future dimensions - clinical nutrition management dpg winter... · 2015-02-12 · dpg was selected...

Inside this issue:

CPE (1) Article:

Malnutrition in

Acute Care:

Diagnosis, Docu-

mentation and

Reimbursement

Impact

3-10

Key Information

Related to

Long-Term Care

and F 325

11-15

CNM DPG

Updates 16-17

Featured

Member 18-19

CNM Executive

Committee 20

Greetings Colleagues!

This year seems to be flying by –

hopefully, most of you are seeing

signs of Spring approaching along

with a feeling of renewal. These

are exciting times to be a nutri-

tion leader as we make significant

contributions to the changing

landscape of healthcare. You are

making a difference each and

every day in how our profession is

perceived and the impact we can

have on the quality of individual

lives as well as healthcare eco-

nomics.

We are making great strides in

accomplishing the objectives set

forth in our strategic plan. Some

of the recent and notable suc-

cesses include the establishment

of our first Quality and Process

Improvement Project Award and

poster submissions for display at

the annual symposium. Kudos to

Sherri Jones and Cindy Hamilton

for their efforts to bring this to

fruition!

Special recognition should also

go to our Research Committee lead by Susan DeHoog and Bar-

bara Isaacs-Jordan for their tire-

less efforts to complete the first

phase of our staffing and produc-

tivity study. They not only pre-

sented the results at FNCE but

will pursue a pilot project to de-

termine how we can apply these

findings towards the develop-

ment of a user friendly tool. We

can all be proud that our CNM

DPG was selected by the Acad-

emy to assist in developing this

much sought after tool for man-

agers, directors and hospital ad-

ministrators.

You also may have noticed en-

hancements to our website and

social media utilization with addi-

tional tools, resources and search

capabilities – thanks to Barb

Pyper and Janel Welch for staying

on top of this.

Also, as I am sure you know, reg-

istration for our Annual Sympo-

sium is open and the agenda is

PACKED with excellent and

timely topics and extraordinary speakers. This is our very first

Future Dimensions

In Clinical Nutrition Practice

A Message From the Chair Winter, 2015

Volume 34, No 1

Kathy Allen, MA, RD, CSO

Chair, CNM DPG

2014-2015

Like us on Facebook! https://www.facebook.c

om/ClinicalNutritionMan

agementDpg

Complete the member survey and

you could win a $25 gift card!

https://www.surveymonkey.com/s/CNM2015svy.

2

Future Dimensions in Clinical Nutrition Practice Winter 2015

symposium in the northwest. Please be sure to

check out the location and program and share it

with your colleagues.

Last but not least --- PLEASE complete the mem-

ber survey. Your input is extremely valuable to

us. Our main objective as your leadership team is

to serve you, our members, to the best of our

abilities. We cannot do this without your input.

This year, you will have the to opportunity to cast

your vote for a potential DPG name change. https://www.surveymonkey.com/s/CNM2015svy

Warmest Regards,

Kathy

3


Malnutrition in Acute Care: Diagnosis,

Documentation and Reimbursement Impact By Alicia Taub, MS, MBA, RDN, CNSC and Holly Guzman, RDN, CSP, CNSC

Protein Calorie Malnutrition (PCM), a condition

present on admission or that develops during

hospitalization, is associated with many adverse

outcomes. Increased risk of infection,1,2

delayed

wound healing,3,4

and extended hospitaliza-

tions5,6

are all known outcomes associated with

malnutrition. Early identification and treatment

of malnutrition can attenuate these outcomes7

and, as the expert in the nutritional care of pa-

tients, it is incumbent upon the Registered Dieti-

tian Nutritionist (RDN) to identify, document and

treat malnutrition within the RDN’s scope of

practice.

The RDN’s comprehensive nutrition assessment

includes the collection of data needed to deter-

mine the patient’s nutritional status. Whether a

patient is found to be adequately nourished or

malnourished, this determination is necessary to

lay the foundation for the plan of care. Based on

the signs and symptoms collected in the nutrition

assessment, the appropriate nutrition diagnosis

is identified and documented using the Interna-

tional Dietetics and Nutrition Terminology

(IDNT).8 In the case of malnutrition, the criteria

established by The Academy of Nutrition and

Dietetics (Academy) and the American Society

for Parenteral and Enteral Nutrition (ASPEN),9

along with clinical judgment, assist the RDN in

selecting the nutrition diagnosis for malnutrition

consistent with the signs and symptoms.

Although the RDN is the expert in nutrition, it is

still the responsibility of the physician to make

the medical diagnosis of malnutrition, as only the

medical diagnoses are coded by documentation

specialists. The physician’s diagnosis is the medi-

cal diagnosis of malnutrition and the RDN’s diag-

nosis is the nutritional diagnosis of malnutrition.

As a member of the healthcare team, the RDN

should share his or her nutritional diagnosis of

malnutrition and plan of care with the physician

so these findings and interventions are consid-

ered when medical diagnoses are made.

The medical diagnosis of malnutrition by the

physician can impact reimbursement. In some

cases, the diagnosis of malnutrition can alter the

final Diagnosis Related Group (DRG) which, de-

pending on the insurer, can increase reimburse-

ment.10

Also, the diagnosis of malnutrition,

along with all other diagnoses, has the ability to

impact Case Mix Index (CMI), a measure of the

severity of illness of the patient population.

The purpose of this article is to:

1. Describe the steps implemented by the clini-

cal nutrition team at St. John Hospital and

Medical Center (SJHMC) in Detroit, MI, in di-

agnosing and documenting malnutrition util-

izing the most current guidelines and tools;

2. Share the impact of RDN malnutrition diag-

nosis on physician medical diagnosis of mal-

nutrition; and

3. Review the revenue impact of the medical

malnutrition diagnosis both in terms of:

a. Revenue realized due to inclusion of

medical malnutrition diagnosis; and

b. Revenue not realized due to omission of

medical malnutrition diagnosis.

RDN Diagnosis of Malnutrition

In the spring of 2013, RDNs at SJHMC were

trained in the Nutrition Focused Physical Assess-

ment (NFPA) portion of the nutrition assessment.

This process began with viewing the following

webinars:

• Nutrition-Focused Physical Examination: En-

hancing Your Clinical Toolbox by W. James

Brewer, DCN, RD, CNSD and Sara Perdue, MS,

RD, CSG, LD. February 28, 2013.

• Applying Academy/ASPEN Guidelines to Iden-

tify and Document Adult Malnutrition: A

Change in Practice by Cynthia Hamilton, MS,

RD, LD and Robert DeChicco, MS, RD, LD,

CNSC. March 21, 2013.

4

Future Dimensions in Clinical Nutrition Practice

These videos set the foundation for understand-

ing the steps in completing the NFPA and the im-

portance of incorporating these criteria in the

diagnosis of malnutrition. The next step was

hands-on physical assessment training by our

senior nutrition support dietitian who was

trained in NFPA (Nancy Park, MS, RD, CNSC). Our

physician nutrition champion also served as a

mentor in this training (Dr. Thomas E. Knuth, MD,

MPH, FACS, CNSC). The training process involved

direct hands-on demonstration for evaluating

muscle mass, fat mass and edema. RDNs were

required to observe the physical assessment

process a few times and demonstrate compe-

tency via return demonstration.

