The Role of Nutrition in Maintaining Health in the Nation's Elderly Evaluating Coverage of Nutrition Services for the Medicare Population (2000) / Chapter Skim
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Executive Summary
Executive Summary
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Although varying amounts of basic nutrition services are included in reimbursement payments in hospital, home health, and post-acute care settings, services have been largely inconsistent or inadequate to meet the needs of the growing elderly population. The Medicare program has traditionally not covered preventive services.
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THE COMMITTEE AND ITS CHARGE In early 1999, the Institute of Medicine appointed an expert committee charged with the task of analyzing available information, hearing from other experts, and developing recommendations regarding technical and policy aspects of the provision of comprehensive nutrition services, delineated as follows: · coverage of nutrition services provided by registered dietitians and other health care practitioners for inpatient medically necessary parenteral and enteral nutrition therapy; · coverage of nutrition services provided by registered dietitians and other health care practitioners for patients in home health and skilled nursing facility settings; and · coverage of nutrition services provided by registered dietitians and other trained health care practitioners in individual counseling and group settings, including both primary and secondary preventive services. In addition, the committee was charged with evaluating, to the extent data were available, the cost and benefit of such services to Medicare beneficiaries as well as the research issues needed to provide additional understanding of the relationship between provision of quality nutrition services and quality-of-life outcomes.
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The second tier of nutrition services is the provision of nutrition therapy, which includes individualized assessment of nutritional status; evaluation of nutritional needs; intervention, which ranges from counseling on diet prescriptions to the provision of enteral (tube feeding) and parenteral (intravenous feeding)
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For conditions where documentation was found to support nutrition intervention, a second question asked Specifically, to what extent are registered dietitians, as well as other health care professionals, qualified by training and credentials to provide such services? Credentialing agencies for various health professionals involved in nutrition care were contacted for professional education and training qualifications.
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The changes in where the service of nutrition therapy is provided and how it is financed however, have led to significant barriers to access for many Medicare beneficiaries. NUTRITIONAL HEALTH IN THE OLDER PERSON In reviewing the importance of nutrition to the health of older Americans, both malnutrition and the role of nutrition in the management of health conditions must be considered.
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In considering the provision of nutrition therapy across the continuum of care, the committee examined evidence for specific diseases and conditions that frequently impact Medicare beneficiaries and produce significant morbidity and mortality, and for which nutrition interventions have generally been recommended. In addition, nutrition services in each of the following distinct patient care settings were evaluated: acute care, short-stay facilities (hospitals)
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Conditions evaluated for which data at this time are lacking or insufficient to support a recommendation for nutrition therapy included cancer and osteoporosis. In the case of osteoporosis, although nutrition intervention through calcium and vitamin D supplementation has clearly been found to improve health outcomes, there is a lack of available evidence to suggest that nutrition therapy, as opposed to basic nutrition education from various health care professionals, would be more effective.
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Recommendation 2. With regard to the selection of health care professionals to provide nutrition therapy, the registered dietitian is currently the single identifiable group with standardized education, clinical training, continuing education, and national credentialing requirements necessary to be directly reimbursed as a provider of nutrition therapy.
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Available evidence regarding the education and training of registered dietitians as well as other health professionals needed to adequately provide nutrition services was systematically reviewed (see chapter 13~. A summary of this information can be found in Table 13.1.
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This broad knowledge base is necessary to translate complex diet prescriptions into meaningful individualized dietary modifications for the layperson. The committee therefore finds that, with regard to the selection of health care professionals, the registered dietitian is currently the single identifiable group of health care professionals with standardized education, clinical training, continuing education, and national credentialing requirements necessary to be a directly reimbursable provider of nutrition therapy.
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The provision of enteral and parenteral nutrition in the acute care setting is currently covered for Medicare beneficiaries as part of the prospective payment system. Medical conditions for which enteral and parenteral nutrition regimes may be warranted were reviewed and it was concluded that their use in preventing complications and overt malnutrition has been shown to be effective for many conditions.
