Medical Nutrition Therapy Part 1

1
Medical Nutrition Therapy Part 1

• A Core Medical Service

Marcy Fenton, MS, RD
Clinical Services Division
Ryan White HIV/AIDS Program Grantee
Meeting August 26, 2008
2
(No Transcript)
3
Objectives

• August 26, 2008
• Explain the rationale for the integration of a
  medical nutrition therapy program in HIV medical
  management
• Describe infrastructure components necessary to
  implement and maintain an HIV medical nutrition
  therapy program
• Identify steps to integrate a medical nutrition
  therapy program as part of their HIV medical
  service

4
Selected Guides and Resources

• Handouts
• Medical Nutrition Therapy Guidelines
• Nutrition Care Process
• Screening Referral Tools
• Comprehensive Brief MNT Assessment Tools
• Anthropometric Body Composition
• Fact Sheets
• International HIV Nutrition
• Professional Organizations
• Articles Reports
• Dietary Guidelines, Food Composition Analysis
• Food Security Programs, Tools Reports
• Screening, referral assessment tools

5
Medical Nutrition Therapy (MNT)

• HRSA/HAB Definition
• Provided by a licensed/Registered Dietitian
• Outside a primary care visit
• Includes the provision of nutritional supplements
• Note MNT provided by someone other than a
  licensed/Registered Dietitian should be recorded
  under psychosocial support services.
• HIV/AIDS Bureau. Instructions for
  Completing the 2008 Ryan White HIV/AIDS Program
  Annual Data Report, Effective Date June 1, 2008.
  http//datasupport.hab.hrsa.gov/2008docs/2008RDRin
  structions.pdf

6
Medical Nutrition Therapy

• American Dietetic Association Defintion
• A specific application of the Nutrition Care
  Process (NCP)
• Occurs in clinical settings
• Focuses on the management of diseases
• Uses the NCP to manage disease
• In-depth individualized nutrition assessment
• Individualized care
• Duration and frequency of care
• Lacey K Pritchett E. Nutrition care
  process and model ADAs road map to quality and
• outcomes management. J Am Diet Assoc
  20031031061-72

7
Vicious Cycle of Malnutrition and HIV
Source Food and Nutrition Technical Assistance
(FANTA) Project Adapted from RCQHC and FANTA
2003. FANTA is managed by the Academy for
Educational Development and funded by the US
Agency for International Development (USAID).
www.fantaproject.org
8
Weight Classification Using BMI
I National Heart, Lung and Blood Institute, II
Magili et al. CID 2006 March, III Amorosa
and Polsk, Kotler Steinhart
9
Overweight, Obesity and HIV
Sources (1) Amorosa et al. JAIDS
2005Aug1539(5)557-61. (2) NHANES 1999-2000
www.cdc.gov 7/03
10
Conditions Associated with Obesity
Hypertension
Gout
Stroke
Mood Disorders
Heart Disease
Hyperlipidemia
Obesity
Sleep Disorders
Non-Insulin Dependent DM
Eating Disorders
Osteoarthritis
Some Cancers
Gall Bladder
Bray GA. 1998 Contemporary Diagnosis and
Management of Obesity, Newtown, PA Handbooks in
Health Care Chapter 4.
11
Rationale for MNT in HIV Medical Care

• Multi-factorial Nutritional Problems
• Nutrition is important in overall health and the
  immune system
• MNT is increasingly regarded as important for
  HIV-infected persons
• Intensive dietary counseling is recommended for
  adults with CVD risk factors
• Adults with HIV dyslipidemia should receive
  nutritional treatment
• Registered dietitians can deliver intensive
  behavioral counseling
• AETC AAHIVM USPSTF Dubé et al USPSTF

12
Necessary Components

• Infrastructure to Implement and Maintain an HIV
  Medical Nutrition Therapy Program

13
MNT A Core Medical Service

• For All People Living with HIV Disease
• Policies
• RD on staff
• Awareness of need for nutrition RD
• Funding for RD services
• Mandate for qualified RD services
• Systematic HIV nutrition training
• Adequate number of MNT encounters per year
• Standards for HIV MNT are recognized
• Guidelines performance measures
• All stakeholders agree on service interpretation
• Screening referral system works