Our RDN Nutrition Assessment Form was modi-

fied to include an area under “Clinical Findings”

to document the results from the NFPA. A mal-

nutrition pocket guide was developed as a handy

reference tool for the RDN to use when complet-

ing nutrition assessments. This tool included: 1)

markers of inflammation to determine the con-

text of malnutrition, 2) physical markers describ-

ing degrees of depletion for muscle and fat mass

and for levels of edema, and 3) criteria for diag-

nosing malnutrition and degree of severity. The

tool also included examples for writing Problem-

Etiology-Signs/Symptoms (PES) statements incor-

porating the type and degree of malnutrition.

RDNs recorded on their work logs the name and

financial identification number (FIN) of all pa-

tients seen on a daily basis. These logs were

modified to allow the RDN to include the nutri-

tional diagnosis of malnutrition (moderate or se-

vere) if the patient met the criteria. Following

each fiscal quarter, all dietitian logs were re-

viewed and each patient with a nutritional diag-

nosis of malnutrition was placed on a master list.

This list was then used to evaluate the reim-

bursement impact, both realized (optimization

achieved due to the inclusion of medical diagno-

sis of malnutrition) and not realized (optimization

missed due to exclusion of medical diagnosis of malnutrition) on cases with RDN intervention.

Documentation of Malnutrition using IDNT

Documentation of malnutrition, moderate or se-

vere, and in which context (social / environ-

mental or illness related – acute or chronic), was

designed using the IDNT PES format. For patients

with Severe Malnutrition, IDNT problem Malnu-

trition (Nutrition Intake - NI – 5.2) was used. For

patients with Moderate Malnutrition, IDNT prob-

lem Inadequate Protein-Energy Intake (NI – 5.3)

was used. Different nutrition diagnoses were

used because the signs and symptoms listed for

each of these nutrition problems corresponded

more closely to the criteria for the malnutrition

diagnosis.9 In creating the PES statement, the

RDN included all signs and symptoms gathered in the nutrition assessment that supported the di-

agnosis of malnutrition. An example of docu-

mentation of the nutrition diagnosis of severe

malnutrition follows:

Malnutrition (NI-5.2) (May have Severe Pro-

tein-Calorie Malnutrition in the context of

chronic illness) related to increased energy

expenditure second to chronic catabolic ill-

ness and altered GI function as evidenced by

underweight status indicated by BMI = 18.4,

severe weight loss of 12% x 3-4 Months ( -

8.2 kg x 3-4 months), poor PO intake <50-

75% of estimated needs x 3-4 months, poor

appetite, chronic colitis, abdominal pain, di-

arrhea, colon CA on chemotherapy, severe

subcutaneous fat and severe muscle wasting

identified as evidenced by very apparent de-

pression between ribs, prominent acromion

process and bilateral depression muscle on

thighs with prominent bones around knees

per RDN physical assessment

Understanding Reimbursement for Hospitals11,12

Medicare, the primary insurer of hospitalized pa-

tients, pays providers via Medicare’s Inpatient

Prospective Payment System (IPPS), which util-

izes the Medicare Severity Diagnosis Related

Groups (MS-DRG) for reimbursement. Medicaid

also uses the same reimbursement system, as do

many other third party payers. Therefore, it is

important to understand how MS-DRGs are de-

signed with the International Classification of Dis-

Winter 2015

5

eases, Ninth Revision, Clinical Modification (ICD-

9-CM) codes in order to understand how a diag-

nosis of malnutrition can impact reimbursement.

ICD-9-CM Codes

ICD-9-CM is based on the World Health Organiza-

tion's Ninth Revision, International Classification

of Diseases (ICD-9). ICD-9-CM is the official sys-

tem of assigning codes to diagnoses and proce-

dures associated with hospital utilization in the

United States. ICD-9-CM codes are divided into

three groups based on severity of illness:

• Major Complication/Co-Morbidity (MCC),

reflecting the highest level of severity and

requiring the highest level of resource use;

• Complication/Co-Morbidity (CC), next

level of severity and less resource use;

and

• Non-CC, not expected to significantly af-

fect severity of illness and resource use.

MS-DRG Codes

Each MS-DRG is denoted by a number and each

inpatient hospital discharge is assigned one MS-

DRG. Assignment of the DRG is based on princi-

ple diagnosis and additional diagnoses, principle

and additional procedures, gender and discharge

status.

MS-DRGs are grouped together based on princi-

pal diagnosis and then subdivided into one, two

or three groups based on secondary diagnosis,

although most are divided into three groups.

Table 1 shows the basic structure of MS-DRGs

and how the addition of MCCs and CCs can

change the final MS-DRG. This figure also shows

how, depending on the DRG, a CC may have no

value, or a CC and MCC may have equal value.

Relative Weights

Under the IPPS reimbursement system, hospitals

are usually paid a set fee for treating patients

assigned the same DRG. However, actual patient

costs can vary significantly based on the severity of illness. In order to capture different costs,

each MS-DRG code is assigned a relative weight

(RW). Within the same MS-DRG group, the RW

for the base DRG increases with the addition of a

CC, and increases even further with the addition

of an MCC. Examples of RW are seen in Table 1.

By adjusting the RW based on the addition of

secondary diagnoses (CCs and MCCs), the extra

costs of patient care and utilization of resources

are accounted for when the final reimbursement

rate is determined.

Base Rate

Base Rates (BR) are unique to each institution

and are based on many variables and multiple

formulas. These rates take into consideration


DRG

Code DRG Long Description Name

DRG Relative

Weight Comment

070 Nonspec Cerebrovasc Disorders w/ MCC 1.71 Most common DRG structure.

Base DRG 072 can be increased

to DRG 071 by a CC or to DRG

070 by a MCC. RW increases

with each DRG.

071 Nonspec Cerebrovasc Disorders w/ CC 1.02

072 Nonspec Cerebrovasc Disorders w/o CC/MCC 0.75

073 Cranial & Periph Nerv Disorders w/ MCC 1.28 Base DRG 074 can be increased

to DRG 073 by an MCC only. CCs

have no value in this DRG group. 074 Cranial & Periph Nerv Disorders w/o MCC 0.88

075 Viral Meningitis w/ CC/MCC 1.76 Base DRG 076 can be increased

to DRG 075 by a CC or MCC. CCs

and MCCs have the same value. 076 Viral Meningitis w/o CC/MCC 0.89

Table 1. DRG Structure – Effect of CC and MCC on Relative Weight (RW)

6

operating and capital expenses and are adjusted

for geographic region, local market labor costs,

indigent care, use of technologies, resident train-

ing and medical education programs. In essence,

the BR is the reimbursement a hospital would

receive for treating the average patient. The BR

for each insurer differs; Medicare’s BR is differ-

ent from Medicaid’s BR which is different from

other insurers’ BRs.

MS-DRG Reimbursement

To determine the reimbursement the hospital

will receive, the MS-DRG RW is multiplied by the

hospital’s BR. See Table 2 for an example.

Case Mix Index

CMI is a number that reflects the severity of ill-

ness of the patient population and is simply the

average of all DRG weights. CMI is determined

by dividing the sum of all DRG-RWs by the num-

ber of patients for a set period of time. The

more MCCs and CCs captured by coders, the

higher the DRG-RW and therefore, the higher

the CMI.

CMI is used by the institution’s finance depart-

ment as a tool to predict revenue and set budg-

ets. In general, the higher the CMI, the higher

the revenue and the lower the average cost per

patient day. The CMI is also one of the variables

used in determining the BR or dollar amount ap-

plied to the RW for each DRG. Therefore, the

CMI for one year will impact revenue for the

next year.13

Status of Medical Malnutrition Diagnosis

In order to evaluate the impact of RDN nutri-

tional diagnosis of malnutrition on the medical

diagnosis of malnutrition, it was necessary to

assess the status of coding for malnutrition. To

obtain this information, a report was generated

by Data Warehouse, a data service used by

SJHMC, listing all cases with malnutrition codes

(see Table 3) from January 1, 2013 through June

30, 2013. Results showed a total of 11,075 adult

admissions, with 678 (6%) of these diagnosed

with malnutrition at discharge.

