Let`s Be Frank: Collaborating With a Nutritional Expert is Crucial

In today’s healthcare arena, the expectation is for improved outcomes to be achieved through patient-centered models of care that rely on the knowledge, expertise, and skills of multiple healthcare professionals navigating toward the same goals. Each member should be seen as equally valuable as they utilize their individual areas of expertise to share knowledge and deliver evidenced-based care that addresses specific patient needs. Any individual provider will have difficulty addressing the multiple complex issues and comorbidities experienced among the wound care population. That said, program managers within the outpatient setting should realize the importance of including a registered dietitian nutritionist (RDN) as part of a collaborative team approach in order for their patients to receive appropriately coordinated care. This article will discuss some benefits to having contributions from the often-misunderstood role of the nutrition expert as part of the wound clinic’s approach to treatment. It’s imperative that program directors and clinicians also review coverage, coding, and reimbursement details for their specific regions, as that information is beyond the scope of this article. 

Addressing Needs for Nutritional Expertise

Team-based healthcare is defined as the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their caregivers — to the extent preferred by each patient — to accomplish shared goals within and across settings to achieve coordinated, high-quality care.”¹ One difficulty shared by many wound clinics is an inconsistency in the employment of team members based on a lack of resource availability, reimbursement for services, or, perhaps, not actively planning ahead appropriately. 

As a lymphedema and physical therapist, this author meets these challenges firsthand. These professions are always listed as being part of a multidisciplinary wound care team, but the reality is that most clinic directors and management companies do not utilize our skills. In fact, many years ago, out of curiosity, I asked the owner of a clinic to consider hiring me. The answer “no” was given rather quickly and without so much as an inquiry into my experience or skills. The reasoning behind the “decision”? I was “too expensive and they did not understand how I would generate revenue.”  

Similarly, the role of the RDN and the RDN’s overall importance as part of a collaborative wound care team are often overlooked. This was informally validated through a recent poll from clinicians among multiple outpatient clinics across the country. Most clinics reported not currently considering the expertise of an RDN as part of their wound patients’ plan of care. 

The Nutritionist’s Role & Expertise

Questions that program managers should consider when determining how one’s clinic could benefit from a nutrition expert include: 1) Do you trust that staff members can identify when a patient is clinically malnourished as defined by such organizations as the Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition? 2) Once accurate clinical diagnosis is confirmed, what are the interventions in place to assist in wound healing? 3) At what point does the need to reassess the effectiveness of interventions and initiate the consult of an RDN begin? An RDN has completed multiple levels of education and training established by the Accreditation Council for Education in Nutrition and Dietetics. A nutritionist may also possess a graduate degree in nutrition. There are other healthcare professionals that may practice “clinical nutrition” by completing studies in the area of nutrition. The Certification Board for Nutrition Specialists offers a certified nutrition specialist credential, the Clinical Nutrition Certification Board offers a certified clinical nutritionist certification, the Clinical Nutrition Certification Board offers a certified clinical nutritionist, and the American Association of Nutritional Consultants offers a certified nutritional consultant credential. 

While qualified nutritionists can justifiably claim to be experts in nutrition, wound clinic program managers must be aware of unqualified individuals with different levels of knowledge who refer to themselves as nutritionists. The term “nutritionist” is not protected in most parts of the world. In many states, nutritionists are accepted as experts who may or may not be qualified healthcare professionals, and some may not have any formal education in this field. A comprehensive program will include nutrition education for disease prevention and nutrition counseling for chronic conditions. The main role of a nutritionist is to help people achieve optimal health by providing information and advice about health and food choices. The expertise of the RDN goes beyond looking at serum hepatic protein levels to determine a patient’s nutritional status, which may not be an adequate determination for malnourishment depending on the patient’s overall health status — inflammation and other disease processes will affect levels. 

Regardless of the circumstances, it’s better understood today how nutrition is important to promote wound healing, even if most of us tend to exclusively tie malnutrition with low albumin/prealbumin levels. Nutritionists tell us otherwise, however. For instance, an RDN may tell us there are many factors that affect albumin/prealbumin levels. If the patient is experiencing inflammation, is taking steroids, or underwent a surgical procedure these levels may not be adequate to determine malnutrition. So what other labs/tests should be ordered to determine nutritional status? This is where the RDN becomes a vital team member.

