When does a long-term care facility (LTC) need a dietitian, and how can a dietitian help a facility address the ongoing challenge of providing nutritious, medically appropriate food that residents like?
November 2016 rules from the Centers for Medicare and Medicaid Services (CMS) require every LTC facility to have a registered or licensed dietitian (depending on the licensing regulations of the state) available full-time, part-time or as a consultant. Those rules had not been overhauled since 1991, and much has changed since then, in both the science of nutrition and the provision of care.
Long-term care facilities have unique food needs and challenges. They must serve nutritious food that tastes good and is within budget, while meeting requirements from the Centers for Medicare and Medicaid Services. A dietitian can help.
Having at least one full-time dietitian is the best way to fulfill all mandated tasks, although a part-time dietitian is a viable option depending on facility size, says Registered Dietitian Courtney Lee, a LTC subject matter expert with Dietitians On Demand, a nationwide staffing company dedicated to dietitians, and consulting dietitian with a virtual private practice, Kitchen Nutrition LLC. Only a registered dietitian is qualified to perform comprehensive nutritional assessments, she says.
While there is no standardized ratio of residents to dietitians, Lee estimates she can do assessments, care planning and documentation for about 10 to 12 residents per day, revisiting each resident approximately once a month.
For example, she covered 65 beds in a large facility. She went in two days a week, which was enough time to conduct assessments and care plans on the required schedule. She worked at another facility that had 180 beds and employed the full-time equivalent of 1.5 dietitians.
Having ready access to a dietitian can expand residents’ menu choices because only dietitians can authorize changes in an approved menu. For example, a diabetic patient will have a strict limit on carbohydrates, and staff may be afraid to fulfill the patient’s request for collard greens instead of the approved spinach. “If you don’t have a dietitian to validate that that’s an OK substitution, you might be saying a lot of unnecessary noes,” she says.
The CMS regulations loosened restrictions on ingredients and now allow facilities to take advantage of locally grown produce or even grow their own. However, using those fresh ingredients effectively and safely requires an extra layer of culinary skill.
“If you don’t understand proper sanitizing of fruits and vegetables, you will be too intimidated to use them, so you need a trained staff and food service director to tap into that opportunity,” Lee says.
Some LTC facilities hire chefs to upgrade the quality of their menus and use great-tasting food as a marketing tool. Chefs must work closely with dietitians so food is both delicious and nutritionally appropriate.
“A chef will want to have X on the menu, and the dietitian will have to say, ‘No, there’s no vegetable,’” Lee says. “There’s a partnership there.”
Most facilities use software for basic nutrition analysis—to ensure there’s enough fiber in a menu overall, for example. However, the dietitian works closely with the chef to fulfill each resident’s needs.
“The patient care experience with food is a reflection of how hard you work. You can see that what you offer changes people’s lives, and you can truly help people.”
— Registered Dietitian Courtney Lee
The biggest challenge for LTC dietitians is making food appetizing for residents. “Sometimes it’s just observing and that’s the advantage of being on site all the time,” Lee says. “If you’re not there, you have to ask a nurse if Mrs. Jones ate her yogurt. If you’re there, you can watch Mrs. Jones, and you might find out that she hates vanilla yogurt but likes strawberry.”
Texture can be a particular obstacle for residents who can’t eat solid food. “Pureed is pureed,” Lee says, adding that dietitians can be inventive while maintaining correct nutrition by using scoops and molds that make foods look more interesting. They can also build menus around naturally soft foods like mashed potatoes, applesauce and high-protein ice cream.
Dietitians sometimes shy away from working in LTC because of a perceived lack of challenge. Hospitals have higher patient turnover and more acutely ill patients, Lee says, and many dietitians have never been in a LTC facility because it’s not required for their training. But when Lee did a stint in long-term care as a student, she fell for the challenge of managing patients with multiple co-morbidities and trying to improve their quality of life.
Lee says a facility trying to lure dietitians should emphasize the opportunity for autonomy, which contrasts sharply with the “hamster on a wheel” environment in acute care.
“In LTC, you can make the care of that patient as awesome as you want it to be. The patient care experience with food is a reflection of how hard you work. You can see that what you offer changes people’s lives, and you can truly help people.”