Approximately 30-50% of hospitalized patients

are malnourished, and only about 3% of patients

with malnutrition are diagnosed in acute care.14

Even though the diagnosis of malnutrition at

SJHMC is double that of the reported average, a

significant percent of the malnourished patient

population is not captured, indicating that a

great opportunity exists to improve processes for assessing and documenting malnutrition.

To evaluate the impact of RDN intervention on

physician diagnosis of malnutrition, all 678 cases

were reviewed to determine if the RDN com-

pleted a nutrition assessment and if the RDN di-

agnosed malnutrition. Only 51% of the cases

with a medical diagnosis of malnutrition by the

physician included a nutritional diagnosis of mal-

nutrition by the RDN. While the RDN has been trained to utilize the criteria supported by the

Academy and ASPEN for the diagnosis of malnu-

trition, the criteria used by physicians are un-

clear. These findings indicate that an opportu-

nity exists for RDNs to communicate with physi-

cians to determine what criteria they use to diag-

nose malnutrition, and to share the Academy/


MS-DRG DRG Long Description Relative Weight Base Rate Reimbursement

682 Renal Failure with MCC 1.59 $7,500 $11,925

683 Renal Failure with CC 1.00 $7,500 $7,500

684 Renal Failure without CC/MCC 0.64 $7,500 $4,800

Table 2. MS-DRG Reimbursement

MCCs 260 – kwashiorkor

261 – nutritional marasmus

262 – severe PCM

CCs 263.0 – malnutrition of moderate degree

263.1 – malnutrition of mild degree

263.8 – other PCM

263.9 – unspecified PCM

Table 3. Nutrition Related MCCs and CCs

7

ASPEN criteria to improve consistency in the di-

agnosis and documentation of malnutrition.

The 678 cases with a malnutrition diagnosis were

evaluated to determine if the final DRG was opti-

mized (changed to a higher weighted DRG in the

same group) by malnutrition coding and, in the

cases that were optimized, if the RDN’s nutrition assessment included the nutritional diagnosis of

malnutrition.

Of the 678 cases, only 14% (95 cases) resulted in

optimization of the DRG by the malnutrition

code. This was due to the majority of cases hav-

ing numerous CC and MCC codes. These findings

also show that a greater percentage (77%) of op-

timized cases included the RDN diagnosis of mal-

nutrition (See Table 4). A common thread ob-

served in reviewing the optimized cases was that

the total number of CC and MCC codes were

fewer, thus allowing for the malnutrition code to

alter the final DRG. This could be due to the RDN

identifying malnutrition in the less severely ill pa-

tients, since many of these cases had fewer CCs

and MCCs.

Revenue Impact of RDN Malnutrition Diagnosis

A master list of all patients diagnosed with mal-nutrition by the RDN from January 1 through

June 30, 2013 was sent to Data Warehouse. An

Excel report was generated listing each case with

the following information: patient name, FIN, in-

surer(s), DRG code and description, and all ICD-9-

CM codes for each DRG. A 2013 listing of all ICD-

9-CM codes, by category (MCC, CC, non-CC), was

added to the Excel report. The report was for-

mulated to cross reference all ICD-9-CM patient

codes with the master list of ICD-9-CM codes and

then assign the ICD-9-CM category to the pa-

tient’s codes. This allowed each case to be

manually reviewed to determine if the malnutri-

tion coding changed the final DRG to the higher

weighted DRG in the same group, or “optimized”

the DRG. The first ICD-9-CM code in each case

represents the principal diagnosis and is not util-

ized in evaluating cases for optimization. These

cases were subdivided into two groups:

• ICD-9-CM malnutrition codes included (physician diagnosed malnutrition): In the

first case, there were multiple MCCs, any one

of which optimized the DRG. In the second

case, the only MCC present was “other severe

malnutrition”. Therefore, the diagnosis of

severe malnutrition optimized the DRG to the

highest level; these cases were classified as

OPTIMIZATION ACHIEVED. See Table 5.

• ICD-9-CM malnutrition codes omitted

(physician did not diagnose malnutrition):

Each of these cases included moderate or se-

vere malnutrition as diagnosed by the RDN,

however, malnutrition was never diagnosed

by the physician. These cases were cross-

referenced with the master list of all patients

diagnosed by the RDN to determine the de-

gree of malnutrition (moderate or severe).

The appropriate ICD-9-CM code class MCC

(ICD-9-CM code 262 for severe malnutrition)

or CC (ICD-9-CM code 263.0 for moderate

malnutrition) was added to the patient’s list

of codes and then the case evaluated for op-

timization. In the first case, omission of se-

vere malnutrition made no difference since

two other MCCs were already diagnosed. In

the second case, a diagnosis of severe malnu-

trition by the physician would have optimized the DRG to the highest level since there were

no other MCCs diagnosed; these cases were

classified as OPTIMIZATION MISSED. See Ta-

ble 6.

For Optimization Achieved cases, the DRG master

list was referenced and the lesser weighted DRG

in the same category was identified. The differ-

ence in weight of these two DRGs multiplied by

the institution’s payer rate (PR) for the specific

insurer would represent the increased revenue

achieved due to the inclusion of the malnutrition

code. For Optimization Missed cases, the greater

weighted DRG in the same category was identi-

fied. The difference in weight of these two DRGs

multiplied by the PR for the specific insurer


Cases Optimized by Malnutrition 95

w/ RDN Diagnosis 73 77%

w/o RDN Diagnosis 22 23%

Table 4. Cases Optimized by Malnutrition

8


would represent the revenue missed due to the

exclusion of the malnutrition code.

Financial analysis of revenue can be determined

by multiplying changes in DRG weights by the PR.

However, cases were not limited to Medicare

and Medicaid patients but included all patients

regardless of insurer. Many commercial insurers

also utilize the MS-DRG reimbursement system

but these third party payers frequently have ex-

ceptions in their contracts that may cap reim-

bursement based on certain criteria. Therefore,

revenue data based on Optimization Achieved

and Optimization Missed cases were determined

by financial analysts on a case-by-case basis al-

lowing for insurer contracts and caveats within the MS-DRG system to be included. The reim-

bursement impact, both Achieved and Missed,

for RDN cases for the 1st

and 2nd

quarters of 2013

are summarized in Tables 7 and 8 (page 10).

Of the 985 cases diagnosed with malnutrition by

the RDN, only 275 were coded, or 28%. Of these,

44 cases optimized the DRG, yielding increased

reimbursement of $296,464 (annualized:

$592,928). Of the 710 cases not coded, 120

cases would have optimized if malnutrition had

been diagnosed by the physician, yielding in-

creased reimbursement of $539,659 (annualized:

$1,079,319). Overall, RDN intervention in malnu-

trition diagnosis and documentation represented

an increase in annualized reimbursement of up to

$1,672,247, of which only 35% was realized.

Plans for Improvement

1. Ensure the diagnosis of malnutrition is consis-

tent between the RDN and physician by edu-

cating physicians on the criteria established by the Academy/ASPEN.

