Starting Out: STEP 1. Implementing the Nutrition Care Process: A Dietitian s Step By Step Guide. Equipment Needed. Our Experience

Transcription

1 Implementing the Nutrition Care Process: A Dietitian s Step By Step Guide Presented By Sara A. Swiderski, MBA, RD, LDN Starting Out: STEP 1 Identify key stakeholders and market NCP by marketing the RD profession: -Dietitians -Department leadership -Nursing leadership -Quality team -Physician team -Hospital Administration Our Experience Equipment Needed Challenges Time Motivation IT connection Limited resources Different Ideas, many years of service Wins Formation of team EMR company representative connection IT s willingness to investigate Administration approving the project Pocket Guide for IDNT Electronic Medical Record Access Copies of Terminology Sheets Conference Room/Conference Line for Meetings Access to test environment Information on EMR package (list) IT # on speed dial/ One representative Starting Out: STEP 2 Get to know your IT representative Questions to Ask: What EMR package has the hospital purchased? What features does it include for dietitians concerning documentation, IDNT pick lists, etc.? What features of the EMR do other clinicians or departments use? RD Strategic Planning: STEP 3 Create an NCP committee Elect a leader with drive and motivation for the process Be positive about change Weekly Meetings/ Conference Calls to discuss progress Use real life examples and conduct case studies Estimate time to be spent on tasks Each part of the NCP requires teaching and practice 1

2 Nutrition Care Process Layout Be Creative and Know Your Audience Initial Nutrition Assessment Assessment Diagnosis Intervention Nutrition Prescription Nutritional Goal Monitoring and Evaluation Think Outside the Box ADIME versus DIMEA -Understand the view your reader has -Identify what is important to the reader -Decide what is unique to the dietitian s role -The note will not be read in full 100% of the time -Review note types and link commonalities STEP 4-Create the Layout DIMEA Diagnosis Diagnosis Intervention Nutrition Prescription Nutritional Goal Monitoring and Evaluation Assessment Discuss build capabilities with IT. Hide certain information for later. Clear and concise wins...break down Case Study approach Include all dietitians; accept different view points Review etiologies, signs/symptoms Do agree upon your top 10, break out into categories for disease/problem if needed Create pick lists or request data base download from EMR company Nutrition Diagnosis: Knowledge and Beliefs (7) s (Diagnosis) Food, nutrition and nutrition-related knowledge deficit (NB-1.1) related to*** as evidenced by*** Harmful beliefs/attitudes about food or nutrition-related topics (NB-1.2) related to *** as evidenced by*** Not ready for diet/lifestyle change (NB-1.3) related to*** as evidenced by*** Self-monitoring deficit (NB-1.4) related to*** as evidenced by*** Disordered eating pattern (NB-1.5) related to *** as evidenced by*** Limited adherence to nutrition-related recommendations(nb-1.6) related to *** as evidenced by*** Undesirable food choices (NB-1.7) related to*** as evidenced by*** Weight Management (4) Underweight (NC-3.1) related to***as evidenced by*** Involuntary weight loss (NC-3.2) related to *** as evidenced by*** Overweight/obesity (NC-3.3) related to *** as evidenced by*** Involuntary weight gain (NC-3.4) related to***as evidenced by*** Functional (4) Swallowing Difficulty (NC-1.1) related to *** as evidenced by*** Chewing (masticatory) difficulty (NC-1.2) related to *** as evidenced by*** Breastfeeding difficulty (NC-1.3) related to*** as evidenced by*** Altered GI function (NC-1.4) related to*** as evidenced by*** Selecting Diagnoses Who is your target patient population? What types of situations do you most encounter? Remember the diagnosis will remain the same until patient status changes Remember to pass the baton 2

3 Intervention Acute Care- Ask: What can you do in the next hours to make a difference? Outpatient Care- Ask: What type of results do I want to see for the follow up visit? Be Realistic about therapy recommended Follow Up Note must include original PES-diagnosis statement and intervention, unless it will change Consider discharge planning interventions-address early on considering shorter length of hospital stay Nutrition Prescription Include in the intervention section Unique to the dietitian Opportunity to customize and promote continued therapy (think out patient) Write the prescription on paper-give to your patient Find Database with IT or build it Sample Nutrition Goals Nutrition Prescription Your dietitian (name) recommends the following for following dietary guidelines for hemodialysis until your next visit with the dietitian: *2000 calories/day *2 grams of Potassium/day *2 grams of Sodium/day 1500mL (6 cups of fluid)/day *Please count fluids that melt at room temperature What do you want the patient to accomplish? How can the patient be directly involved in their care? How do we motivate the patient to create and own their goals? Recommend to follow up with (name) the renal outpatient dietitian Meal replacement recommendation: (name) Frequency: once a day Dietitian Signature: Date: Goal: Adequate protein to spare energy and improve visceral protein stores Collaborate with your patient, make it achievable in the long run Include your intervention: Commercial beverage-will supplement with high protein shake with 10 grams of protein per serving Monitoring and Evaluating Our checklist for accurate patient evaluation Excellent tool for other disciplines to know and understand Important for follow up visits This is your To Do List Ask: Is the patient improving with my current intervention? Review with your team what exactly you dojob tasks 3