14
MNT A Core Medical Service

• For All People Living with HIV Disease
• People
• Language, cultural HIV sensitivity
• Patient informed early accept MNT is part of a
  core medical service
• Provider administrators educated support
• RDs are qualified available
• Salary is adequate
• RDs are trained familiar with HIV disease
  nutrition
• RD pool is adequate

15
MNT A Core Medical Service

• For All People Living with HIV Disease
• Procedures
• RD provides consistent quality patient care
• RD-MD communication
• Support for RD
• Teamwork, resources, technology
• Client compliance
• Screening referral system
• Health care administrative teamwork

16
MNT A Core Medical Service

• For All People Living with HIV Disease?
• Place
• Office space
• Equipment
• Tools
• Confidentiality

17
Levels Frequency of HIV MNT

• Ongoing MNT
• Minimum interventions
• 1-2 times/year for Level 1
• Level 1 HIV/AIDS asymptomatic
• 2-6 times/year for Levels 2, 3, 4
• Level 2 HIV/AIDS symptomatic but stable
• Level 3 HIV/AIDS acute
• Level 4 Palliative
• Los Angeles County MNT Standards of Care, 2005
  ADA HIV Adult Medical Nutrition
• Therapy Protocols, 1998.

18
Length of MNT

• Initial, Comprehensive Follow-up
• Comprehensive assessment MNT
• Initial and as needed
• 60 minutes
• Ongoing MNT
• 15 to 45 minutes
• Los Angeles County Commission on HIV Medical
  Nutrition Therapy Standards
• of Care, 2005 HIV Adults MNT Protocols, 1999
  (ADA)

19
RD Staffing

• In HIV Medical Care
• At minimum 1 RD to maximum
• 500 adult patients in diverse stages
• 250 adult patients in acute stages
• 250 pediatric patients
• Ideally 1 RD to maximum
• 350 adult patients in diverse stages
• Los Angeles County Commission on HIV Medical
  Nutrition Therapy Standards of Care, 2005 DC
  Nutrition Alliance www.hivresources.com/RDRatio.h
  tml HIV Adults MNT Protocols, 1999 (ADA)

20
RD Staffing

• Plan for Growth
• 1 RD to maximum 500 HIV adult patients in
  diverse stages
• 56,300 new infections in United States in 2008
• Requires 112.6 additional FTE RDs/year
• Los Angeles County Commission on HIV
  Medical Nutrition Therapy Standards of Care,
• 2005 HIV Adults MNT Protocols, 1999 (ADA)
• CDC. Basic Statistics. August, 2008
  www.cdc.gov/hiv/topics/surveillance/basic.htm

21
Basic Qualifications of RDs

• Completed the minimum of a Baccalaureate degree
  awarded by US regionally accredited college, or
  university or foreign equivalent
• Met current academic requirements as approved by
  the Commission on Accreditation for Dietetics
  Education (CADE) of ADA
• Completed a minimum of 900 supervised practice
  hours or pre-professional experience
  accredited/approved by CADE of ADA
• Successfully completed the Registration
  Examination for Dietitians
• Remit annual registration maintenance fee
• Accrued 75 units of continuing professional
  education every 5 years
• Commission on Dietetic Registration
  www.cdrnet.org/about/rddefinition.htm

22
HIV Registered Dietitian

• Essential Ingredients
• Grounded in nutrition science
• Eager interested in providing nutrition care to
  people living with HIV
• Supported by clinic team administration to
• Fully participate on team
• Receive ongoing learning opportunities

23
HIV Registered Dietitian

• Responsibilities in Providing Care
• Works with medical team to identify and correct
  causes of nutrition problems
• Refers to providers and other disciplines
• Participates in team case conferences
• Promotes continuity of care
• Creates screening tools, forms, educational
  materials
• Monitors nutrition-related laboratory,
  anthropometric, other values

24
Nutrition Care Process Model (NCPM)

• Standardized Terminology
• Designed to improve
• Consistency quality of patient care
• Predictability of patient outcomes
• Four steps
• Nutrition Assessment
• Nutrition Diagnosis
• Nutrition Intervention
• Nutrition Monitoring Nutrition Evaluation
• Lacey K Pritchett E. Nutrition care
  process and model ADAs road map to quality and
  outcomes management. J Am Diet Assoc
  20031031061-72 ADA International Dietetics and
  Nutrition Terminology (IDNT) Reference Manual
  Standardized Language for the Nutrition Care
  Process, 1st Edition, 2008 www.eatright.org/ada/f
  iles/ncp_publication_2008_june_1_07.pdf