2. Ensure Clinical Documentation Specialists

(CDS) are familiar with Academy/ASPEN crite-

ria for malnutrition diagnosis and RDN docu-

mentation in the medical record. CDSs are

employed by hospitals to review the medical

record and ensure that documentation cap-

Name FIN DRG

Code

DRG Descrip-

tion W MCC/CC Insurance

Diagnosis

Number

Final

Diagnosis

ICD-

9-CM

Class

ICD-9-CM

Description

Case 1 xxx 871

SEPTIC OR SEV

SEPSIS WO MV

96+ HRS W MCC

Medicare 1 38.9 MCC SEPTICEMIA NOS

2 486 MCC PNEUMONIA,

ORGANISM NOS

3 262.00 MCC OTH SEVERE

MALNUTRITION

4 707.23 MCC PRESSURE ULCER

STAGE III

5 204.1 CC CHR LYMPH LEUK

NO REMISS

Case 2 xxx 329

MAJ SML & LG

BOWEL PX W

MCC

Medicare 1 560 CC INTUSSUSCEP-

TION

2 262.00 MCC OTH SEVERE

MALNUTRITION

3 518 CC PULMONARY

COLLAPSE

4 511.9 CC PLEURAL EFFU-

SION NOS

5 V85.22 N BD MS INDX

26.0-26.9 ADL

Table 5: Evaluation for Optimization - malnutrition diagnosed by RDN and physician, and coded

ICD-9-CM 262.0 - Severe PCM is one

of many MCC codes. DRG can be opti-

mized by any MCC.

OPTIMIZATION ACHIEVED. ICD-9-CM

262.0 - Severe PCM is the ONLY MCC

and is responsible for optimization of

DRG.

9


tures the severity of illness. If documentation

in the medical record is incomplete or am-

biguous, they are required to query physi-

cians for clarification. CDSs can thus assist in

communicating the RDN diagnosis of malnu-

trition to physicians.

3. Investigate the feasibility of adding an en-

hancement to the electronic medical record

(EMR) that would allow the RDN to send a

direct communication to physicians with their

malnutrition diagnosis and plan of care.

4. Share the results of this report with hospital

administration to gain support to:

a. Implement proposed EMR enhancement

b. Increase RDN staffing to ensure all nutri-tion assessments and re-assessments

are completed on a timely basis.

Summary

Over half of the criteria used to diagnose malnu-

trition come from the NFPA. A comprehensive

nutrition assessment must incorporate findings

from the NFPA in order for the RDN to accurately

diagnose malnutrition. Hands-on training in

NFPA will improve the RDN’s comfort level and

confidence in completing this task as part of the

assessment.

If the RDN diagnoses malnutrition, this finding

must be shared with the physician along with the

planned interventions to improve the patient’s

nutritional status. If the physician agrees with

the RDN, the physician should diagnose the de-

gree of malnutrition so it can be appropriately

coded. Although very few MS-DRG cases will op-

timize due to the presence of the malnutrition

diagnosis, the revenue impact can be quite sig-

nificant in those cases that do. If each case with

a diagnosis of malnutrition by the RDN had also

been diagnosed by the physician, SJHMC had the

potential to increase revenue by over one million

dollars in 2014 (data from six months annual-

ized).

Name FIN DRG

Code

DRG Descrip-

tion W MCC/CC Insurance

Diagnosis

Number

Final

Diagnosis

ICD-9-

CM

Class

ICD-9-CM

Description

Case 3 xxx 871

SEPTIC OR SEV

SEPSIS WO MV

96+ HRS W MCC

Medicare 1 38.4 MCC GRAM-NEG SEPTI-

CEMIA NOS

2 785.59 MCC SHOCK W/O

TRAUMA NEC

3 584.9 MCC ACUTE RENAL FAIL-

URE NOS

4 276.3 CC ALKALOSIS

5 285.1 CC AC POSTHEMOR-

RHAG ANEMIA

Case 4 xxx 470

MAJ JT

REPL/REATTACH

LE WO MCC

Medicare 1 733.49 CC ASEPT NECROSIS

BONE NEC

2 285.1 CC AC POSTHEMOR-

RHAG ANEMIA

3 715.35 N LOC OSTEOARTH

NOS-PELVIS

4 428 N CONGESTVE HRT

FAILUR NOS

5 496 CC CHR AIRWAY OB-

STRUCT NEC

Table 6: Evaluation for Optimization - malnutrition diagnosed by RDN but not physician, and not coded

Severe PCM diagnosed by RDN. No mal-

nutrition diagnosis by physician and

therefore no ICD-9-CM malnutrition

code. Case already optimized by two

other MCCs.

OPTIMIZATION MISSED. Severe PCM

diagnosed by RDN. No malnutrition

diagnosis by physician and therefore

no ICD-9-CM malnutrition code. Case

would have optimized had physician

diagnosed severe PCM.

10


Cases Jan - Mar Apr - Jun

Submitted by RDNs 477 508

Coded *

ICD-9-CM Code 262 70 98

ICD-9-CM Code 263.9 52 55

Total 122 153

Optimized by Malnutrition 19 25

Revenue $128,780 $167,683

RDNs are the experts in nutrition and have the

tools to assess patients and diagnose malnutri-

tion. Communicating their findings and interven-

tions with physicians can improve patient out-

comes and the medical diagnosis of malnutrition.

Coders can then apply the appropriate ICD-9-CM

codes for malnutrition. Documenting all cases of

malnutrition can significantly increase revenue as

was demonstrated in the review of medical re-

port for wound-healing patients. Am J Surg.

2004;188(1A Suppl):52-56.

5. Braunschweig C, Gomez S, Sheean PM. Impact

of declines in nutritional status on outcomes in

adult patients hospitalized for more than 7

days. J Am Diet Assoc. 2000; 100(11):1316-

1322.

6. Neumayer LA, Smout RJ, Horn HG, Horn SD.

Early and sufficient feeding reduces length of

stay and charges in surgical patients. J Surg Res.

2001;95(1):73-77.

7. Somanchi M, Tao X, Mullin GE. The facilitated

early enteral and dietary management effec-

tiveness trial in hospitalized patients with mal-

nutrition. J Parenter Enteral Nutr. 2011;35

(2):209-216.

8. Academy of Nutrition and Dietetics. Interna-

tional Dietetics and Nutrition Terminology

(IDNT) Reference Manual. Standardized Lan-

guage for the Nutrition Care Process. Fourth

Edition. 2012.

9. White JV, Geunter P, Jensen G, et al. Consensus

statement of the Academy of Nutrition and Die-

tetics / American Society for Parenteral and

Enteral Nutrition: characteristics recommended

for the identification and documentation of

adult malnutrition (undernutrition). J Parenter

Enteral Nutr. 2012;36(3):275-283.

10. Giannopoulos GA, Merriman LR, Rumsey A,

Zwiebel DS. Malnutrition coding 101: financial

impact and more. Nutr Clin Pract. 2013;28

(6):698-709.

11. Centers for Disease Control. http://

www.cdc.gov/nchs/icd/icd9cm.htm. Retrieved

1/1/2015.

12. Advance Healthcare Network. http://health-

information.advanceweb.com/Web-Extras/CCS-

Prep/An-Inpatient-Prospective-Payment-

System-Refresher-MS-DRGs-2.aspx Retrieved

1/1/2015.

