The role of renal dietitians in an integrated care model

I spoke with Debbie Benner, MA, RD, CSR, Vice President of Clinical Support and Patient Alignment at DaVita HealthCare Partners Inc. about how the integrated care model affects renal dietitians and their patients. -by Rebecca Zumoff

NN&I: Do you believe integrated care models are impacting or will impact how dietitians treat patients and work with the rest of the renal care team?

Benner: Yes, integrated care models will have a positive impact on the way dietitians provide nutrition care in kidney care settings. The influence of this model is already bringing change and will continue to evolve creating an inspiring future for dietitians.

Dietitians have a key role with education to support improvements in patient management of diet, fluid, medications and physical activity, all of which contribute to patients staying healthy and out of the hospital.

The integrated care model aligns to the dietitian’s holistic approach, which is at the heart of nutritional care; incorporating the art (feelings, senses, thoughts) and science of food, nutrition and preventative health.

Dietitians will continue to partner and collaborate with the interdisciplinary care team. All team members will need to have increased recognition of the patient as the center of the integrated care model. At DaVita, we have transitioned to focusing on the clinical quality pyramid, where the patient-centered approach delivers a patient experience that is caring, respectful and empathetic.

With a keen focus on developing ways to keep patients healthier and avoid hospitalizations, integrated care models are rapidly changing the paradigm for health care delivery systems in the dialysis setting. In this type of environment, the face of nutritional care likewise needs to be poised for change. More

Patients have indicated they are looking for a more holistic approach where caregivers are treating more than just their disease and are partnering to positively impact their health-related quality of life. Using their nutrition expertise dietitians contribute to quality of life and well-being, which enables patients to spend more special moments with family, friends and activities that bring them fulfillment.

NN&I: Do you think the role of the dietitian is evolving?

Benner: Over the past 20 years, I have seen the role of the renal dietitian evolve significantly. Dietitians have gained increasing respect as the clinical guide for nutrition, fluid and Mineral and Bone Disease (MBD) management. Integrated care incorporates preventative health and a more holistic approach that will continue to elevate the importance of nutritional aspects of health and well-being.

Dietitians are taking their expertise and passion in the science of nutrition and blending it with the need and priority of personalized care to positively impact not just health, but ultimately quality of life.

With patient experience and quality of life being at the top of the hierarchy of care, dietitians and care teams need to strengthen the patient’s motivation to change and help them to achieve their health-related goals. In the integrated model it will be even more valuable for dietitians to partner with other members of the care team as well as the patient to drive holistic care, prevent hospitalizations and improve outcomes. Integrated care may lead to dietitians expanding their focus to include physical well-being, activities of daily living, strength, frailty, home care, food procurement and preparation as well as food choices and supplements.

NN&I: What do you think are the largest issues/obstacles affecting renal dietitians?

Benner: To truly connect with patients, dietitians will need to develop their own self-awareness and expertise in behavioral skills and approaches that can positively influence and impact patient engagement, activation and experience.

Dietitians have a wealth of knowledge and a strong desire and urgency to share their expertise, but it is important that they first understand and prioritize what is most important to the individual patient.

Dietitians will need to customize their approach and interventions while balancing health care priorities with the patient’s individual life, culture, needs, challenges and most important to affirm and build on positive aspects. To address this need, at DaVita we are in the process of providing a comprehensive motivational interviewing training program for all of our 1,900 dietitians. DaVita is partnering with an motivational interviewing expert to provide live training and ongoing skill building sessions that develop and sustain the motivational interviewing approach and principles among our dietitians. With the current case loads, dietitians need to prioritize use of these skills and approaches to effectively intervene based on hospitalization risk.

NN&I: What do you think are the greatest areas for improvement in the field?

Benner: The opportunities lie with dietitians becoming a trusted health guide to patients with online resources and tele-health models of the future. I envision a future where dietitians will be able to connect with patients in their homes through online interactive resources to chat, answer questions, and provide guidance on food choices and preparation, as well as ways to improve health through physical activity and healthy living.

Patients have a wealth of information and apps available through technology and dietitians will need to be supportive and guide the practical use and benefits. DaVita has been building online resources and a patient portal to provide the information and options patients are looking for in this technology rich environment. Our dietitians are continuously contributing to our library of kidney-friendly recipes and the expansion of international recipe resources as well as nutrition information on our website.

Another area that is evolving is an increasing need for personalized early CKD nutrition education. Patients diagnosed with early stages of CKD are seeking nutrition resources that will help them stay healthier and potentially delay progression of their kidney disease. Yet, there are very few dietitians specializing in nutritional care during early stages of CKD due to complicated reimbursement issues.

The integrated kidney care model will need to provide dietitian nutritional counseling to patients at risk with diabetes and hypertension to achieve better outcomes.

NN&I: What advice would you give a new dietitian entering nephrology

Benner: Dietitians entering kidney care will want to hone their expertise in behavioral science in addition to specializing in nephrology nutrition. Dietitians will need to develop their skills and expertise in the areas of engaging patients with techniques such as motivational interviewing and behavioral activation. Dietitians will want to apply and practice their ability to elicit and evoke change talk. A collaborative, patient-centered approach will be critical to a dietitian’s success to empower patients within an integrated care model.

In addition, our experience is that dietitians entering kidney care need specialized nephrology nutrition training. At DaVita, we provide over 80 hours of specialized nephrology nutrition training for our new-hire dietitians entering without kidney care experience. In addition, we provide ongoing development programs for dietitians while in their first year of nephrology practice. For our experienced dietitians we provide semi-annual connection meetings to share best practices and expertise with their dietitian peers on an ongoing basis. These processes ensure our patients receive consistent high quality nutritional care at each of our centers.

NN&I: Do you think the number of patients a dietitian treats has changed over the years? Do you think dietitians are often stretched too thin?

Benner: Several years ago, most dialysis facilities only contracted with renal dietitians or allocated very limited time for nutrition services. Fortunately, the kidney care community recognized that more intensive nutrition interventions contribute to improved mortality and dietitians evolved to predominantly full-time specialist in kidney care. Dietitians have a central role managing nutrition, fluid and MBD in addition to contributing to improvements with adequacy and decreasing hospitalization. These components are fundamental to kidney care and are core to many quality metrics today. Yet, we all must recognize the health care environment has limited resources and therefore requires strategies to optimize how to efficiently and effectively achieve quality and positively influence outcomes.

Dietitians are not alone in the need to optimize their time and resources to maximize value. Every team member will need to continually evaluate and prioritize how their time is spent and use strategies that ensure the best use of their time. Team members need to embrace electronic documentation systems and online resources to streamline efforts. Using innovative clinical pathways, screenings and guidelines will support best practice, efficiencies and effectiveness.

A common concern raised by professionals is the limited time they have to spend with their patients.

There is a common misperception that addressing emotional and psychosocial needs will greatly increase visit time. It has been our experience that these approaches, such as using motivational interviewing, actually increase the efficiency of visits and decrease the time spent while providing greater teammate fulfillment. Time spent offering recommendations that are not relevant for patients, or will never be implemented, is time wasted. Focusing on what is most important to patients allows providers to spend less time trying to provide external motivation because patients are able to find internal motivation once they are involved in the goal-setting process.

Also, many health professionals are relieved to find that they no longer have to feel responsible for developing solutions to difficult problems. Patients holistically become the focus of the interaction, rather than just their disease. And patients are more invested when they drive the process to develop plans to reach goals and overcome barriers.