What it means to be a dietitian in long-term care
One of the many options you have in the field of dietetics is to work as a registered dietitian in long-term care. The age of this population has expanded to include younger residents and their needs have changed. Now, the terms “long-term care” or “nursing and rehab center” are used more universally to include a broader spectrum of care. Depending on the size of the facility, it is not uncommon to serve as a single site dietitian. Most facilities have one full time dietitian and a food service manager for approximately 150 residents.
The duties of the dietitian vary from clinical care documentation to assisting with tray service and meal operations to completion of MDS records. In this all-inclusive blog, we’ll review everything you need to know about working in long-term care, provide resources to assist you with a temporary assignment, and help you prepare for success in an upcoming survey.
In this article you will find:
- What to expect on your first day in long-term care
- Important MDS terminology you need to know
- How to choose between therapeutic and liberal diets
- The importance of evaluating weight changes
- How to craft individualized care plans
- What you need to know about the patient-driven payment model
- How to prepare for a long-term care survey
On your first day in long-term care
Most dietitian offices in long-term care are inside the kitchen or close by. If you haven’t learned where your space will be during the interview process, then on your way in, ask the receptionist to show you the way. Once you’ve had a chance to place your things down and have found a computer, your first stop should be going to meet the kitchen manager and staff. Often, the food service staff and the dietitian work closely together, as you will need to communicate resident food preferences and diet changes with them on a regular basis.
Typically, a daily morning meeting will be held with all the department heads and administration. This meeting provides an opportunity to go over things that happened over the last 24 hours. New admissions, hospital returns, falls that occurred, new orders given, or changes in condition will be discussed and reviewed with the team. Each department will have a chance to share information regarding their area of expertise. For example, as the dietitian, you may notify the team of a significant weight change, request a re-weight on a resident, explain a diet change or share information obtained from a family member pertaining to the plan of care. The meeting serves to follow up on things discussed the day prior and prevent a delay in care. It is a good time to identify and meet key people with whom you will be working and benefit from having effective communication with them on a regular basis.
Key people and their relationship with the RD
With all your coworkers and peers, learn how they like to be contacted and provide them with your preferred way as well. Find out what meetings they like the RD to attend and come prepared with any necessary information they want you to provide.
The administrator is who you may need to see if you need access to the facility’s computer system or an email account set up. This person is in charge of the facility, and you should introduce yourself promptly and communicate thoroughly with them if any issues arise that you cannot handle on your own.
Director of Nursing (DON) and Assistant Director of Nursing (ADON)
The DON and ADON are the heads of the entire nursing department including nurse managers, floor nurses, and nursing assistants. They are the ones assigning staff to obtain weekly/monthly weights, tracking facility wounds, feeding, and recording meal percentages, just to name a few. To the dietitian, the nursing staff are your lifeline. They ensure the resident eats, receives their supplements, is weighed timely, and they are a wealth of information when it comes to providing you with what you need to complete your assessment or recommend the appropriate intervention.
The MDS coordinator can assist you with anything MDS related. They are well-educated on MDS regulations and can direct you to a reference if you have a question regarding Section K. There are usually a few people who focus their efforts on Medicare documentation and reimbursement. They are a great resource to you and usually know everything about every resident in the building.
The director of social services is typically in charge of scheduling care plan meetings with resident and their responsible parties. Ask them when and where the meetings are held and which ones they want you to attend. They also generally keep a list of residents receiving hospice services and are aware of upcoming discharges, which may be helpful to you.
The activities department may assist in menu distribution if the facility has a select menu. This department also needs to communicate with you regarding residents who are on modified diets and/or thickened liquids since they provide refreshments to residents during special programs and activities.
The speech therapist communicates diet consistency changes, and their documentation helps you complete the MDS. Good communication between the speech therapist and dietitian ensures the resident receives the least restrictive diet and can consume adequate nutrition to prevent weight loss.
Important MDS Terminology You Need to Know
MDS in long-term care stands for Minimum Data Set. It is a tool used to determine the overall health status for all residents in long-term care facilities certified to participate in Medicare or Medicaid. The MDS allows data to be collected regarding the physical, psychological, and psychosocial functioning of the residents. Each discipline is assigned a section(s) that they must complete timely and accurately as part of the larger picture. In addition to completion of the MDS, a progress note or assessment must be entered into the EMR that matches the date that the MDS is completed. Below are some of the most important terms to review before completing a MDS for the first time.
