- Email: [email protected]
Registered Dietitian Nutritionists Bring Value to Emerging Health Care Delivery Models
FROM THE ACADEMY
Registered Dietitian Nutritionists Bring Value to Emerging Health Care Delivery Models Bonnie T. Jortberg, PhD, RD; Michael O. Fleming, MD, FAAFP ABSTRACT Health care in the United States is the most expensive in the world; however, most citizens do not receive quality care that is comprehensive and coordinated. To address this gap, the Institute for Healthcare Improvement developed the Triple Aim (ie, improving population health, improving the patient experience, and reducing costs), which has been adopted by patient-centered medical homes and accountable care organizations. The patient-centered medical home and other population health models focus on improving the care for all people, particularly those with multiple morbidities. The Joint Principles of the Patient-Centered Medical Home, developed by the major primary care physician organizations in 2007, recognizes the key role of the multidisciplinary team in meeting the challenge of caring for these individuals. Registered dietitian nutritionists (RDNs) bring value to this multidisciplinary team by providing care coordination, evidence-based care, and quality-improvement leadership. RDNs have demonstrated efficacy for improvements in outcomes for patients with a wide variety of medical conditions. Primary care physicians, as well as several patient-centered medical home and population health demonstration projects, have reported the benefits of RDNs as part of the integrated primary care team. One of the most significant barriers to integrating RDNs into primary care has been an insufficient reimbursement model. Newer innovative payment models provide the opportunity to overcome this barrier. In order to achieve this integration, the Academy of Nutrition and Dietetics and RDNs must fully understand and embrace the opportunities and challenges that the new health care delivery and payment models present, and be prepared and empowered to lead the necessary changes. All stakeholders within the health care system need to more fully recognize and embrace the value and multidimensional role of the RDN on the multidisciplinary team. The Academy’s Patient-Centered Medical Home/Accountable Care Organizations Workgroup Report provides a framework for the Academy, its members, and key partners to use to achieve this goal. J Acad Nutr Diet. 2014;114:2017-2022.
T
HE ULTIMATE GOAL OF ALL health care is meeting the needs of the individual patient. In a world of limited resources, viewed through the lens of a changing population, rapid advances in knowledge, and increasingly complex needs, the concept of value—quality outcomes relative to costs (see Figure)—becomes paramount. This white paper defines the role of the registered dietitian nutritionist (RDN) in achieving value in the context of several of the new payment models. Health care in the United States is the most expensive in the world, accounting for 17% of the gross national product, and estimates put that percentage to 20% by 2020.1 Although the United States spends a significant amount of money on health care, most of our citizens do not receive quality care that is comprehensive and coordinated. To 2212-2672/Copyright ª 2014 by the Academy of Nutrition and Dietetics. http://dx.doi.org/10.1016/j.jand.2014.08.025
ª 2014 by the Academy of Nutrition and Dietetics.
address this gap, the Institute for Healthcare Improvement developed the Triple Aim—defined as simultaneously improving population health, improving the patient experience of care, and reducing per-capita cost—as a goal for new health systems that contribute to the overall health of populations while reducing costs.1 Both the patientcentered medical home (PCMH) and the concept of the accountable care organization (ACO) have adopted the Triple Aim as a fundamental notion in improving health care.
Considering the complexities of providing quality care and meeting patients’ health care needs, it is difficult to imagine any clinician providing care in isolation. The incorporation of multiple perspectives of various disciplines offers the benefit of diverse knowledge and experience. Therefore, a high-performing multidisciplinary team is now widely recognized as an essential tool for constructing a more patient-centered, coordinated, and effective health care delivery system.2
THE PCMH AND ACO All registered dietitians are nutritionists, but not all nutritionists are registered dietitians. The Academy’s Board of Directors and Commission on Dietetic Registration have determined that those who hold the credential Registered Dietitian (RD) may optionally use “Registered Dietitian Nutritionist” (RDN) instead. The two credentials have identical meanings. In this document, the term RDN is used to refer to both registered dietitians and registered dietitian nutritionists.
The concept of patient-centeredness was identified as one of the six aims of quality in the Institute of Medicine’s 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Approved August 2014 by the Coding and Coverage Committee of the Academy of Nutrition and Dietetics and the PCMH/ ACO Workgroup of the Coding and Coverage Committee.