Effective Collaboration in the Clinic

Hospital-based outpatient departments such as wound clinics have access to other hospital departments — meaning clinic managers can have access to hospital nutritionists and dietitians for assistance in developing policies and procedures on how to utilize them in the clinic. These dietitians and nutritionists can serve our patients effectively, even when access to these professionals is limited. During a recent interview with Nancy Collins, PhD, RDN, LD, FAPWCA, FAND,² various options to increase access to dietitians were discussed. What follows is a list of suggested ways wound clinic staff members should collaborate with the RDN:

• To determine malnutrition or the risk of malnutrition among patients. Interestingly, one study found a wound care facility reported 44% of patients had either no form of nutritional screening while 56% were screened. However, 72% of patients were identified as having malnutrition, but were not referred for consultation.³ When a screening tool identifies a patient as malnourished, a dietitian can be consulted.  The problem lies for those clinics that are not able to have access to a dietitian.  Dr. Collins mentioned that there are dietitians and nutritionists that also practice in the private settings.  
• To suggest/provide appropriate training for wound clinic staff on malnutrition diagnosing and establishing care plans.
• To select proper patient education materials to distribute. 
• To be available as an ongoing resource when wound care clinicians have questions or encounter challenges.

RDNs can be located and identified online by searching the national database of the Academy of Nutrition and Dietetics at www.eatright.org/find-an-expert.

Access Through Telemedicine, Government Programs

For those clinics that struggle to employ the services of an RDN due to location or lack of resources, a possible solution may be to incorporate telemedicine. There are resources available that can assist with the use of telemedicine. Additionally, Medicare beneficiaries may have coverage for nutritional services.  According to Medicare officials, those patients living with diabetes, kidney disease, or those who’ve undergone kidney transplant in the last 36 months and are Part B beneficiaries may be eligible for medical nutrition therapy (MNT).⁴ Additionally, Medicare Part B covers MNT services and certain related services. A nutrition professional who meets certain requirements can provide these services, which may include an initial nutrition and lifestyle assessment, one-on-one nutritional counseling, and follow-up visits to check on progress in managing diet.”⁴ Those located in rural areas may be able to rely on nutritional professionals in different locations to provide MNT through telehealth.⁵ For those patients who receive dialysis in a dialysis facility, Medicare covers MNT as part of overall dialysis care.⁶

For those wound care clinicians who aren’t collaborating with a nutritional expert, the question to be asking yourself is, “How am I individualizing nutritional interventions based on wound etiology and the patient’s disease process?” The answer is, you are not. 

Frank Aviles Jr is wound care service line director at Natchitoches (LA) Regional Medical Center; wound care and lymphedema instructor at the Academy of Lymphatic Studies, Sebastian, FL; physical therapist/wound care consultant at Louisiana Extended Care Hospital, Lafayette, LA; and physical therapist/wound care consultant at Cane River Therapy Services LLC, Natchitoches.

References

1. Mitchell PH, Wynia MK, Golden R, et al. Core Principles & Values of Effective Team-Based Health Care. Discussion Paper. National AHEC Organization. Oak Creek, WI. 2012. Accessed online: www.nationalahec.org/pdfs/vsrt-team-based-care-principles-values.pdf

2. Aviles F. Oral interview.  Nancy Collins. 18 Oct 2016.

3. Somanchi M, Tao X, Mullin GE. The facilitated early enteral and dietary management effectiveness trial in hospitalized patients with malnutrition. JPEN J Parenter Enteral Nutr. 2011;35(2):209-16.

4. Nutrition Therapy Services (Medical). Medicare. Accessed online: www.medicare.gov/coverage/nutrition-therapy-services.html#1368

5. Telehealth. Medicare. Accessed online: www.medicare.gov/coverage/telehealth.html

6. Dialysis (Kidney) Services & Supplies. Medicare. Accessed online: www.medicare.gov/coverage/dialysis-services-and-supplies.html