Services of registered dietitians or nutritional professionals for diabetes training services and medical nutrition therapy (the costs of such services are covered but not as a billable RHC visit).

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The mission of the Rural Health Services Development (RHSD) Program is to develop and maintain primary health care services in rural areas; provide financial and technical assistance to primary care clinics; and, coordinate similar programs of the federal government and other State and voluntary agencies.

The RHSD Program awards grants to community-based, private, non-profit, licensed primary health care clinics throughout rural California for the provision of comprehensive primary and preventive health care services.

About one-sixth of California’s population lives in rural areas and is geographically spread throughout most of California. Rural residents are older, poorer, and have dramatically fewer health resources than their urban counterparts. Sparsity of physician distribution, coupled with climatic, topographic, and distance factors, isolates rural residents from accessible and available services.

Utilizing a variety of funding streams, the RHSD Program has successfully assisted rural community clinics in enhancing both primary medical and dental care services, nutrition counseling and health education. The goal is to improve the health status of targeted population groups living in medically underserved rural areas of the state.

Several states licensure statutes describe that a physician or a health care provider authorized to prescribe dietary treatments initiate a referral for nutrition services. It will be noted, therefore, that the referral of a qualified health care provider, such as a physician, is apparently an essential antecedent to the RD’s ability to practice dietetics or nutritional services of any kind. The statutes of some other states also contain references to a physician’s participation or supervision in the nutrition care process, but they are not nearly as restrictive as Alabama and California.

California State Regulation:

“[A] registered dietitian or other nutritional professional meeting the qualifications [of this statute] may, upon referral by a health care provider authorized to prescribe dietary treatments, provide nutritional and dietary counseling, conduct nutritional and dietary assessments and develop nutritional and dietary treatments, including therapeutic diets, for individuals or groups of patients in licensed institutional facilities or in private office settings.” Cal. Bus. & Prof. Code, § 2586.

Prior to initiating nutrition services such as medical nutrition therapy services, RDs should consider whether a referral is necessary or appropriate. A variety of factors impact referrals including payer policies that may be providing direct reimbursement to the RD, the extent to which state licensure laws may define the need for a referral, facility policies such as those addressing quality clinical care and continuity and the type of service being provided by the RD. [For more details, see the August 2008 Journal of the American Dietetic Association article, “Referral Systems in Ambulatory Care–Providing Access to the Nutrition Care Process.”]

For example, the federal government, under Medicare Part B, explicitly requires a “treating physician’s” referral for Medicare Part B–covered medical nutrition therapy services for diabetes and non-dialysis kidney disease provided by RD Medicare providers. There are instances in which private sector payers do not require a referral, as in the case of many disease management programs where MNT or nutrition services are included as part of the disease management program. In many of these cases, patients/clients qualify for the service based on their existing health condition, such as diabetes or obesity, which allow the patients/clients direct access to MNT services without the need for a physician referral.

Currently, only a handful of the 46 state laws that regulate dietitians or nutritionists through licensure, statutory certification or registration explicitly require a referral or physician order. Still, RDs should not assume that their state does not have such a requirement. Even in explicit cases, the referral language may differ in each state’s legislation.

Insurance Resources

Medical Nutrition Therapy improves patient outcomes, quality of life and lowers health-care costs. Medicare covers outpatient MNT provided by registered dietitians for beneficiaries with diabetes, chronic renal insufficiency/end-stage renal disease (non-dialysis renal disease) or post kidney transplant. Many other private insurance companies also cover MNT services for a variety of conditions and diseases (see below).

MNT includes nutritional diagnostic, therapeutic and counseling services for the purpose of disease management. Qualifying patients generally receive three hours of MNT in the first year and two hours of MNT in subsequent years. For changes in medical diagnosis, condition or treatment, Medicare covers additional hours of MNT.

The following are a few easy steps to ensure patients are eligible to receive MNT:

1.          Medicare requires a physician order for patients to see an RD for MNT. When making a referral the physician should be sure to:

• Include the diagnosis and diagnosis code(s) for diabetes or non-dialysis kidney disease.
• Send recent lab data and medications with the referral form.
• Document the medical necessity for MNT in the patient’s medical chart.

2.          The nurse should make an appointment with an RD at a local hospital out-patient clinic, physician clinic or the registered dietitian’s private practice office.

3.          When additional hours of MNT are needed for your patient, another referral and medical record documentation are needed.

Sample 

• The assessment begins with an evaluation of the patient’s ability to consume food.
• The RD looks at current and past eating habits. A diet record completed by the patient or a family member is reviewed and discussed.
• The RD obtains a medical history such as weight and weight history, selected laboratory tests and medications that may affect nutritional status.
• The RD then examines the patient for signs of under- or over-nourishment; conditions that may affect swallowing, digestion, and the body’s ability to absorb or use the food eaten.
• Food intolerance and allergies; religious, cultural, ethnic, and personal food preferences; and diet prescriptions are also taken into account.
• The RD may also ask for information from the physician or other providers such as nurses, speech pathologists, and occupational therapists.
• The RD interprets all the information and designs an individualized plan of action including education, if needed.
• Two to three nutrition therapy sessions are recommended for optimal results.