25
NCPM

ADA NUTRITION CARE PROCESS
AND MODEL





Screening
Referral



System


Ø

Identify risk factors

Ø

Use appropriate tools
and methods

Ø

Involve
interdisciplinary
collaboration


Nutrition Diagnosis





Ø

Identify and label problem


Nutrition Assessment



Ø

Determine cause/contributing risk




Ø

Obtain/collect timely and

factors




appropriate
data



Ø

Cluster signs and symptoms/



Ø

Analyze/interpret with
defining characteristics

evidence
-
based standards





Ø

Document


Document


Relationship

Between



Patient/Client/Group
Nutrition Intervention



Dietetics

Ø

Plan nutrition intervention




Professional


Formulate goals and

determine a plan of action
Ø

Implement the nutrition intervention




Care is delivered and actions
Nutrition Monitoring and

-
are carried out

Evaluation

Ø

Documen
t
Ø

Monitor progress


Ø

Measure outcome indicators

Ø

Evaluate outcomes

Ø

Document


Outcomes


Management Sys
tem
Ø

Monitor the success of the Nutrition Care
Process implementation

Ø

Evaluate the impact with aggregate data

Ø

Identify and analyze causes of less than
optimal performance and outcomes

Ø

Refine the use of the Nutrition Care

Process






26
Nutrition Screening

• Definition
• Screening
• Those preventive services in which a test or
  standardized examination procedure is used to
• identify patients requiring special
  intervention?
• Nutrition screening
• A process used to identify nutritional problems
  and risk factors
• US Preventive Services Task Force, Guide to
  Clinical Preventive Services, 2nd ed. Washington,
  
• DC US Department of Health and Human
  Services , Office of Disease Prevention and
  Health
• Promotion 1996
• Hammond K. Krauses Food Nutrition
  Therapy, 12th ed. Elsevier, 2008

27
Screening and Referral

• Recognizing Nutrition-Related Problems
• Review screen
• v if your patients have had any of the
  nutrition-related problems, concerns or
  conditions?
• Review referral criteria
• Los Angeles County Commission on HIV.
  Medical Nutrition Therapy Standards of Care,
  September 2005 Includes Nutrition Screen
  Referral Criteria for Adults (18 Years) with
  HIV/AIDS (ADA MNT Evidence-Based Guides for
  Practice, March 2005) www.hivcommission-la.info/1c
  ms1_034030.pdf

28
Screening Tool (ADA, 2005)
29
Nutrition Screening

• Goals
• Determine whether a more detailed assessment
• is warranted
• Quickly identify individuals who are
• Malnourished
• At nutritional risk
• Likely to become at nutritional risk, or
• Need further assessment
• Improve medical care decisions

30
Screening Test

• Appropriate Parameters
• Tailor to the population served
• Tailor to the nutrition care services to be
  provided
• Different screens for different conditions
• Oncology
• Obstetrics
• Renal dialysis
• HIV

31
HIV Nutrition Screening

• When, How Often, How?
• When How often?
• New/re-entry into care within 6 months
• Ongoing at least every 6 months
• Changes in medical diagnosis, nutrition status
• How?
• Criteria for screening
• Screening tool
• Primary care provider (PCP) signature/date
• Stored in medical record
• Source Nutrition Screen Referral Criteria for
  Adults (18 Years) with HIV/AIDS. ADA MNT
• Evidence Based Guides for Practice, March 2005

32
Nutrition Screening Tool

• Utilization in 38 Los Angeles County Clinics

33
HIV MNT Referral

• PCP Refers for MNT
• Referral documentation includes
• Signature and date of physician or authorized
  person to refer for MNT
• PCPs reason (desired outcome) for MNT
• Medical diagnoses
• Recent lab data medications
• Consent to release medical information
• Proof of residency, income, HIV diagnosis
• Source ADA MNT Evidence Based Guides for
  Practice, March 2005

