Editor”s note: The Conditions for Coverage of Participation for dialysis facilities took effect Oct. 14, placing a greater emphasis on patient assessment, technical and safety issues, and data reporting. This is the third article in our series on how the new Conditions affect the day-to-day operations of the dialysis clinic.
The newly released Conditions of Coverage have many implications for renal dietitians, most notably to improve patient outcomes and optimize patient care with an interdisciplinary team-based approach. This article will review the definition of a qualified dietitian and the requirements as they pertain to the Comprehensive Interdisciplinary Patient Assessment (CIPA) and Quality Assessment and Performance Improvement (QAPI) requirements.
The Conditions now requires that dietitians working in dialysis must have evidence of registration with the Commission on Dietetic Registration, the credentialing agency for the American Dietetic Association (ADA), and must meet the applicable scope of practice board and licensure requirements of the state in which they are employed. Dietitians must also have a minimum of one year of professional work experience in clinical nutrition as a registered dietitian after successful completion of the registration exam. Experience in clinical nutrition as an intern (prior to registration) would not count toward this requirement, nor would food service experience. The National Kidney Foundation/Council of Renal Nutrition and the American Dietetic Association Renal Practice Group (ADA RPG) supported this definition. The definition is consistent with quality standards for dietetic practice.
Comprehensive interdisciplinary Patient Assessment (CIPA)
As part of the interdisciplinary team (IDT), the dietitian is responsible for providing each patient with an individualized and comprehensive assessment of his or her needs. The comprehensive assessment is then utilized to develop the patient”s treatment plan and expectations for care. The CIPA must be completed by an interdisciplinary team and should be individualized. The CIPA is the first step in the new care planning process. The Conditions define the minimum assessment criteria required. The dietitian must complete the evaluation of each patient”s nutritional status. The minimum criteria for the nutrition assessment include:
- Anthropometrics and recent changes, which include height, weight, body mass index, and percentage of recent weight change and frame size
- Diabetes management, including glycemic control, medications, education and assessment of diet, and medication adherence
- Mineral and bone disorder management, including trends in calcium, phosphorus and PTH, medications, education, and assessment of adherence
- Cultural and social factors related to diet
- Subjective data related to appetite, dietary intake, and nutritional status such as weight history, weight changes, and pica behavior
- Objective data related to nutritional status, including serum albumin and nPCR
A sample CIPA is available on the National Kidney Foundation Web site at www.kidney.org. This form can be used as is, or sections can be incorporated into an existing tool used by the dialysis center. A follow-up reassessment must be completed three months after the initial assessment. This follow-up should address how well patients follow their treatment plan, and it should reevaluate their educational, rehabilitation, and nutritional needs, adjustment to the dialysis regimen, and appropriateness of the plan of care. If the patient is stable, then only annual assessments are required after the three-month assessment. Unstable patients are required to have a monthly assessment.
The regulations provide the following minimum criteria for defining unstable conditions:
- Extended or frequent hospitalizations
- Marked deterioration in health status
- Significant change in psychosocial needs, or
- Concurrent poor nutritional status, unmanaged anemia, and inadequate dialysis
Per the interpretive guidelines (IGs), the IDT has the flexibility to use its professional judgment to further define instability based on their patient population.
QAPI and MAT
Quality assessment and performance improvement (QAPI) addresses facility aggregate data and requires facility-based assessment and improvement of care with an emphasis on indicators related to improved health outcomes and the prevention and reduction of medical errors. The QAPI program must be a continuous process designed to achieve measurable improvement. Performance standards are based on current professionally-accepted clinical practice standards.
The measures assessment tool (MAT) is a new tool found in the interpretive guidelines and identifies standards to be measured, including adequacy of dialysis, nutritional status, mineral metabolism, anemia management, vascular access, medical injuries and errors, patient satisfaction, infection control, patient education on treatment options, and patient physical and mental functioning. Facilities are directed to compare their outcomes with other facilities in their state, their ESRD Network, and around the country.
