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Objectives Scope of Practice Variations, Dilemmas and Impact on Health Care Reform

Sari Edelstein, PhD, RD Simmons College •

Portions of this presentation were taken from an unpublished manuscript: Edelstein S, Molinski C, Laidlaw, J. Reported Scope of Practice Variations .

Scope of Practice Defined As…. • …the broad range of services and expectations of the profession and are not intended to be exhaustive; however, the activities described reflect current practice within the profession. • Dietetics practitioners may not be competent to practice in all areas of the field of dietetics. Individuals are expected to practice only in designated areas where they are competent based on their education, training, and experience. • •

• The Learner will be able to discuss the variation of tasks they may or may not professionally perform as RDs. • The Learner will be able to delineate how the variations in Scope of Practice affects the RD role in Health Care Reform.

Where Do We Get Our Scope of Practice Guidelines? • Scope of Dietetics Practice Framework • Decision Tree and Decision Analysis Tool • ADA’s Code of Ethics

American Dietetic Association: Scope of Dietetics Practice Framework (April 2005 Journal Article) Understanding and Using the Scope of Dietetics Practice Framework: A Step-Wise Approach (March 2006 Journal Article)

Scope of Dietetics Practice Framework – – – – – – – – – – –

The Decision Tree and Decision Analysis Tool

SOP SOPP for RDs in Oncology Nutrition Care SOP SOPP for RDs in Nephrology Care SOP SOPP for RDs in Pediatric Nutrition SOPP for RDs in Education of Dietetics Practitioners SOP SOPP ffor RD RDs in i SSports t Di Dietetics t ti SOPP for RDs in Management of Food and Nutrition Systems SOP in Nutrition Care and SOPP for RDs SOP in Nutrition Care and SOPP for DTRs SOP SOPP for RDs in Nutrition Support SOP SOPP for RDs in Behavioral Health Care SOP SOPP for RDs in Diabetes Care

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ADA’s Code of Ethics • The Code of Ethics was adopted to “reflect the values and ethical principles guiding the dietetics profession and to set forth commitments and obligations of the dietetics practitioner to public, clients,, the profession, p , colleagues g and other professionals.” • The Code consists of a comprehensible list of ethics including integrity, science-based practice, professional judgment and compliance with applicable laws and regulations.

Decision Analysis Tool Continued • Do the policies and procedures, your manual, or your credentialing and privileging for your employer permit the activity or service? • Does performing the activity pass the “reasonable and prudent” test for dietetics practice? • Is the activity authorized by federal statute, if applicable (e.g., Medicare Medical Nutrition Therapy)?

Scope of Practice Survey Data Collection • Voluntary basis was sent via electronic mail to active members of several dietetic listservs (Pedi-Listserv from the University of Iowa, Diabetes Care and Education Dietetic Practice Group from the ADA, and Massachusetts Dietetic Association), where members could download the survey from zoomerang.com • N=163

Decision Analysis Tool

• Part B: Education, Credentialing and Privileging • If th the activity ti it or service i was nott iincluded l d d iin your b basic i DTR/RD education program, have you since completed a training program that demonstrates competence? • Is the activity or service becoming routine across the profession that it can reasonably and prudently be assumed within scope?

Challenges to Scope of Practice • On an ADA Webinar on clinical privileging, “fewer than 50% of Webinar participants knew for certain whether there was a legal scope of practice in the state where they were employed.”

Findings • Demographic data from the participants indicated that the majority where from the Northeast • (38%; n=62), worked in medical centers or hospitals • (74%, n=119), and had a Masters degree (56%, n=91).

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Scope of Practice • Participants were asked if they had heard of the term scope of practice and if they felt they knew the general meaning of the phrase. • Most survey participants (98%; n=159) answered yes.

Survey Question

Survey Question • -Have you ever been asked to write diet orders? • 6 67% % (n=107) ( 0 ) off participants i i answered d Yes, with 9% (n=13) stating they thought the task was not within the dietetics scope of practice.

Survey Question

• -Have you ever been asked to make the final tube feeding decision?

• -Have you ever been asked to write parenteral nutrition orders?

• 8 85% % (n=136) ( 36) answered d Yes, with i h 9% ((n=13) 3) stating they thought the task was not within the dietetics scope of practice.

• 6 61% % (n=97) ( 9 ) answered d Yes, with i h 6% ((n=10) 0) stating they thought the task was not within the dietetics scope of practice.

Survey Question • -Have you ever been asked to advance diet orders? • 56% 6% (n=89) ( 89) answered d Yes, with i h 19% 9% ((n=27) 2 ) stating they thought the task was not within the dietetics scope of practice.

Survey Question • -Have you ever been asked to feed a patient? • 19% (n=29) answered Yes, with 50% (n=68) stating i they h thought h h the h taskk was not within i hi the dietetics scope of practice.

