Residential long-term care, also known as assisted living or independent living, is a highly specific employment setting for dietitians. The responsibilities of dietitians working in residential long-term care are similar to those of dietitians in other clinical settings, however, when the role is examined closely a number of differences emerge.
- Patient vs Client vs Resident
- Goal of Optimising Health Through Nutrition
- Relationship with Person Receiving Nutrition Care
- Types of Outcomes Achieved
- Types of Regulations (Regulations vs Interpretative Guidelines--Federal vs State)
- Interprofessional Relationships and Roles
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PATIENT VS CLIENT VS RESIDENT |
One difference is the way in which the individual receiving care is described. In the hospital setting, the term used to describe the individual dietitians provide care for is "patient". In the outpatient setting, the preferred term tends to be "client". In the long-term care setting, the preferred term is "Resident". The way we refer to these individuals is consistent with other aspects of the nutrition care provided in the long-term care setting.
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GOAL OF OPTIMIZING HEALTH THROUGH NUTRITION |
The overall goal of optimizing health through nutrition is consistent throughout all settings, however the focus may be slightly different in the various settings as described below.
| Setting | Nutritional Focus |
|---|---|
| Acute care inpatient setting | The focus is on how to provide nutrition care to inpatients that will "restore" a previous level of health. |
| Outpatient setting | The focus is on how to help the client adjust their lifestyle to optimize long-term health by minimizing the impact of chronic medical conditions. |
| Residential care - Skilled nursing setting | The focus is on helping the resident/s achieve the best quality of life and highest level of independent living possible. |
Quality nutritional practice in long-term care involves careful assessment of,
- Barriers to adequate nutrition and changes in weight (e.g. unintended weight loss or weight gain)
- Reduction of nutrition-related risk factors
- Specialized diets, food preferences, and food presentation
- Awareness of the importance of psychosocial and environmental issues; and
- Consideration of the role of medication
One of the specialized diets common in residential care/skilled nursing facilities are diets for dysphagia. A recent initiative has standardized the terminology used (2019), The International Dysphagia Diet Standardization Initiative (IDDSI) identifies the 8 levels (0 to 7) to describe food textures and drink thickness. Drinks are measured from Levels 0 – 4, while foods are measured from Levels 3 – 7. The IDDSI framework is a diagram summarizes the levels and words and descriptions of these levels. Diet orders may need to specify both the food texture and fluid consistency when necessary, for example, a Level 4 diet would combine the designated food and beverage, Level 4 "Pureed food with Extremely thick" fluids or Level 3 would be "Liquidized food and Moderately thick" fluids.
Interventions often involve "restorative" programs intended to assist the resident to return or maintain as much independence as possible. Restorative Dining is an example of a restorative program that is directly focusing on helping residents consume their meals, snacks and/or supplements when there are cognitive or swallowing difficulties. In this facility, Melanie, a Certified Nursing Assistant describes her specific role in Restorative Dining in this facility.
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Sloane P, lvey J, Helton M, Barrick A. Cerna A. Nutritional Issues in Long-Term Care. J of Am Med Dir Assoc. 9(7): 2008. p 476-485. https://doi.org/10.1016/j.jamda.2008.03.005
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RELATIONSHIP WITH PERSON RECEIVING NUTRITION CARE |
One of the major differences is the type of rapport and relationship the dietitian has with the resident.
In the inpatient setting, the dietitian knows their interaction with their patients is likely to be of short duration with discharge seeing the patient go home or to another type of residential setting (rehabilitation, residential care or skilled nursing care). In some integrated health systems the dietitian who interacts with an individual in the inpatient setting may also have outpatient responsibilities and have the opportunity to provide care across these two settings. However, in many instances the inpatient dietitian is unlikely to see their client again unless or until they need inpatient care again. The dietitian is the expert in meeting nutritional requirements in an acute episode of care and hopefully short period of hospitalization.
In contrast the rapport and relationship with the residents in long-term care is anticipated to be much longer; over a period of months to years. It is anticipated that the goal may not be to prepare the resident for transition back to their previous living situation, but to help them make their current living situation as comfortable as possible by incorporating as many of their preferences from their previous living situation as possible. Since the relationship is long-term, in a way the dietitian becomes a part of a new and different "family" for them; one that helps the resident to achieve their activities of daily living.