Under a federal Medicaid Home and Community-Based, Long Term Care Services Waiver, the Multipurpose Senior Services Program (MSSP) provides comprehensive case management to assist frail elderly persons to remain at home.

Each of the MSSP sites provide social and health case management for frail elderly clients who are certifiable for placement in a nursing facility but who wish to remain in the community. The goal of the program is to arrange for and monitor the use of community services to prevent or delay premature institutional placement of these frail clients. The services must be provided at a cost lower than that for nursing facility care.

The services that MSSP clients may utilize include:

Nutrition counseling as well as liquid medical nutritionals have frequently been provided through MSSP. The dietitian may contract with MSSP through their local Area Agency on Aging (AAA).

Clients eligible for the program must be 65 years of age or older, currently eligible for Medi-Cal, and certified or certifiable for placement in a nursing facility. MSSP site staff make this certification determination based upon Medi-Cal criteria for placement.

Home Health Care Opportunities Expand for Registered Dietitians, According to Practice Paper from American Dietetic Association

June 01, 2009

The American Dietetic Association has released an updated Practice Paper on opportunities for nutrition professionals to provide home health care. The paper has been published in the June 2009 issue of the Journal of the American Dietetic Association. It summarizes the expanding role of registered dietitians in home care, such as counseling patients and families, providing and monitoring nutrition support therapies, educating referral sources on the benefits of home care, lobbying for improved home care coverage and advocating for the home care patient.

Practice Papers are evaluative summaries of scientific information and/or practical application that address topics in dietetics practice of importance to American Dietetic Association members. They are intended to provide opportunities for critical reasoning and quality improvement in dietetics practice and to include peer-reviewed perspectives from experts in the field. Practice Papers generally are written on emerging areas of dietetics and should not be interpreted as official positions of ADA.

“There are unlimited possibilities for professional growth for RDs in the arena of home care not only as providers of nutrition care, but also as administrators, case managers and researchers,” said registered dietitian Mary P. (Trisha) Fuhrman, author of ADA’s home health care Practice Paper. “In particular, home care is an expanding opportunity for pediatric and geriatric nutrition specialists,” she said.

According to ADA’s Practice Paper, home care is a dynamic area of health care. Since its inception in the 1880s, it has grown to provide care to more than 7.6 million people with annual expenditures exceeding $57.6 billion in 2007. Ninety-three percent of home care patients are treated by a Medicare- or Medicaid-certified agency. There were 9,284 Medicare-certified home health agencies in 2007 with a total of 253,162 full-time employees. The total number of home health employees was estimated at 867,100 people in 2006.

“The role of RDs in home care can only expand as RDs are involved in providing safe and effective nutrition services in the home and alternate site settings,” according to the Practice Paper. “RDs must adhere to all laws and regulations while providing nutrition services that meet the unique needs and values of the individual. It is also imperative for RDs to be advocates for inclusion of nutrition in (Medicare and Medicaid) guidelines and accrediting body standards. RDs need to know their state home health agency regulations and work with their state affiliates to lobby their state health departments to insure acceptable language that defines at a minimum a definition of a qualified dietitian and nutrition services in home health.”

The paper concludes: “Home care practice is now established, but the opportunities to demonstrate the benefit of more involvement of RDs in home care and home infusion are abounding. RDs can not only provide the nutrition intervention that augments the medical care provided, but through clinical oversight and emotional support, RDs can enhance clinical outcomes as well as positively impact each patient’s quality of life.”

See ADA article

• Specialized Diet Planning: Home care dietitians create individualized plans to address each patient’s illness and special health needs. The home health care dietitians take into consideration each patient’s unique lifestyle to create a healthy diet plan for their needs. Home health care dietitians can also provide nutrition education for patients and their families that focus on nutrition concerns and each patient’s particular illness.

• Enteral Nutrition: Enteral Nutrition is a nutrition support service for patients who are not able to receive nutrients by mouth but do have functioning digestive tracts. With enteral nutrition support, an individual receives nutrition through a feeding tube placed in the patient’s stomach or intestine. This service is commonly needed by stoke patients who have trouble swallowing, patients with neuromuscular diseases, or patients with head or neck cancer.

• Total Parenteral Nutrition (TPN): Total Parenteral Nutrition is for patients who are unable to receive nutrients by mouth or feeding tube. This form of nutrition support uses IV infusion therapy to supply patients with a balanced amount of calories, vitamins, minerals, proteins, and fats as prescribed by their physician.

• Type 2 Diabetes
• Heart Disease
• Gastrointestinal Diseases
• Kidney Disease
• Liver Disease
• Gallbladder Disease
• Unintended Weight Loss