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Survey Question

Survey Question

• -Have you ever been asked to write a prescription?

• -Have you ever been asked to care for a gastric tube insertion site?

• 40% (n=64) answered Yes, with 54% (n=74) stating they thought the task was not within the dietetics scope of practice.

• 12% 2% (n=19) ( 9) answered d Yes, with i h6 64% % ((n=91) 9 ) stating they thought the task was not within the dietetics scope of practice. •

Statistical Significance • Dietitians who worked in medical centers (n=62) answered that they perform more tasks that they consider not to be within the dietetics scope of practice practice.

Others Tasks that were not Viewed as within the Scope of Practice • order or give non-nutritional medications, • fill out insurance reimbursement for formula, • perform finger-sticks for cholesterol screening,

• P=.01 using a one tailed t-test

Other Tasks that were not Viewed as within the Scope of Practice continued

• sort out medications for home health clients, • take blood pressures, • educate patients on tube feeding set ups, and

• psychiatric intervention beyond simple behavioral issues around feeding,

RDs Opinion of Tasks that are asked of other Allied Health Professionals • recommending formula, tube feeding and diet orders, • attending di ethics hi meetings i about b ffeeding di issues, • writing TPN orders and tube feeding orders, performing calorie count assessments,

• test blood glucose

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RDs Opinion of Tasks that are asked of other Allied Health Professionals Continued • giving nutritional advice/education for a variety of disease states, • ordering d i vitamins, i i • giving food allergy information, and • managing eating disorders

Massachusetts State Law • Section 206. No person shall hold himself out to be a licensed dietitian/nutritionist unless so licensed under the applicable provisions of this chapter. … • (a) pursuing a degree in dietetics or nutrition at an accredited college or university … • (b) fulfilling the professional experience requirement in dietetic or nutrition necessary for licensure ….under the supervision of a licensed dietitian/nutritionist and in accordance with professional standards of practice… • (c) furnishing information regarding food, food material, or dietary supplements;

Mass Law: 268 CMR 5.00: Professional Standards and Ethical Codes • (c) Licensees shall recognize and exercise professional judgment within the limits of their qualifications and collaborate with others seek counsel, others, counsel or make referrals as appropriate. Licensees shall not provide any services beyond the scope of their practice or for which they are not appropriately licensed.

ADA’s Order Writing and Privileging • But, many considerations must be made that entail individual state licensure law, Medicare/Medicaid protocols, hospital policy defined by the medical executive committee with clear and concise written policies and procedures, accrediting agencies guidelines (risk management g and quality q y areas)) patient p safetyy considerations, and scope of professional liability the employer covers. • Some solutions to these problems have been the creation of the use of protocols and standing orders that include diet orders and are preprinted and placed in the patient chart under the guise of the medical team which is led by a physician

Massachusetts State Law Continued • (d) furnishing information about food, food products, or dietary supplements to customers in connection with the marketing and distribution of such items; • (e) practicing a health profession that he is otherwise authorized to practice under chapter 112 of the General Laws; or • (f) practicing a health profession that includes a dietetic or nutritional practice component, including, but not limited to, holistic medicine, naturopathic medicine, homeopathic medicine, macrobiotics, ayurvedic therapy, polarity therapy, shiatsu therapy, massage therapy, and herbal therapy.

Dilemma

• Protect our Scope of Practice or be replaced • VS • Medical Liability

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Liability Article by S. Palmer, Today’ Dietitian, Feb 2008

Sample Cases for RDs • Practicing Medicine without a license; who makes the diagnosis or determines the diet prescription? • Not getting Physician’s written referral • Giving Exercise Advice without a license • Not referring to a Certified sports professional • Putting your hands on patients; performing procedures • Bad outcomes: ex. bariatric post-op

Malpractice Insurance Coverage

Dilemma

• Was standard of care followed?

• RD understanding of SOP • MD understanding of SOP

• 1-2 million $ coverage

• Balanced with:

• Documentation?

• Actual SOP • State Law

Health Care Reform • Cost savings by prevention! • ADA’s statement by the Healthcare Reform Taskk Group: G “expand nutrition services to a broader range where MNT will improve health outcomes…”

ADA Recommendations • Expand the Medical Nutrition Therapy (MNT) benefit in Medicare. • Include MNT in all government-run government run health programs. • Include RDs to be a part of the medical home. • Strengthen language in community and home-health programs to include MNT.

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ADA Recommendations Continued • Provide workforce grants to recruit students to the field of dietetics. Children s Obesity • Fund the authorized $25 billion Children's Demonstration Program. • Require that restaurant labeling be sufficiently valid, consumer tested and include nutrition education and evaluation.

Recommendations • Work with payers to define the scope of practice for RDs and RDs with specialty certificates. • Work with medical groups for RDs to be included • Be active in public policy reform to include RDs.

Thank-you!

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