Chapter 23 Scope of Practice for the RDN and NDTR

the relationship of the SOP and SOPP hierarchy to the Career Development Guide, showing the competent level is generally a duration of three years of practice; proficient level allows for the opportunity to begin to acquire specialist credentials as the RDN obtains opera- tional skills and adeptly practices long term; and the expert level demonstrates a building and maintaining of knowledge, skills, and advanced credentials (23). Board Certified Specialist credentials offered by the Commission on Dietetic Registration are in geron- tological nutrition (CSG), oncology nutrition (CSO), renal nutrition (CSR), sports nutrition (CSSD) and pediatric nutrition (CSP). Other credentials held by RDNs are listed in Figure 2 of the Academy of Nutrition and Dietetics: Scope of Practice for the Registered Dietitian (24) and outlined by the creden- tialing agency and the credential name. Some examples include certified professional coder (CPC), Board Certified in advanced diabetes management (BC- ADM), ACSM-certified Personal Trainer, certified dia- betes educator (CDE), certified dietary manager (CDM), certified case manager (CCM), certified culi- nary professional, (CCP), certified eating disorders registered dietitian (CEDRD), certified health educator specialist (CHES), certified nutrition support clinician (CNSC), certified professional in healthcare quality (CPHQ), school nutrition specialist (SNS), and project management professional (PMP). The SOP and SOPP for RDNs in Extended Care Settings extensively review this segment of the popu- lation. They state that 70% of people aged 65 years and older will require some form of long-term care services and/or assistance with activities of daily living during their lifetime, according to the US Department of Health and Human Services. Currently there are 9 million people living in the United States who are older than 65 and require long-term care (23). That number is expected to increase to 12 million by 2020. It is estimated that individuals will spend at least three years in long- term care, two years of which will be spent at home taking advantage of community-based programs such as home health care, adult day care, home care, and senior centers. As an individual’s activities of daily living decline, he or she may transition into a health care community such as adult foster care, assisted living, continuing care retirement communities, board and care homes, or skilled nursing facilities (23).

The SOP and SOPP clearly state that nutrition care provided by RDNs in the extended care settings is broad and typically addresses needs of individuals with multiple complex comorbidities rather than just one ailment. Residents aged 65 years and older commonly

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present with chronic kidney disease, diabetes mellitus, stroke, cancer, and heart disease. Other great resources for RDNs to utilize as they ensure quality indicators are met for older adults who need coordinated care are the SOP and SOPP in diabetes care, nephrology nutri- tion, oncology nutrition, behavioral health, and nutri- tion support. The RDN needs to consider an individual’s right to choose treatment modalities that are consistent with his or her beliefs and goals for health care and quality of life. In the extended care set- tings, the depth of RDN involvement with an individ- ual is dependent on his or her nutrition needs, the policies of the facility, and the desires and expectations of the individual and surrogate decision-makers. The RDN must consider end-of-life decisions that may sig- nificantly affect the development of nutrition care interventions for hydration and nourishment (23). The standards also review the issues where RDNs need awareness when performing functions for oversee- ing the nutrition care of individuals in the extended care settings, whether employed by or contracted with a health care organization. Namely, consultant RDNs rely heavily on members of the interdisciplinary team for comprehensive overviews of individuals’ health status, whereas RDNs employed by a facility maintain a more hands-on relationship with individuals. Interdisciplinary team members who care for individuals are specific to the organization and may include the physician, nurse, minimum data set coordinator, social worker, therapists (eg, physical, occupational, recreational, and speech- language), pharmacist, dietitian, dietetic technician, chef, dietary manager, safety and quality manager, and food production and sanitation supervisor. Regardless of the practice scenario, RDNs must meet regulatory com- pliance standards set forth by CMS or other regulatory agencies for the particular health care setting while achieving nutrition outcomes consistent with profes- sional standards, person-centered care, and individual wishes (23).

SUMMARY

The RDN and NDTR must realize the importance of establishing an excellence enterprise within the extended care settings arena. Any undertaking in directing and coordinating safe, timely, person- centered care to ensure the highest-quality delivery of food and nutrition services to the older adult will require effort and at times seem difficult. Nutrition businesses in older adult care need to establish collabo- rative partnerships that make a difference, generate a return on investment, meet the aims of the national quality strategy, measure provider and organization performance, and continuously improve. Take time to