Section K in the MDS is the typically the registered dietitian’s responsibility. This section focuses on assessing the resident’s nutritional status as well as their swallowing ability. For this section to be completed properly, an assessment of the resident must be completed to determine the following: height, weight, BMI, if there is a swallowing disorder present, and need for a therapeutic or modified consistency diet. This section can also indicate whether the resident has received IV hydration, TPN, and/or tube feeding and how much. Section K requires an RD signature to finalize the submission.
Look Back Period and the ARD
The look back period may also be referred to as the observation time frame. A resident’s condition is captured over the period of time consisting of seven days, ending on 11:59 PM on the Assessment Reference Date (ARD). The ARD refers to the specific end date of the look back period. Only occurrences that happened during these seven days are captured on the MDS assessment.
CAA stands for Care Area Assessment and is found in Section V. The CAA process puts focus on problems identified in the MDS. Occurrences that trigger further investigation will flag and they will require explanation and interpretation.
A significant change in condition prompts an additional (unplanned) resident assessment/evaluation and requires completion of Section K and a CAA, if indicated. In terms of weight change, a significant gain or loss is identified as +/-5% in the past 30 days or +/-10% in the last 180 days.
How to choose between a therapeutic and liberalized diet
Making the choice between ordering a therapeutic diet vs liberalizing a resident’s diet in long-term care is an important one. In the case of a true long-term care resident of the facility who has no plans to discharge, often liberalizing their diet is the best approach. Other factors to consider include the resident’s age, overall condition, their appetite, how their weight is trending and (maybe most important) their desire to follow your recommendations.
Many long-term care facilities also house short stay rehabilitation units. In this case, the residents are more likely managing their disease states with diet and may be more open to education on a therapeutic diet.
In any case, residents’ rights should always be honored. It is the dietitian’s job to explain the diet recommendations as they pertain to the resident’s health conditions and how dietary changes can impact health and quality of life. You may also wish to discuss the potential complications of not following a therapeutic diet as a way to encourage them to consider your plan.
The care plan meeting is a good place to discuss the possibility of liberalizing a resident’s diet if you want to get the input of the rest of the healthcare team and the resident’s family members. An open discussion allows you to take all things into consideration and base your decision on more than just your opinion. Towards the end of life, quality of life becomes a priority for most residents. Often, allowing a regular diet maximizes the resident’s nutritional intake and increases palatability.
The importance of evaluating weight changes
As a dietitian in long-term care, one of the main areas of focus is tracking and evaluating weight changes. Most facilities adhere to the policy of each resident is weighed on admission, weekly for four weeks, then monthly, as appropriate.
Beginning on your initial assessment, you should obtain a weight history from the resident. What is their usual body weight? Have they recently gained or lost weight? If so, was it planned or unplanned? From here, flag significant weight changes during their weekly weight monitoring. If a resident’s weight changes +/-3% in a week, begin to investigate and document accordingly. Consider things such as meal percentages, fluid shifts, edema, and decreased appetite as contributing factors.
If the resident is at risk for continued loss, initiate an intervention by adding fortified foods, between-meal snacks, or nutritional supplementation. Notifying the resident’s responsible party and their physician is a necessary part of your documentation. The physician may want to adjust the resident’s diuretic or add an appetite stimulant. Offer your clinical judgement to the team and request additional interventions as you see fit.
Significant Weight Change Requiring Documentation
- 1 month: +/-5%
- 3 months: +/-7.5%
- 6 months: +/-10%
Holding a weekly weight meeting is a good way to ensure everyone is aware of the residents who flag for weight changes. This prompts the nursing staff to help encourage these residents at mealtime and communicate anything they see as potential concerns for ongoing weight change. Addressing weight changes is a team effort that is orchestrated by the dietitian. Thorough documentation is key and will be looked at closely during the annual survey.
How to craft individualized care plans
Each resident in a long-term care facility has a set of care plans that act as a guide for taking the best care of each person. Care plans are individualized and address both medical and non-medical concerns.