34
Barriers To Nutrition Counseling

• UMJMMC Prenatal Primary Care Clinics for
  HIV Positive Women
• 2003 Quality Assurance Review for Ryan White
  Funding
• Low completion rates of nutrition referrals
• 13/96 (13.5) Nutrition Referrals completed with
  total annual patient number of 175.
• Time delays in referral appointments
• Locations not co-ordinated
• Frustrated MD, ARNPs do not refer
• RD turn over
• LM Parker, University of Miami School of Medicine

35
Plan of Improvement

• RD
• Placed as TEAM MEMBER
• Covers 2 Prenatal/Primary Care clinics on a
  part-time basis,
• 8 hours per week
• Develop an approved protocol for automatic
  referrals
• All diabetic, hypertensive, clients, etc.
• Bill for re-imbursement of RD time
• Ryan White, Drug Company Studies, Grants
• Monitor
• Plan of improvement, quantitative and qualitative
  data revise as needed
• LM Parker, University of Miami School of Medicine

36
Nutrition Consultations Completion Rates
LM Parker, University of Miami School of Medicine
37
HIV Nutrition Evidence Analysis

• Completed Questions
• What is the evidence to support Medical Nutrition
  Therapy for people with HIV infection?
• What are the caloric needs of people with HIV
  infection?
• What is the evidence to support in people with
  HIV infection?
• Education on foodborne illness (and for their
  caregivers)
• ADA HIV Evidence Analysis Workgroup,
  www.adaevidencelibrary.org

38
HIV Nutrition Evidence Analysis

• Completed Questions
• A particular dietary intake of carbohydrate?
• A particular dietary intake of protein?
• The consumption of specific fatty acids?
• Dietary treatment of diarrhea/malabsorption?
• ADA HIV Evidence Analysis Workgroup,
  www.adaevidencelibrary.org

39
HIV Clinical Performance Measures

• ADA Recommended MNT Measures
• of clients with HIV infection who
• Have been screened for nutrition related problems
  (Tier 2)
• Received medical nutrition therapy (Tier 3, 1 of
  2)
• Per conditions MNT Rx by MD
• Have been provided medical nutrition therapy by a
  registered dietitian (Tier 3, 2 of 2)
• American Dietetic Association, June 2007

40
Basic Nutrition Checklist

• Questions
• Are medical nutrition therapy services available?
• Are there written policies and procedures for the
  referral of patients to MNT services?
• If yes, are services provided by a certified
  registered dietitian?
• Are nutrition consult notes maintained and
  include in the patients medical record?
• Are patient educational materials regarding
  nutrition and HIV available and routinely
  distributed to patients?
• If yes, are the materials culturally and
  linguistically appropriate and written for the
  reading and comprehension level of most clinic
  patients?

41
Educating RDs Providers

• AIDS Education Training Centers
• Make RDs an AETC target audience
• RDs need HIV specialized HIV nutrition
• PCPs need HIV nutrition training
• Impacts
• Patient medical and nutrition care in clinic
• RDs knowledge, sensitivity, willingness
• Collaboration on needed research
• Patient outcomes
• Individual RDs regional AETC programs

42
HRSA Nutrition Manual
Spanish English
43
Acknowledgments

• Mary Orticke, RN, MPH
• Chief, Clinical Services Division
• Los Angeles County
• Office of AIDS Programs and Policy
• Janelle LHeureux, MS, RD
• AIDS Project Los Angeles
• Linda M Parker, BS, MS, DSc
• University of Miami School of Medicine
• Deborah S. Cummins, PhD
• Scientific Affairs and Research
• American Dietetic Association
• Pamela Rothpletz-Puglia EdD RD
• Director of Nutrition and Wellness
• University of Medicine and Dentistry of New
  Jersey (UMDNJ)

44
For More Information

• Marcy Fenton, M.S., R.D.
• Program Manager, Clinical Services Division
• Office of AIDS Programs and Policy
• 600 South Commonwealth Avenue, 10th Floor
• Los Angeles, California 90005-4001
• Phone [phone]
• Fax [phone]
• E-mail mfenton_at_ph.lacounty.gov
• This presentation is available at
• www.publichealth.lacounty.gov/aids