The true value of a dietitian in long-term care

If you’ve ever wondered how to attach a dollar value to the work a dietitian does in long-term care, this blog has the answers. Centers for Medicare and Medicaid Services (CMS) requires that long-term care facilities provide appropriate nutrition care to their residents, and in an ideal situation, this care is completed or overseen by a registered dietitian.

CMS regulations

CMS has staffing regulations that pertain to registered dietitians (“dietitians”) in addition to standards for long-term care residents’ nutrition care. These standards are best met by dietitians because dietitians are the only clinicians on the interdisciplinary team with the unique expertise to provide customized solutions to nutritional concerns. CMS requires that a facility either employ a dietitian full time, or have a consulting dietitian with frequent, scheduled visits.¹

Registered dietitians are the ideal professional to oversee long-term care resident care because of their extensive clinical training, ability to use medical nutrition therapy (MNT), capacity for order writing privileges, and ability to address malnutrition. These unique qualifications add improved quality of life, increased customer satisfaction, and improved survey scores to long term care facilities.

Dietitian coverage requirements vary by state and are very low compared to the ideal scenario of having a full-time dietitian.

Staffing requirements will vary by the size of each facility, but it is important to note that a dietitian can provide value to a long-term care facility beyond the minimum requirements. These include tasks such as menu review, attendance to important committees and meetings, and order-writing privileges, all of which help improve a resident’s clinical outcomes, satisfaction, and quality of life.

Menus must be reviewed for nutritional adequacy by the dietitian.¹ CMS long-term care facilities must ensure their residents maintain acceptable parameters of nutrition status and are offered a therapeutic diet when appropriate.¹  CMS regulations require that a person from the food and nutrition team participates on the interdisciplinary care plan team and makes allowances for dietitians to have diet order-writing privileges with facility approval.¹

Reimbursement under the patient driven payment model

As of October 1, 2019, skilled nursing divisions of long-term care facilities receive reimbursement for services provided to residents under CMS’ Patient Driven Payment Model (PDPM). PDPM aims to reimburse facilities more accurately compared to previous payment models. This new payment structure will be applied for any Medicare/Medicaid resident who receives skilled therapies.²

PDPM reimburses facilities based on care provided by five case-mix components. One of these case-mix components, Non-Therapy Ancillary (NTA), includes conditions and services managed by a dietitian. Within the NTA category is a list of comorbidities. Any qualifying comorbidities that a resident has can be coded on the Long-Term Care Minimum Data Set (MDS). Comorbidities are assigned point values. The intention is to reimburse facilities at a higher rate for residents who require more intensive or specialized care. There are several NTA comorbidities that require care from a dietitian, some of which are listed below.^{2, 3}

• Parenteral nutrition (high)—7 points
• Parenteral nutrition (low)—3 points
• Feeding tube—1 point
• Morbid obesity—1 point
• Malnutrition—1 point

Early data are available on how PDPM has impacted reimbursement for long-term care facilities. This is discussed in the section entitled, “Increased Reimbursement, available via the free download linked in this blog.

One specific NTA comorbidity, malnutrition, not only requires care from a dietitian to treat, but it actually requires a dietitian’s assessment to accurately diagnose. Only a dietitian can complete a full nutrition assessment on any resident identified at risk for malnutrition. The dietitian is trained to critically evaluate weight trends, nutritional intake, and to complete a nutrition-focused physical exam. All of these elements are documented in the dietitian’s assessment, which is essential documentation to support a physician’s diagnosis of malnutrition.

PDPM also streamlines MDS documentation and incentivizes long-term care facilities for completing early and accurate MDS assessments. The reimbursement rate that a facility receives for a specific admission is based on the five-day MDS assessment. Thus, if a facility wants to claim NTA comorbidities for a specific resident, the comorbidities and any supporting documentation must be documented early in the resident’s admission to the long-term care facility.² This is impactful and underscores the importance of having a full-time dietitian, rather than one who provides intermittent consulting services. If a dietitian is not present to complete

For more on why you should choose a registered dietitian, including training, order writing privileges and the tangible results associated with choosing a registered dietitian, down the free eBook!

References

Centers for Medicare and Medicaid Services (2017, November 9) State Operations Manual Appendix PP—Guidance to Surveyors for Long-Term Care Facilities. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf

Centers for Medicare & Medicaid Services. SNF PPS: Patient Driven Payment Model. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/MLN_CalL_PDPM_Presentation_508.pdf. Accessed July 2, 2019.

Centers for Medicare & Medicaid Services. Patient Driven Payment Model; Fact Sheet: NTA Comorbidity Score. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/PDPM_Fact_Sheet_NTAComorbidityScoring_v2_508.pdf. Revised February 14, 2019. Accessed July 2, 2019.