13. Sturgeon J. Stew on This: Case Mix Basics. For

The Record. 2007;10(11):6.

http://www.fortherecordmag.com

14. Corkins ME, Guenter P, DiMaria-Ghalili RA, et

al. A.S.P.E.N. Data Brief 2014: Use of enteral

and parenteral nutrition in hospitalized patients

with a diagnosis of malnutrition: United States,

2010. Nutr Clin Pract. 2014;29(5):698-700.

Alicia Taub is the Clinical Nutrition Manager and

Holly Guzman a Neonatal and Nutrition Support

Table 7. OPTIMIZATION ACHIEVED – malnutri-

tion diagnosis documented by RDN, and coded *

Coders did not use ICD-9-CM codes: 263, 263.1 or 263.8

Cases Jan - Mar Apr - Jun

Submitted by RDNs 477 508

Not Coded 355 355

Optimization Missed 56 64

Revenue missed $219,927 $319,732

Table 8. OPTIMIZATION MISSED – malnutrition

diagnosis documented by RDN, but not coded

cord coding and financial data at SJHMC.

References

1. DiMaria-Ghalili RA. Changes in nutritional

status and postoperative outcomes in elderly

CABG patients. Biol Res Nurs. 2004;4(2):73-84.

2. Hoffer LJ. Clinical nutrition: 1. Protein-energy

malnutrition in the inpatient. Can Med Assoc J.

2001;165(10):1345-49.

3. Baldwin C, Parson TJ. Dietary advice and nutri-

tional supplements in the management of ill-

ness-related malnutrition: a systematic review.

Clin Nutr. 2004;23(6):1267-1279.

4. Mechanick JI. Practical aspects of nutrition sup-

11


Key Information Related to

Long-Term Care and F 325 By Krista Clark, MBA, RD, LD

In long-term care (LTC), Registered Dietitian Nu-

tritionists (RDNs) are keenly aware of F 325,

which relates to nutrition. F 325 is the CMS

guideline for surveyors that states:

Based on a resident’s comprehensive assess-

ment, the facility must ensure that a resident--

§483.25(i)(1) Maintains acceptable parame-

ters of nutritional status, such as body weight

and protein levels, unless the resident’s clini-

cal condition demonstrates that this is not

possible; and

§483.25(i)(2) Receives a therapeutic diet

when there is a nutritional problem1

We know that impaired nutritional status is NOT

a normal part of aging and may be associated

with an increased risk of mortality, impaired

wound healing, a decline in function, fluid and

electrolyte imbalance/dehydration, and un-

planned weight change. Since intake is not the

only factor that affects nutritional status, nutri-

tion-related interventions only sometimes im-

prove markers of nutritional status such as body

weight and laboratory results. While they can

often be stabilized or improved, nutritional defi-

cits and imbalances may take time to improve or

they may not be fully correctable in some indi-

viduals. Therefore, to optimize a resident’s nu-

tritional status, we must use a systematic ap-

proach:

• Identify and assess BOTH the resident’s

nutritional status and risk factors for nutri-

tional compromise

• Evaluate and analyze the assessment in-

formation, which must include subjective

information from the resident or family

• Develop and consistently implement perti-

nent approaches

• Monitor the effectiveness of interventions

and revise them as necessary

Nutrition Assessment

Assessment is a systematic process of obtaining,

verifying, and interpreting data in order to make

decisions about the nature and cause of nutrition

-related problems. It provides information that

helps to define meaningful interventions to ad-

dress any nutrition-related problems. It should

include observation, gathering, and considera-

tion of information relevant to each resident’s

eating and nutritional status to clarify nutritional

issues, needs, and goals in the context of the

resident’s overall condition. It is key to identify

usual body weight, a history of reduced appetite

or progressive weight loss or gain prior to admis-

sion, medical conditions such as a stroke, and

events such as recent surgery which may have

affected a resident’s nutritional status and risks.2

In LTC, physical and functional assessment of a

resident should include a description of his or

her overall appearance such as robust, thin,

obese, or cachectic and other findings including

level of consciousness, responsiveness, affect,

oral health and dentition, ability to use the hands

and arms, and the condition of the hair, nails,

and skin that may affect or reflect nutritional

status.3

Further information on nutritional physi-

cal and functional assessment can be found else-

where.

Height should be actually measured by the resi-

dent standing or estimated via arm span or knee

height, as often reported heights or height docu-

mented from acute facilities are inaccurate.

Weight must also be measured upon admission

or readmission to establish a baseline weight,

weekly for the first four weeks after admission,

and at least monthly thereafter to help identify

and document trends such as insidious weight

loss. Weighing may also be pertinent if there is a

significant change in condition, food intake has

12


declined and persisted (e.g. for more than a

week), or there is evidence of altered nutritional

status or fluid and electrolyte imbalance. In

some cases, weight monitoring is not indicated,

such as when the individual is terminally ill and

requests only comfort care.4

Both nutrient and fluid needs

should be estimated and

compared to intake to deter-

mine if intake is adequate to

meet those needs. Usually

meal intakes are documented

as a percentage such as 25%,

50%, 75%, or 100%. Dieti-

tians may become concerned

if meal intake is 50% or less

but those residents with lower calorie needs may

actually be meeting their nutritional require-

ments. Thus, meal intake should be compared to

estimated nutrient needs and the nutrient con-

tent of meals.3

When estimating needs and evaluating intake,

the RDN must consider underlying illnesses or

problems. The inability to consume meals pro-

vided may be the result of the form or consis-

tency of food or fluid, cognitive or functional de-

cline, arthritis-related impaired movement, neu-

ropathic pain, or insufficient assistance. Food or

fluid provision may be inadequate at meals or

through tube feedings. Environmental factors

may affect intake or appetite such as the comfort

and level of disruption in the dining environment.

Adverse consequences related to medications

should be considered. The resident may require

increased calories due to wandering, pacing, or

rocking. Digestion and absorption may be im-

paired due to gastrointestinal disorders or gastric

surgery. Nutrient and fluid loss may occur from

prolonged diarrhea or vomiting. Further, hyper-

metabolic states such as pressure ulcers, other

wounds, advanced COPD, pneumonia and other

infections, cancer, hyperthyroidism, and fever

increase demands for calories, protein, and

fluid.2

In analysis, assessment information is used to

determine a resident’s nutritional status AND to

develop an individualized plan of care. Conclu-

sions may include, but are not limited to, a target

desirable body weight range that is based on the

individual’s overall condition, goals, prognosis,

and usual body weight; approxi-

mate nutrient and fluid needs;

whether and to what extent

weight stabilization or improve-

ment can be anticipated;

whether altered weight or nutri-

tional status could be related to

an underlying medical condition;

unplanned or undesirable weight

change and significance of that

change; identification of a clini-

cally pertinent basis for a conclusion that a resi-

dent could not attain or maintain acceptable pa-

rameters of nutritional status; and specification

of the nutritional concern(s). A clear statement

of the nature of nutritional concerns provides the

basis for resident-specific interventions. The fol-

lowing are examples:

• Poor food and fluid intake – The resident is

consuming less than 50% of calorie and

protein needs, and has increased nutri-

tional needs due to constant pacing. The

resident has also lost significant weight of

5% over the last month and is taking medi-

cations that may affect appetite.

• Specific clinical conditions – The resident

has an infection with a fever and is in a

hypermetabolic state associated with in-

creased demand for energy, protein, and

fluid. The resident also has a neuromuscu-

lar disorder and impaired cognition affect-

ing attention and the ability to feed self.

Resident Rights

The Care Plan MUST consider resident choice.

The RDN, with the interdisciplinary team, can

help the resident exercise their rights effectively

by discussing with the resident (or the resident’s

representative), the resident’s condition, treat-

ment options and related risks and benefits, ex-

“The Care Plan MUST con-

sider resident choice. The

RDN, with the interdiscipli-

nary team, can help the

resident exercise their

rights effectively...”