The dietitian’s care plan addresses:
- Why the resident is at risk for nutritional complications
- Use of adaptive equipment at meals
- Significant weight gain or loss and nutritional interventions
The care plan is established on admission to the facility and reviewed during each assessment. A care plan should be updated any time a change to the resident’s plan of care occurs. For example, if a supplement is added due to weight loss, the care plan should be updated accordingly. If a resident was on a textured modified diet and has had a diet upgrade, the care plan should be reviewed and updated to reflect the new order.
A care plan meeting is held on a quarterly basis and whenever there is a significant change in the resident’s condition that could result in a change to their care. The interdisciplinary team is present as well as the resident’s family or responsible party. The resident is invited to the meeting and is welcome to attend if they wish to participate. A care plan meeting can be held in person or via telephone. If family members are unable to attend, a copy of the care plan can be sent in the mail to the resident’s responsible party.
What you need to know about the Medicare Patient-Driven Payment Model (PDPM)
Since 2019, the PDPM replaced the way long-term care facilities are reimbursed by Medicare and Medicaid. This change in reimbursement gives credit to facilities for the services that dietitians provide. Specifically, the facility receives additional payments for any resident who requires complex medical treatments due to conditions such as stage 4 pressure injuries, morbid obesity, malnutrition, tube feedings, or TPN.
Under PDPM, case-mix components refer to the care the resident receives while residing in a nursing facility. PDPM includes 5 case-mix components:
- Physical Therapy
- Occupational Therapy
- Speech therapy
- Non-therapy ancillary (NTA)
As dietitians, we play a role in two of the five categories—speech therapy and non-therapy ancillary. The dietitian can work with the speech therapist to determine whether a resident would benefit form a modified textured diet due to a swallowing disorder. As mentioned above, a swallowing problem should be coded in Section K of the MDS. A resident’s NTA score is identified by tallying points for each comorbidity. There are 50 conditions and services that are factored into the total score. Five of these pertain directly to the dietitian and their services including (in order of highest point value to lowest):
- Resident receives 51% or more of total calories via IV feeding (7 points)
- Resident receives 26% to 50% of total calories via IV feeding and an average of 501 ml fluid via IV per day (3 points)
- Morbid obesity as defined as BMI ≥ 40 kg/m2 (1 point)
- Malnutrition determined by a valid screening tool and physician documentation (1 point)
- Resident has a feeding tube (1 point)
Under PDPM, therapy is no longer the primary source of reimbursement in long-term care. Rather, accurate assessments, thorough documentation, and the timely capture of services provided are all vital to receiving all entitled reimbursements.
How to prepare for a long-term care survey
Preparing for the annual long-term care survey should be on your radar all year long. This way, you can avoid feeling overwhelmed in the days and weeks leading up to the big day. The survey dates are unannounced, but the administrator is typically able to gauge a window of when to expect the surveyors to enter the building. As you go about your daily work, focus your efforts on the following with an emphasis on timeliness, thorough documentation, and accuracy.
- Initial Assessments
- Quarterly reviews
- Annual review
- Weekly and monthly weight change documentation
- Weekly wound notes on all residents being followed by the wound care team
Monthly documentation on:
- Resident receiving tube feeding
- Residents receiving TPN
- Residents receiving dialysis
Keep a log of your high-risk residents and the date of your last note. This allows you to pull data quickly if the surveyors ask for a list of a particular resident profile. Stay organized and inform someone else where this information is kept in the event you are out of the building when the survey team arrives.
Check in with the food service manager and staff. You will have already reviewed the menu cycle and signed it, as well as the menu extensions. This will be stored in the kitchen for easy access because the survey team will request this documentation during their visit. Assist the manager and supervisor with kitchen audits on a monthly basis to prepare for survey time. Do not wait until the last minute to realize that food temperatures have not been taken during the cook’s vacation!
Lastly, when approached by the survey team, stay calm and answer the questions asked. There is no need to share additional information and do not argue. Rather, provide what is requested and be open to their comments and suggestions. If you do not have the answer, it’s okay. Tell them you are not sure, but you know who to ask to find the answer, then get back to them quickly with your response. The survey team is there to ensure residents’ safety. Keep in mind, many of them have worked in your shoes prior to becoming a surveyor, so they know what you are going through.
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