Recommendation sharing/report writing - 30 min-utes/visit.;' Summary conference with management personnel -60minutes/month

Time Estimates for Management Functions.;' Sanitation evaluation -1 hour/month.;' Four week menu cycle with modifications - 20hours/ cycle.;' Addition of modified diets to menus - 1 hour and 30minutes/ additional diet.;' Mealtime Observation (in kitchen and dining area) -30 to 45 minutes/visit.;' Gathering outcome data -1 hour/month

Time Estimates for Education Functions.;' Inservice preparation and delivery - 30 to 60min-utes/month.;' Discharge instruction - 30 minutes/resident

The Consultant Dietitian

Adequacy of Consultant Hours ...(continued from page 4)

Summary

Time estimates for the tasks cited above vary greatly withthe skills of the consultant. If a consultant finds that a taskis consistently taking longer than the guidelines discussedin this paper, skills and knowledge should be evaluated.

Consultant dietitians need to communicate their worth toadministrators and be assertive leaders in long term care.A dietitian that under estimates time requirements for a jobcould be charged with malpractice by placing the residentat risk for malnutrition. Inaccurate estimation of hoursrequired in a facility can give rise to two scenarios: a dietit-ian that leaves a facility before her work is complete, and adietitian that stays without pay until the job is finished.The dietitian that miscalculates the hours but stays andworks until the work is done meets the nutritional needs ofthe resident but not her own business needs.Miscalculation of hours can cause a ripple affect throughthe entire consultant dietitian industry. A tarnished pro-fessional image, inadequate reimbursement, and the

potential for bad publicity are only a few results of sub-standard consultant practice.

Adequacy of Consultant Hours Worksheet

Task Estimated Number TotalTime Min.

ClinicalNutrition Screen 15 min/resNutritional Assessment formoderate to hiqh risk 45/60 min/resOn-going at risk document-ation, wt. loss, pressuresores, tube feedinq 20 min/resCare Plan Conferences 1 hr/weekSummarv Conference 60 min/moMDS 10 min/resReferrals 20 min/res

ManagementSanitation Inspection 1 hr/moWritinq 4 Week Cycle Menu 20 hrs/cvcleAdditional Modified DietWriting 90 min/dietGatherinq Outcome Data 1 hr/moMeal Time Observation 30/45 min/visit

EducationInservice 30160 min/moDischarce Instruction 30 min/res

Total

Additional ReadingMedical Nutrition Therapy Across the Continuum of Care, 2ndEdition, American Dietetic Association, Chicago, 1998.

Steps to Success for the Consultant Dietitian, ConsultantDietitians in Health Care Facilities, 1998.Inservice Manual, Consultant Dietitians in Health CareFacilities, 1997.Dining Skills Manual, Supplement and Video, ConsultantDietitians in Health Care Facilities, 1993,1998and 1993.Nutrition Care of the Older Adult, American DieteticAssociation, Chicago, 1998.r----------------------,

FoodSafety.gov - A New Web Site Established

"www.FoodSafety.gov" is a "gateway" web sitedesigned to help the public find government food safe-ty information more readily on the web. The site pro-vides links to food safety-related web sites from federal,state and local government agencies."www.FoodSafety.gov" is one of the initiatives of theMay 1997National Food Safety Initiative Report to thePresident. This site was developed by the FDA's Centerfor Food Safety and Applied Nutrition (CFSAN)in con-sultation with USDA's Food Safety Inspection Service(FSIS).http://www.FoodSafety.gov /L ~

The Consultant Dietitian Page 5

Adequacy of Consultant Hours Worksheet These are averages. You need to add or subtract any duties that are different from what is listed.

TASK Estimated Number TotalTime Min.

ClinicalNutrition Screen - deduct 15 min/res if someone else 15 min/res screens residentNutritional Assessment for moderate to high risk 45/60 min/resOn-going at risk documentation, wt. loss, pressure 20 min/res sores, tube feedingCare Plan Conferences 1 hr/weekSummary Conferences - with Administrator, DNS and DM 60 min/monthWeekly Communication with nursing - nursing to give 30 min per you wt. changes, skin and TF info visit minimumTravel time between resident and where you chart

ManagementSanitation Inspection 60 min/monthWriting 4 week cycle menu 20 hrs/cycleAdditional modified diet writing 90 min/dietGathering Outcome Data 60 min/monthCommunication with dietary manager or tech 30 min/visit

EducationIn-service 30-60

min/monthDischarge Instruction 30 min/resWeekly nutrition team meetings 30-60 min

Total

Reprinted from the CD-HCF strategy paper "Adequacy of RD Hours" by Jody Vogelzang, RD MS LD FADA and Pam Womack RDConsultant Dietitians in Health Care Facilities (CD-HCF) 2000