13

pected outcomes, personal preferences, and any

potential consequences of accepting or refusing

treatment. If the resident or representative de-

clines specific interventions, the facility must ad-

dress the resident’s concerns and offer relevant

alternatives. Many risk factors and some causes

of weight loss can be addressed, at least par-

tially, BUT others may not be modifiable – cer-

tain interventions may not be indicated or appro-

priate, based on individual goals and prognosis.

In regards to a therapeutic or mechanically al-

tered diet, dietary restrictions may help in select

situations. The use must be justified however, as

restrictions may also impair adequate nutrition

and lead to further decline in nutritional status,

especially in already malnourished or at-risk indi-

viduals. Diet liberalization can enhance the qual-

ity of life and nutritional status in older adults in

LTC. A resident or their representative may de-

cide to decline medically relevant dietary restric-

tions. If so, benefits vs. risks must be identified,

communicated, and documented, AND the resi-

dent and RDN with the interdisciplinary team

should collaborate to identify possible alterna-

tives.

Nutrition Monitoring

Monitoring is necessary for all residents whether

nutritionally stable or nutritionally compromised

or at risk for compromise, although more inten-

sive monitoring is indicated for residents with

impaired or at-risk nutritional status. In LTC,

monitoring should include a review of resident-

specific factors identified as part of the compre-

hensive resident assessment and any follow-up

assessments. Observing for and recognizing the

emergence of new risk factors such as acute

medical illness, pressure ulcers, or fever is im-

perative. The continued relevance of any current

nutritional interventions such as therapeutic di-

ets, tube feedings, or nutritional supplements

must be reviewed and the rationale for continu-

ing or stopping interventions must be docu-

mented.

The CMS Survey in LTC

CMS surveyors use a very detailed investigative

protocol when assessing compliance with F 325.

Their objectives are to determine if the facility

has practices in place to maintain acceptable pa-

rameters of nutritional status based on the com-

prehensive assessment. They evaluate whether

failure to maintain acceptable parameters of nu-

tritional status was avoidable or unavoidable.

They determine if the resident has received a

therapeutic diet if indicated. Finally, they deter-

mine if the facility identified and addressed risk

factors for, and causes of, impaired nutritional

status, or documented why they could not or

should not do so for a resident at nutritional risk.

Residents are observed during the initial tour

and throughout the survey process. Two meals

are observed with attention to serving sizes,

preferences, nutritional supplements, adaptive

equipment, feeding assistance, and prescribed

therapeutic diets to determine if interventions in

the care plan are implemented. The resident,

family, and/or resident’s representative is inter-

viewed to determine if the staff are responsive

to the resident’s eating ability and support

needs, food and dining preferences, whether the

resident is offered choices and substitutions at

meal times, and if treatment options, related

risks and benefits, expected outcomes, possible

consequences, and alternatives or other inter-

ventions were discussed and offered.

Interdisciplinary team members on all shifts, in-

cluding the RDN, are interviewed to determine

how food and fluid intake, oral eating ability, and

weight – and any changes to these parameters –

are monitored and reported and how nutrition

interventions are provided. If documented inter-

ventions or care provided appear to be inconsis-

tent with current standards of practice, physi-

cians and other healthcare providers are inter-

viewed to collect information about the resi-

dent’s nutritional risks and needs, including the

rationale for chosen interventions, how current

interventions are evaluated for effectiveness,

how interventions are managed, how the inter-

disciplinary team decided to maintain or change

interventions, and the rationale for not interven-

ing to address identified needs.5


14


Additionally, the medical record documentation

is reviewed thoroughly to ensure each resident

has been evaluated for nutritional status, those

who are at nutritional risk are clearly identified,

whether interventions have been developed and

implemented in a timely fashion, whether the

residents were monitored for progress, the effec-

tiveness of interventions, and especially if a resi-

dent’s decline or failure to improve from a nutri-

tional standpoint was avoidable or unavoidable.

Specifically, dietitians must document all of the

following, when applicable:

• Desirable body weight range

• Weight loss or gain and whether it was

significant

• Significant change in a resident’s intake

and reasons for the change, if known

• Appropriate interventions implemented

• If dietary restrictions are indicated

• If the resident was encouraged to make

food and care choices

• Chewing and/or swallowing problems and

how these are addressed

• Type of assistance needed to eat or drink

• Identified medication interactions

• Review of abnormal lab results and how

these were addressed nutritionally, if ap-

propriate

• If the resident’s current nutritional status

is met or improving towards established

goals

Finally, the care plan is reviewed to determine if

it is based on the assessment. It must have

measurable objectives and appropriate time

frames for goals to be met. Specific interventions

must be outlined for each problem identified to

try to maintain or improve parameters of nutri-

tional status. Further, it must take into consid-

eration the resident’s overall personal goals,

choices, preferences, prognosis, conditions, as-

sessed risks, and needs.1

Ultimately, the facility is in compliance with F

325, Nutrition, if staff have:

• Assessed the residents’ nutritional status

and identified factors that put the resi-

dent at risk of not maintaining acceptable

parameters of nutritional status

• Analyzed all available information to iden-

tify the medical conditions, causes, and

problems related to the residents’ condi-

tion and needs

• Provided a therapeutic diet when indi-

cated or provided justification for not pro-

viding a therapeutic diet

• Clearly defined and implemented inter-

ventions to maintain or improve nutri-

tional status that are consistent with the

residents’ assessed needs, choices, goals,

and recognized standards of practice

• Provided clinical justification for why in-

terventions were not implemented

• Monitored and evaluated the residents’

response to interventions and revised ap-

proaches as needed, or justified continua-

tion of current approaches1

Conclusion

LTC is a very complex field. Unlike acute care,

residents typically stay in the facility for the re-

mainder of their lives. Therefore, nutritional care

is a long-term and ongoing process. Residents

must be reassessed constantly and care plans

and interventions revised based on the progres-

sion or decline of their nutritional status. Dieti-

tians are key in improving and stabilizing the resi-

dents’ quality of life.

References

1. Department of Health and Human Services/

CMS. Nursing Homes - Issuance of Revised

Nutrition and Sanitary Conditions (Tags F325

and F371) as Part of Appendix PP, State Op-

erations Manual, and Training Materials. Bal-

timore, MD. June 20, 2008.

2. Morley JE, Thomas DR, Kamel HK. Nutritional

deficiencies in long-term care. Council for Nu-

tritional Clinical Strategies in Long-Term Care.

February 2004. www.LTCnutrition.org.

3. Bowman JJ, Keller HH. Assessing nutritional

risk of long-term care residents. Can J Diet

Pract Res. 2005;66(3):155-161.

15


Managing Editor:

Jennifer Doley, MBA, RD,

CNSC, FAND

520-872-6109

[email protected]

Lead Features Editor:

Lisa Trombley, MA, RD, CNSC

310-903-2900

[email protected]

Features Editors:

Leigh-Anne Wooten, MS, RD, LDN

704-355-6660

[email protected]

Amanda Nederostek, MS, RD, CD

(801) 662-5303

[email protected]

Interested in contributing an article to the newsletter? Topics of interest in-

clude leadership, management, inno-

vations in clinical practice, research

and outcomes, nutrition legislation

and public policy, reimbursement and

coding, informatics, healthcare re-

form, and many others. If interested,

please contact an editor.

4. Richardson B. Long term care nutrition and

the CMS 2007 Action Plan. Association of Nu-

trition and Food Service Professionals. Die-

tary Manager. May 2007. Pp 17-21.