The staff at a residential living or skilled nursing facility attribute the rewards of working in this setting to the types of relationships they can form with the residents. Hear professionals talk about how they decided to work in residential care-skilled nursting setting and the rewards from each of their perspectives.
| Registered Dietitian | Registered Nurse |
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| Occupational Therapy | Social Worker |
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TYPES OF OUTCOMES ACHIEVED |
In the inpatient setting one of the major goals is to decrease the length of acute care hospitalization by supporting a rapid recovery, meet the nutritional requirements of the acute medical condition, and prevent re-admissions.
In the outpatient setting one of the major goals is to reduce impact of long term chronic medical conditions. Goal attainment is often measured by "risk factor" reduction, e.g. weight changes, changes in serum lipid levels, and levels of serum hemoglobin A1C.
In the residential care setting, the major goal is to maintain the highest quality of life possible. Measures of goal attainment will be resident satisfaction with food and nutrition, maintenance of healthy weight, meeting nutritional needs, and optimizing ability to perform activities of daily living (often directly related to maintenance of healthy weight).
The Academy's Evidence Based Nutrition Practice Guideline for Unintended Weight Loss of Older Adults lists potential Monitoring and Evaluation indicators as from the following domains:
| eNCPT Domains | Examples of indicators |
|---|---|
| Anthropometric Measurements | e.g. weekly weights until weight stabilizes, weight change |
| Biochemical Data, Medical Tests and Procedures | e.g. Hemoglobin A1C, hydration status (electrolyte balance and urinalysis) |
| Client History | e.g. medical diagnoses related to cognitive decline, depression, neurological disease, hydration status, presence of infection and pressure ulcers or recent hospitalization |
| Food and Nutrition-related History | e.g. changes in dietary intake, food, fluid and nutrient intake, eating dependency, low physical activity level, decreased activities of daily living |
| Nutrition Focused Physical Examination Findings | e.g. presence or changes in pressure injury (ies), impaired wound healing, decrease in apetite, depression, dementia, cognitive changes, swallowing problems |
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TYPES OF REGULATIONS (REGULATIONS VS INTERPRETATIVE GUIDELINES AND FEDERAL VS STATE) |
| What is the difference between a regulation and an interpretative guideline? | What are MDS and CAAs? |
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The regulations that guide the residential care setting are also quite different from those that guide the inpatient or outpatient settings. The majority of residential care settings operate under the federal and state regulations for residential care. There are significant safeguards to ensure that residents rights are protected and that the nutrition care is individualized.
In the inpatient setting, the accreditation requirements usually will result in dietitians being full time employees of the organization, however in the residential care or skilled nursing requirements allow more flexibility and allow the institution to choose between full time employed dietitians, part time employed, and consultant dietitians. The dietitian is often a "consultant" to the facility with a contract that specifies the number of hours needed based on the number of residents, the turn over of residents, and the level of nutrition care required by the residents. (This case is based on a situation where the dietitian is a consultant and in the facility 2 times per week).
| Considerations when determining the number of consulting hours needed. | ||
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The Omnibus Budget Reconciliation Act (OBRA) often referred to as the Nursing Home Reform Act of 1987 sets forth federal standards of how care should be provided to residents. This Act is interpreted with the U.S. Code of Federal Regulations (42 CFR Part 483). The quality of care mandates contained within OBRA, and the regulations, require that a nursing home must provide services and activities to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care. The Secretary of the Department of Health and Human Services (DHHS) has designated CMS to administer the standards compliance aspects of these programs.
Centers for Centers for Medicare & Medicaid Services (CMS) regulatory requirements guide many aspects of residential care facilities. The Resident Assessment Instrument (RAI) includes three components: The Minimum Data Set (MDS) 3.0 and Care Area Assessment (CAA) and Utilization Guidelines are included in the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual.