4 Assessment Monitoring and Evaluation: 1. Total energy intake goal is 75% or greater on a consistent basis 2. Weight-maintain present weight or gain 5 pounds to usual weight of Skin-Be present during body repositioning with nursing or physical therapy 4. Albumin-Improve to 3.0 or greater Review how you decide what enters the note and what to leave out Do not repeat information Do not copy and paste other discipline s notes unless it supports your assessment and is nutritionally focused Nutrition, Nutrition, Nutrition Are we going to measure something? Assessment: Diagnosis: Keep consistent and use admit diagnosis or determine how it will relate to your diagnosis. If it does not relate-leave it out. Past Medical History: Include diagnosis pertinent to your plan of action. Diet Order: Document Intake: Document, or if on nursing flow sheet, already a part of the chart and on record-no need. If a problem, make your diagnosis. Chewing/Swallowing problems-if nursing records, leave out. Appetite/Intake PTA-If nursing records, leave out. Food allergies-part of the EMR; record if discussing for intervention/monitoring portion of note. Cultural/religious preference- Discuss if tied in to your diagnosis/intervention. Anthropometrics: Include if you are going to want to produce data reports on patient populations you serve. Ht: Wt: BMI: IBW: UBW: Pressure Ulcer Present: Part of the Nursing assessment. No need to include Medications: Steroid, megace, folate vitamin B12, MVI, vitamin D, calcium, zinc. *Again, no need to include unless you will be addressing each one. Labs: Display results as needed to support your diagnosis. They too are part of the record and already on file and reported. Calorie Needs: This should go in nutrition prescription -DIMEA Format Pt Admitted with *** on 07/31/12. Diagnosis: Altered nutrition-related laboratory values related to end stage renal disease as evidenced by abnormal potassium level of 5.6. Intervention: Recommended modifications of high potassium foods with diet education handout. Nutrition Prescription: Recommended mineral intake of 2 gram potassium per day. Goals: Potassium level to 5.0. Monitoring/Evaluating: Modified diet of 2 gram potassium Potassium Intake with food diary, Potassium lab Assessment: Potassium intake of 2700 mg per day. Types of high potassium foods consumed are tomatoes, potatoes, and dried fruit. Weight change of -2 kg post dialysis. Potassium of 5.6 is above normal limits. Medication and herbal supplement use include phosphate binders Short Note -No Nutrition Dx IDNT IV -added to nutrition diagnosis section Diet is intervention *There will be patients with lower acuity levels which may not require in depth intervention 4

5 STEP 5-Tracking Outcomes NCP Implemented-Now What?! Obstacles: - Short length of stay-what can be measured? - No RD on Home Health Team - No Developed Work Flow for Contacting Outside RD Colleagues Changes to Make: -Utilize outpatient dietitian staff (if available) -Establish relationships with inpatients -Coordinate care for discharge-refer to outpatient colleagues and home health Tracking Outcomes Goal is to improve outcomes in patient care -Identify what patients struggle with -Performance Improvement projects -Financial responsibility Tracking Outcomes Create RD team profiles -Be unit specific -Uniform education materials -Agree to similar methods for patient care Outpatient services to use results as ways to market the dietitian Tracking Outcomes Identify parameters that can be pulled from the EHR Make the connection from hospital to home : Supplement recommendation provided in the hospital setting-is patient following at home? Referral made to outpatient nutrition-was the appointment made and kept? Tracking Outcomes-Questions to Consider Enteral feedings-are the recommended amounts provided or held at times that would affect patient outcome? Patient education material- Did the patient understand what I was teaching? Is my teaching regimen reducing readmission rates for a certain disease state? How to Set Up Data Collection 5

6 Continuum of Care Home Health Skilled Nursing Facility Home with Family Home alone References Pocket Guide for International Dietetics and Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process Third Edition, Different risk factors associated with each in terms nutrition therapy outcomes 6