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designates the geriatric population as a high-risk group and has emphasized nutrition in its on-site inspections during the past few years, increased attention still has to be drawn to developing and implementing standards related to the process of assessing the nutritional and functional status of elders as well as identifying and correcting inadequacies of care. Nutrition services for Medicare beneficiaries in acute care, home care, and long-term care settings are covered largely through bundled payment systems.
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4 NUTRITION AND HEALTH IN THE NATION'S ELDERLY TABLE ES.2 Hospital Settings: Evaluation of Nutrition Support Interventions Observational Consensus Systematic Some Cli Studiesa Document Review Trial Evi Intervention GPb Elderly GP Elderly GP Elderly GP E1` Gastrointestinal Short bowel Enteral ~ - ~ Parenteral ~ - ~ Fistulas Enteral ~ - ~ Parenteral ~ - ~ Inflammatory bowel disease Enteral ~ - ~ Parenteral ~ - ~ Pancreatitis Enteral ~ - ~ Parenteral ~ - ~ Liver disease Enteral ~ - ~ Parenteral ~ - ~ HIV/AIDS Enteral Parenteral Cancer Therapy Chemotherapy Enteral ~ - ~ Parenteral ~ - ~ Radiation Therapy Enteral ~ - ~ Parenteral ~ - ~ Renal Failure Acute Enteral Parenteral Chronic Enteral Parenteral Critical Illness Enteral Parenteral Perioperative Abdominal Enteral Parenteral Hip fracture Enteral Parenteral a This category includes case series, case-control studies, cohort studies and nonrandomized trials of nutrition-based therapies including nonhuman studies. b GP = general population.
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EXECUTIVE SUMMARY 15 antic v Elderly Some Clinical Trial Evidence Extensive Clinical Trial Evidence GP Elderly GP Elderly Overall Strength of Evidence Supporting Nutrition Therapy for Elderly Persons Efficacious Efficacious Insufficient data Efficacious Insufficient data Not primary therapy Insufficient data Insufficient data Insufficient data Insufficient data Insufficient data Insufficient data Not supported Not supported Not supported Not supported Insufficient data Insufficient data Insufficient data Not supported Insufficient data Insufficient data Selected efficacy Selected efficacy rr Elllcaclous Insufficient data
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Both types of nutrition services are needed in this setting: nutrition education and nutrition therapy. A registered dietitian should be available to serve as a consultant to health professionals providing basic nutrition education and follow-up, as well as to provide nutrition therapy, when indicated, directly to Medicare beneficiaries being cared for in a home setting.
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The adequate provision of services and the staffing of appropriately credentialed nutrition professionals in home care are essential for the training and education of home health nurses and nurses aides so that they may adequately provide appropriate basic nutrition screening and other services. In addition, nutrition professionals should provide nutrition therapy directly to homebound patients when indicated.
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As Medicare shifts to a prospective payment system for skilled nursing and long-term care facilities, the nutrition services provided must not be compromised, but should be improved beyond the current pattern of practice. Some states require that long-term care facilities employ dietitians for so little time (8 hours per month)
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with diagnosis-specific utilization rates ranging from 5 to 30 percent. Some of these costs will be passed on to Medicare beneficiaries through associated premium increases.
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Basic nutrition advice for healthy living and the primary prevention of disease can often be provided by a multitude of health care professionals who have had less extensive academic preparation in nutrition science and/or clinical training than a registered dietitian. This is not considered a service that should be a separately covered benefit to Medicare beneficiaries.
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U.S. Preventive Services Task Force.
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Medicare beneficiaries covered by health maintenance organizations (HMO) may be eligible for additional preventive and other services, sometimes by paying an additional premium, but HMOs vary greatly in the extent to which they-offer benefits not required by Medicare (Kaiser Family Foundation, 1998~.
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