The MDS item sets are used to collect and submit patient data to CMS. This MDS data informs payment, quality, and the survey process. A core set of screening, clinical, and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. The items in the MDS standardize communication about resident problems and conditions within nursing homes, between nursing homes, and between nursing homes and outside agencies. The required subsets of data items for each MDS assessment and tracking document (e.g.., Comprehensive, Quarterly, OBRA Discharge, Entry Tracking, PPS item sets) can be found in Appendix H.
The Minimum Data Set (MDS) is a core set of elements reflecting screening, clinical and functional status. It is required for all residents in nursing homes that are certified by Medicare or Medicaid participation (payment). The elements included have common definitions and coding methodology which enables standardized communication about resident's problems and conditions. The Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual includes guidance on the frequency of assessment and which data elements are to be addressed in each assessment.
There are 17 separate assessments included as shown below in the MDS forms:
| A—Identification Information | J—Health Conditions | ||
| B—Hearing, speech, and Vision | K—Swallowing/Nutritional Status | ||
| C—Cognitive Patterns | L—Oral/Dental Status | ||
| D—Mood | M—Skin Conditions | ||
| E—Behavior | N—Medications | ||
| F—Preference for Customary Routine and Activities | O—Special Treatments, Procedures, and Programs | ||
| G—Functional Status | P—Restraints and Alarms | ||
| GG—Functional Abilities and Goals | Q—Participation in Assessment and Goal Setting | ||
| H—Bladder and Bowel | V—Care Area Assessment (CAA) Summary | ||
| I—Active Diagnoses | X—Correction Request | ||
| Z—Assessment Administration |
Care Area Assessment (CAA) Process is designed to assist in collecting and interpreting the data recorded in the MDS. It includes worksheets and identifies Care Area Triggers (CAT) that indicate residents to have or are at risk for developing problems and should receive additional assessment and potentially intervention. These worksheets are often included in the residents health record.
Care Area Assessment (CAA) Process is outlined in Chapter 4 of the MDS manual that is designed to assist the assessor to systematically interpret the information recorded on the MDS. Once a care area has been triggered, evidence-based clinical resources are used to conduct an assessment of the potential problem and determine whether or not to create a care plan for it. The CAA process helps to focus on key issues identified during the assessment process so decisions as about whether and how to intervene can be explored with the resident.
This process has three components:
• Care Area Triggers (CATs) are specific resident responses for one or a combination of MDS elements. The triggers identify residents who have or are at risk for developing specific functional problems and require further assessment.
• Care Area Assessment (CAA) is the further investigation of triggered areas, to determine if the care area triggers require interventions and care planning. Following are the 20 areas that are identified.
| Care Area Assessments in the Resident Assessment Instrument, Version 3.0 | |||
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| 1. Delirium | 11. Falls | ||
| 2. Cognitive Loss/Dementia | 12. Nutritional Status | ||
| 3. Visual Function | 13. Feeding Tubes | ||
| 4. Communication | 14. Dehydration/Fluid Maintenance | ||
| 5. Activity of Daily Living (ADL) Functional / Rehabilitation Potential | 15. Dental Care | ||
| 6. Urinary Incontinence and Indwelling Catheter | 16. Pressure Ulcer/Injury | ||
| 7. Psychosocial Well-Being | 17. Psychotropic Medication Use | ||
| 8. Mood State | 18. Physical Restraints | ||
| 9. Behavioral Symptoms | 19. Pain | ||
| 10. Activities | 20. Return to Community Referral | ||
• CAA Summary (Section V of the MDS) provides a location for documentation of the care area(s) that have triggered from the MDS, the decisions made during the CAA process regarding whether or not to proceed to care planning, and the location and date of the CAA documentation.
• Comprehensive Assessment includes the completion of the MDS as well as the CAA process, followed by the development and/or review of the comprehensive care plan. Comprehensive MDS assessments include Admission, Annual, Significant Change in Status Assessment and Significant Correction to Prior Comprehensive Assessment.
CMS also includes a CMS Online Manual System addressing day-to-day operating instructions, policies, and procedures based on statutes and regulations, guidelines, models, and directives. The OBRA act directs that the State health agencies and other appropriate agencies to determine that health care entities meet Federal standards. The State may license institutions based on their ability to meet all applicable Federal health standards for Medicaid participation, subject to validation by the Secretary as described in the State Operations Manual.