5. Handy L. Deficiency free in nutrition status:

using new interpretive guidance and protocol

for F325. Association of Nutrition and Food

Service Professionals. Dietary Manager. Sep-

tember 2008. Pp 10-15.

Krista Clark is a member of the Academy Infor-

matics committee focusing on long term

care. She has also provided nutrition services in

long term care for 12 years. She can be reached

at [email protected].

Visit us at the CNM DPG website—cnmdpg.org. Available resources include:

• Searchable member directory

• Resource library

• The DPG’s guiding principles and strategic plan

• The Standards of Professional Performance for Dietitians in Clinical Nutrition Management

• Newsletter archives

• CNM annual report to members

• Eblast archives

• Information on the Informatics and Quality and Process Improvement (QPI) subunits

• Sign up for the CNM electronic mailing list (EML)

• Sign up for the QPI EML—in the members only section, click on the Subunits tab, then QPI

• Update your CNM profile—click on Edit Your Profile in the Member Info section

For additional information, contact us at: [email protected]

One free CPEU available to CNM DPG members!

1. Read the article titled “Malnutrition in Acute Care: Diagnosis, Documentation and Reimburse-

ment Impact” by Alicia Taub and Holly Guzman.

2. Log on to the CNM DPG website at cnmdpg.org

3. Go to the member’s only section and click on the link for the CPE Exam

4. Take the exam; your CPE certificate will be emailed to you within one week

This article has been approved for 1 CPE, Level 3; Learning Needs Codes 3005, 7080, 7170. The

test will remain available for three years after the publication date of this edition of Future

Dimensions in Clinical Nutrition Practice (February 9th

, 2015).

16


Quality and Process Improvement

Sub-Unit Update By Sherri Jones, MS, MBA, RDN, LDN, FAND

QPI Project Contest Update:

Several communications went out about the new Quality/Process Improvement Project Award Program. Appli-

cations for the contest were accepted through January 16, 2015. This was an extension from the original De-

cember 29, 2014 deadline, as it was difficult for CNM members to meet the December deadline with the hustle

and bustle of the holiday season. I am thrilled to report that we received a total of 17 project submissions.

That is fantastic for the kickoff year of the contest. I want to thank those CNM members who submitted and

those who encouraged others to submit. A variety of projects were received covering both clinical and food

service topics, for example: Malnutrition Identification, In Room Dining, Volume Based Tube Feedings, and Pa-

tient Feeding Programs to name a few.

The next step is for the 17 projects to be judged by a 5 member panel from the CNM Executive Committee. The

projects will be ranked into the “top ten” and a 1st

place winner will be identified. The 1st

place winner will be

announced on stage at the 2015 CNM Symposium and will receive free symposium registration (a $360 value).

In addition, the top ten projects will be showcased as poster presentations at the symposium for additional

CEUs. This will provide the opportunity to learn from the quality improvement initiatives others have accom-

plished. We also plan to publish the top ten projects in the CNM newsletter as well as on the QPI Sub-Unit

website. Look for the winners to be announced…

QPI Sub-Unit Session @ Annual CNM Symposium – April 2015:

The QPI Sub-Unit is gearing up for our session at the CNM Symposium this year in Seattle, WA. We will high-

light our sub-unit updates, and most excitedly, announce the 1st

place winner for our QPI Project Contest. We

will then turn the remainder of the session over to our guest speaker, Sharon McCauley, Director Quality Man-

agement for the Academy of Nutrition and Dietetics. Sharon will review what has been happening in Quality at

the Academy and resources available to Academy members. We are looking forward to what Sharon has to

share. CNMs will surely be enlightened.

Special QPI Sub-Unit Electronic Mailing List (EML):

Reminder…don’t forget about our special EML. We have more than 100 subscribers. The purpose of this QPI

EML is to pose questions and share resources related to quality and process improvement. If you are not cur-

rently subscribed to the QPI EML and wish to do so, go through the QPI Sub-Unit webpage or enter the follow-

ing URL directly: http://www.cnmdpg.org/members/page/qpi-sub-unit-member-info.

And as always, if you have any questions or suggestions for the new Quality and Process Improvement Sub-

Unit feel free to contact the sub-unit Chair and/or Vice-Chair. The sub-unit is a member benefit, and thus, we

want to be sure to meet your needs and expectations. Continue to visit the QPI Sub-Unit section of the web-

site for updates.

QPI Sub-Unit Chair: Sherri Jones, MS, MBA, RDN, LDN, FAND [email protected]

QPI Sub-Unit Vice-Chair: Cindy Hamilton, MS, RD, LD [email protected]

CNM DPG Announcements

17


Research Committee Report By Susan DeHoog, RD

Phase 1 of the staffing and productivity study was completed last summer. Results were presented at

a session at FNCE in Atlanta, and will be presented again at the CNM Symposium in Seattle. A poster

reviewing the outcomes of the study is also being displayed at Nutrition Week in February . A journal

article has been submitted to the Journal of the Academy of Nutrition and Dietetics; publication is

expected in the next couple of months.

Financial support from the CDR is being considered for Phase 2, in which studies will assess the corre-

lation, if any, between RDN time and patient outcomes in order to develop and validate a gold stan-

dard staffing model. We expect to hear soon if we will receive a grant for this phase.

Informatics Sub-Unit Report By Janel Welch, MS, RD, LD

The Informatics Sub Committee has been working to roll out the 2015 CNM Member Survey. The sur-

vey will run February 20 until April 5. If you complete the survey, your name will be entered into a

drawing for a $25.00 gift card. The CNM Executive Committee would like to get your feedback re-

garding the idea of changing our DPG name. Yes, this is a big decision, however we want our name to

welcome members in all areas of leadership and management, not just clinical nutrition manage-

ment. The survey will provide the option of keeping our original name so if you are opposed to a

change that will be accounted for. We are hoping for a great response rate so we encourage you to

please take the time to respond: https://www.surveymonkey.com/s/CNM2015svy.

The Informatics Sub-Unit also encourages you to visit the CNM website and check out the resources

available for members. If you are interested in sharing materials with other members, please post

them on the member EML, as we continuously monitor for tools that all members would benefit

from. Another feature of the website is the member profile directory. This gives you the ability to

find other CNM members who have similar interests or are using the same electronic medical record

as you are. This gives members another opportunity to network with peers.

Advertisements in Future Dimensions

CNM accepts advertising for publication in Future Dimensions in Clinical Nutrition Management. All ads are

subject to approval by the Review Committee and must meet established guidelines. All ads must be camera

ready and received by the Editor by copy deadlines. Fees must accompany the ad at the time of submission.

CNM members receive a 20% discount. Send all inquiries to the Managing Editor, Future Dimensions in Clinical

Nutrition Management. Publication of an advertisement in Future Dimensions in Clinical Nutrition Manage-

ment should not be construed as endorsement of the advertiser or the product by the CNM DPG or the Acad-

emy of Nutrition and Dietetics.

Future Dimensions In Clinical Nutrition Management Viewpoints and statements in these materials do not necessarily reflect policies and/or official positions of the

Clinical Nutrition Management Dietetic Practice Group or the Academy of Nutrition and Dietetics. © 2014

Clinical Nutrition Management Dietetic Practice Group of the Academy of Nutrition and Dietetics. All rights re-

served.

18

Future Dimensions in Clinical Nutrition Practice

Briefly describe your

current job and rele-

vant past positions.