The MAT uses an albumin goal of 4.0 mg/dL. Most centers target a goal of 3.5 mg/dL or greater. This has generated a flurry of discussion on the RenalRD listserv. While developing an FAQ document about the Conditions (FAQ can be found at http://www.kidney.org/professionals/CRN/), NKF/CRN reached out to CMS for their perspective. The summary of the Kidney Disease Outcomes Quality Initiative nutrition guideline states: “A pre-dialysis or stabilized serum albumin equal to or greater than the lower limit of the normal range (approximately 4.0 mg/dL for the bromcresol green method or BCG) is the outcome goal.” Therefore, CMS set 4.0 g/dL as the intended target. Several research studies have reported significantly elevated risks of death and hospitalization with albumin < 4.0 mg/dL. The KDOQI nutrition guideline states: “…hypoalbuminemia is highly predictive of future mortality risk when present at the time of initiation of chronic dialysis, as well as during the course of maintenance dialysis.” The guideline also states that other factors besides nutrition, such as inflammation or acute or chronic stress, can contribute to hypoalbuminemia.
CMS recognizes that meeting the albumin goal may be a challenge for some patients. When patients do not meet targets, the expectation is that there will be a review of the reasons why the indicator may be below target and a plan developed to address that. The plan of care would document an individualized approach by the IDT to address this deficiency.
Author bio: Ms. Karalis works for Abbott Renal Care, based in Chicago, Ill., and is this year”s Council of Renal Nutrition chair. She is also a member of NN&I”s Editorial Advisory Board.
Support of Texas dietitian staffing ratio
The Texas state regulations for licensing dialysis facilities were recently up for renewal. NKF/CRN expressed their support of maintaining the current Texas regulations regarding patient-to-RD staffing ratios of one full-time equivalent of dietitian time for up to 100 patients for all modalities. In addition to the CfC, which has added many additional documentation requirements of the dietitian, several studies support the need to maintain adequate dietitian staffing ratios to allow for sufficient time required for nutrition assessment and intervention to improve and optimize patient outcomes.
Protein energy malnutrition is common in dialysis patients and is one of the strongest predictors of morbidity and mortality. In a 2008 report to Congress, the Medicare Payment Advisory Commission reported nutritional care, measured by serum albumin > 4.0 g/dL, is one area that has not improved since 1997. The report recognized the critical role of the dietitian in improving nutritional care, and at the same time acknowledged lack of time as a significant barrier in preventing adequate assessment of nutritional status (cited by 40% of dietitians in a survey).1
A recent study confirms that nutritional interventions that increase serum albumin by > 0.2 g/dL may lead to considerable improvements in lowering mortality, hospitalizations, and treatment costs.2 In a recent community-based randomized controlled trial, nutrition intervention by a registered dietitian, tailored to patient specific barriers, resulted in improvements in albumin levels in dialysis patients. Patients that received nutritional intervention had a 3.5 fold greater increase in albumin levels compared with control patients.3
Akpelel and Bailey also found that over a relatively short period of time, serum albumin levels of severely malnourished patients were increased by intensive dietary counseling by a registered dietitian.4 -M.K.
1. Burrowes et al. Multiple factors affect renal dietitians” use of the NKF- KDOQI adult nutrition guidelines. Jour Renal Nutr Vol 15 No 4 Oct 2005 pp 407-426
2. Lacson et al. Potential impact of nutritional intervention on ESRD hospitalization, death and treatment costs. Jour Renal Nutr Vol 17 No 6 Nov 2007 pp 363-371
3. Leon et al. Improving albumin levels among HD patients: A community-based randomized controlled trial. Am Jrnl Kid Dis Vol 48. No 1 July 2006; pp 28-36
4. Akpelel L, Bailey JL. Nutrition counseling impacts serum albumin levels. Jour Renal Nutr Vol 14 No 3 July 2004; pp 143-148