Agreements between the Secretary and the various States, territories, and the District of Columbia stipulate that State Agencies designated by the Governors are responsible for the performance of the certification functions created by §1864 of the Act, that the designated agencies will keep necessary and appropriate records to be furnished as required by delegates of the Secretary, and that they will employ management methods, personnel procedures, equal opportunity policies, and merit systems procedures in accordance with agreed upon or established practices. Appendix PP - Guidance to Surveyors for Long Term Care Facilities includes specific details of the process for certification.
Advanced directives in long term care are described in CMS guidance.
- A health care proxy is a document that names someone you trust to make health decisions if you can’t. This is also called a durable power of attorney.
- A living will tells which treatment you want if your life is threatened, including dialysis and breathing machines; resuscitation; tube feeding; and organ or tissue donation after you die.
Resident rights are also specifically described in the Code of Federal Regulations §483.10 - Resident rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. There is also specific guidance on the exercise of rights, planning and implementing care, choice of attending physician, respect and dignity and self-determination.
| Patient Bill of Rights and Food Requests | ||
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INTERPROFESSIONAL RELATIONSHIPS AND ROLES |
The members of the interdisciplinary team that provide care for residents in residential living and skilled nursing are similar to those you might find in a hospital or acute care setting, however their roles are slightly different. Listen to 14 different team members describe their roles in this facility.
Often the documentation in residential care-skilled nursing facilities is interdisciplinary. For example, sample care plans are developed for common problems (e.g. malnutrition) that allow each profession to insert their contribution to the intervention to resolve, improve, or stop the progression of the problem.
Do Registered Dietitians/Nutritionists write orders in the residential living/skilled nursing settings? It depends on the facility. Hear how it works in this facility.
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Communication between the dietitian and the other members of the healthcare team is very important in the residential care-skilled nursing setting, particularily when the dietitian may not be in the facility every day.
In this case, the robust communication system includes the following aspects. The dietitian is responsible for evaluating the current system at the institution and ensuring that the communication systems are effective.
- Tradition of verbal contact with key residential care staff during each day in the facility
- In-box for notes from residential care staff, intake records from CDM, and communication from Care Coordinator regarding CMS required forms
- Written coordination form with signatures acknowledging receipt of message
- Separate writted recommendation for physician that requires signatures acknowledging receipt and action
- Separate cumulative tracking form with key M&E/Re-assessment parameters
- Choice to attend Care Planning Meetings if key information regarding care needs to be discussed by phone or in person (CDM attends each Care Planning Meeting)
- Required documentation specified by CMS (MDS Section K and CAAs)
- Separate Nutrition Assessment/Progress note completed by dietitian
References
Sloane P, lvey J, Helton M, Barrick A. Cerna A. Nutritional Issues in Long-Term Care. J of Am Med Dir Assoc. 9(7): 2008. p 476-485. Available from: https://doi.org/10.1016/j.jamda.2008.03.005
Unintended Weight Loss in Older Adults Evidence Based Nutrition Practice Guideline. Available at Evidence Analysis LIbrary. Accessed July 15, 2020. Available from: https://www.andeal.org/topic.cfm?menu=5294
Title 41, Chapter IV, Part 483, Subpart B-Requirements for Long Term Care Facilities, U.S. Code of Federal Regulations. Accessed July 18 2020. Available from: https://www.govregs.com/regulations/expand/title42_chapterIV_part483_subpartB_section483.10#title42_chapterIV_part483_subpartB_section483.10.
Advance directives & long-term care. Accessed July 18, 2020. Available from: https://www.medicare.gov/manage-your-health/advance-directives-long-term-care.
State Operations Manual. CMS Regulations and Guidance. Accessed July 18 2020. Available from: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107c01pdf.pdf.
Federal Nursing Home Reform Act from the Omnibus Budget Reconciliation Act of 1987; OBRA ‘87 Summary. Accessed on July 18 2020. Available from: https://www.ncmust.com/doclib/OBRA87summary.pdf