I am the Clinical Nutri-

tion Operations Man-

ager for UnityPoint

Health in Des Moines,

Iowa. Our depart-

ment services 4 Unity-

Point hospitals on 3

campuses, serving

neonates to cente-

narians. We have 24

inpatient dietitians, three outpatient dietitians,

three consultant dietitians, eight diet technicians, one supervisor and a room service call center

that processes about 40,000-50,000 meal re-

quests and patient orders each month.

My job is focused on CBORD database mainte-

nance, patient menu development and imple-

mentation (in concert with Aramark), policies and

procedures, and auditing records for clinical and

non-clinical performance measures. I am also

charged with the management of our outpatient

counseling and consulting staff. We are also

working on plans to staff about 30 UnityPoint

outpatient clinics in central Iowa with RDs.

Prior to this position, I was an inpatient clinical

dietitian at UnityPoint Health for 15 years, spe-

cializing in cardiac and critical care. I was a late-

comer to dietetics, passing the exam at the age of

38. I have been many things in this life; a profes-

sional athlete and a college coach, a foods re-

searcher, a concert promoter, a medical records

officer for a charity hospital overseas, and an en-

trepreneur in agribusiness.

What do you love most about your job?

I love the team with whom I work, and I really

enjoy the camaraderie of the other Clinical Nutri-

tion Managers for the UnityPoint Health affiliates

from Sioux City, Iowa to Madison, Wisconsin. I

do love the idea that I am a coach and a guide by

the side. I enjoy the change of tasks from week

to week. I still enjoy patient contact via inten-

tional rounding and bilingual education.

What is the most challenging part of your job?

We have a very experienced staff; almost ½ of

the clinical staff have been with us for more than

20 years. That is a double-edged sword; on one

hand we have a wealth of expertise and on the

other, there is on occasion incredible inertia

against positive change. My CNM counterpart

and I have found some deeply entrenched be-

havior that is challenging to coach and difficult to

finesse, given our relatively recent arrival. We are working on it.

I also struggle with the devil that lives in the de-

tails. The diet management system and the elec-

tronic health records that we use are a marvel,

but the incredible detail work that they require

pulls my attention away from other pressing

matters more than I would like.

Healthcare is not an agile enterprise. We are a

large hospital group with a large food service

contract organization, and I have had to re-think

my horizons about change since starting this job.

In my old business, we could re-tool and start a

new venture inside of two weeks. That doesn’t

happen here, and I have to consider that.

What advice do you have for RDs new to man-

agement, or for those interested in becoming

managers?

Go into business. Get an MBA. Better yet, do

both. Do something other than just clinical work

if you want to be a great manager. I don’t want

to discount clinical dietetics experience, but I do

so precious little with it now since I left the floors

just 15 months ago. The skills that carry the day

for me now are what I learned from starting my

own business and what I learned being an ath-

letic coach.

Featured Member: Brian J. Smith, RDN, LD

Winter 2015

19


Describe what you think the ideal role of the RD

should be 30 years from now. What do you

think we need to do as a profession to get to

that point?

There will be many roles for dietitians in 30 years.

I think we need to make the tent a little bigger for

dietitians who are not inclined to take care of a

hospital floor for a living. There is so much op-

portunity and so very few people who are able to

capitalize on those opportunities. The trick is to

be very good at matchmaking skill sets to what

the job requires. I hope to be one of those

matchmakers as we proceed into the future.

The fact remains that in 10-15 years, we will be staring down a significant shortfall of qualified

people relative to the jobs available. I would go

after those who are not traditionally thought of

for our profession. As a male, I find it almost

laughable that I am in a minority of about 3% in

this profession. We have some work to do.

Finally, we still need to advocate for credentialing

and reimbursement for our work. It is very diffi-

cult for us to justify our value to the organization

when we provide so very little in the way of reve-

nue. Money still talks.

If you couldn’t be a dietitian anymore, what pro-

fession would you choose?

I would probably either go back into education or

into consulting. I loved a teaching gig that I had

at the Iowa Culinary Institute, which I had to quit

when my wife passed away. When my children

are out of the house, I might consider going back

into post-secondary teaching. The consulting idea

also intrigues me. I did project work overseas and I would like to do that again possibly when my

daughters are launched into their adult lives.

20

Chair

Kathryn Allen, MA, RD, CSO

[email protected]

Chair-Elect

Caroline Steele, MS, RD, CSP, IBCLC

[email protected]

Immediate Past Chair

Young Hee Kim, MS, RD, LDN, CNSC

[email protected]

Secretary

Jennifer Wilson, MS, RD, LDN

[email protected]

Treasurer

Janet Barcroft, RD, LDN

[email protected]

Newsletter Managing Editor

Jennifer Doley, MBA, RD, CNSC, FAND

[email protected]

Features Editors

Lisa E. Trombley, MA, RD, CNSC

[email protected]

Leigh-Anne Wooten, MS, RD, LDN

[email protected]

Amanda Nederostek, MS, RD, CD

[email protected]

Nominating Committee Chair

Lisa Cherry, MS, RD, CNSC

[email protected]

Chair Elect

Wendy Phillips, MS, RD, CNSC, CLE

[email protected]

Committee Members

Tamara Smith, RD, LD

[email protected]

Kelly Danis, RD, LDN

[email protected]

CNM DPG Delegate to the HOD

Mary Jane Rogalski, MBA, RD, LDN

[email protected]

Nutrition Informatics Chair

Janel Welch, MS, RD, LD

[email protected]

Nutrition Informatics Vice-Chair

Ann Childers, MS, RDN, MHA, LD

[email protected]

Committee Members

Krista Clark, MBA, RD, LD

[email protected]

CNM EML Administrator

Deb Hutsler, MS, RD, LD

[email protected]

Assistant Administrator

Laurie Szekely

[email protected]

Public Policy Chair

Julie Haase, MS, RD, CD

[email protected]

Member Services Chair

Kerry Scott, RDN, CD

[email protected]

Committee Members

Alexandra Lautenschlaeger,

RD, LD, LDN

Alexandra.Lautenschlaeger@

rutherfordregional.com

Renee S. Winter-Bertsch,

[email protected]

Marsha Kenner, MS, RD, LDN

[email protected]

Lynn Becker, RD, LD

[email protected]

Professional Development Chair

Kelly Danis, RD, LDN

[email protected]

Committee Members

Beverly J.D. Hernandez,

PhD, RD, LDN

[email protected]

Winter 2015 Future Dimensions in Clinical Nutrition Practice

Clinical Nutrition Management Dietetic Practice Group

2014—2015 Executive Committee

Cathy Montgomery, RD, LD

[email protected]

Melissa Payne, MS, RD, LDN [email protected]

Research Co-Chairs

Susan DeHoog, RD

[email protected]

Barbara Isaacs Jordan, MS, RD,

CDN

[email protected]

Research DPBRN Liaison

Jessie Pavlinac, MS, RD, CSR, LD

[email protected]

Committee Members

Debby Kasper, RD, LDN, SNS

[email protected]

Barbara Lusk, RD, LDN

[email protected]

Quality and Process

Improvement Chair

Sherri L. Jones,

MS, MBA, RD, LDN, FAND

[email protected]

Quality and Process

Improvement Vice-Chair

Cynthia Hamilton, MS, RD, LD

[email protected]

Fundraising Chair

Sharron Lent, RD, LD

[email protected]

Immediate Past Chair

Monica Milonovich, MS, RD, LD

[email protected]

Academy of Nutrition and

Dietetics Manager, DPG / MIG

Relations

Mya Wilson, MPH, MBA

[email protected]

future dimensions - clinical nutrition management dpg winter... · 2015-02-12 · dpg was selected...

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