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FROM THE ACADEMY Value ¼
Quality Outcomesa Costsb
a
Person’s needs and goals met. Not just dollar costs, but also reputational costs and market share.
b
Figure. Definition of “value” in health care. Century.3 The Institute of Medicine stated that patient-centeredness is defined as “providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.” In 2002, a group of national family medicine organizations launched The Future of Family Medicine Project. This project culminated with the publication of “The Future of Family Medicine: A Collaborative Project of the Family Medicine Community.”4 The final recommendations of this report would prove to be prescient, recognizing the needs of the American population in a changing world. It stated: “The leadership of US family medicine organizations is committed to a transformative process. In partnership with others, this process has the potential to integrate health care to improve the health of all Americans. This process should include taking steps to ensure that every American has a personal medical home.” Following in the footsteps of this report, the American College of Physicians published a policy paper, “The Advanced Medical Home: A PatientCentered, Physician-Guided Model of Health Care” 5 that proposed fundamental changes in the way primary care is delivered. The PCMH is a philosophy of primary care that is focused on the individual. It delivers comprehensive, team-based, coordinated, and accessible care, and it continually strives toward the six aims of quality. It is a philosophy of health care delivery that encourages providers and care teams to work together to meet the needs of the individual and their families, where people are treated with respect, dignity, and compassion, and enable strong and trusting relationships with all members of the care team. Above all, the medical home is not a final destination; instead, it is a model for achieving primary care excellence. The 2018
medical neighborhood is an important part of the PCMH, as it includes other health care services for the patient, including the RDN, community and social service organizations, and state and local public health agencies. The goals of improving population health and managing costs have been consistent across countries and populations. There is a strong correlation between primary care and population health. Several studies have compared primary care internationally and within the United States. These have provided evidence of the benefits of strong primary care, in terms of better opportunities to control costs, improved quality of care, better population health, and less socioeconomic inequality in health.6-8 Studies have shown that regions with a higher primary care physician density, but not a higher specialist density, have a healthier population than regions with a higher specialist and lower primary care physician density.9-11 Both the structure of care and the coordination and comprehensiveness of primary care have a positive relationship with health outcomes for individuals with chronic disease, such as ischemic heart disease, cerebrovascular disease, diabetes, asthma, bronchitis, and emphysema. ACOs are essentially defined as a coalescence of providers who are jointly held accountable for achieving measured quality improvements and reductions in the rate of spending growth for a defined population of patients.12 These health care organizations may involve a variety of provider configurations, ranging from integrated delivery systems and primary care medical groups to hospital-based systems and virtual networks of physicians, such as independent practice associations. RDNs are active and valuable resources within and for these systems. Many of these ACOs encompass primary care practices that are recognized as PCMHs. With the enactment of the Patient Protection and Affordable Care Act of 2010 (the Patient Protection and Affordable Care Act of 2010 includes a number of provisions that establish ACOs in Medicare and other federal programs and that encourage public-private collaboration for accountable care. These include a “shared savings” accountable care program in Section 3022 and
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
additional flexibility for implementing accountable care in Section 10307),13 the concept of ACOs as an alternative to the current volume-based system now has the official imprimatur of health reform. Consumers and health care professionals alike have anticipated change in both the effectiveness and clinical efficiency of a damaged system. However, despite some encouraging reports, to date the ACOs have not demonstrated the significant savings originally envisioned.14 Regardless of the outcomes of ACOs in particular, the overall concept of population health management remains critical to the success of achieving the Triple Aim. Concomitant to this goal, teams that include RDNs must be part of any care-delivery strategy focused on managing the health of populations. Implementation of ACOs is likely to be more effective if it can be aligned with a range of other reforms that also increase the emphasis on and support for improving quality and reducing costs. This is particularly true for primary careeoriented reforms, such as the PCMH.12
ROLE OF THE PRIMARY CARE PHYSICIAN The Joint Principles of the PatientCentered Medical Home,15 as adopted by the Patient-Centered Primary Care Collaborative, includes the following principles:
The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients. The personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care, chronic care, preventive services, and end-oflife care. Care is coordinated and/or integrated across all elements of the complex health care system (eg, nutrition services, subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (eg, December 2014 Volume 114 Number 12
FROM THE ACADEMY family, public, and private community-based services). Therefore, the ultimate expression of this philosophy of care is an integrated care team led by a primary care physician whose role is to meet all of the health care needs of each person for whom they care by coordinating this care across the multiple sites and disciplines. One way to view this philosophy is as a “solar system” that places the person in the center. There may be a number of satellites in motion in the system, some moving in and out based on need, but the care team of the PCMH is in a permanent “orbit” around that center, with the trajectory and radius of that orbit defined by the individual person’s needs. As the individual ages or develops chronic diseases, the orbit and the makeup of the team change to meet the needs. However, the central premise is to always meet these patient-specific needs. This vision of an integrated team requires careful coordination and inclusion of the right health care professional to provide the right care for the patient. However, challenges exist. According to the Association of American Medical College’s Center for Workforce Studies, by 2010 there will be 45,000 too few primary care physicians.16 This looming shortage shines the spotlight on the other members of this team, and suggests the notion of effectively expanding the new model team to include other health care professionals, such as RDNs. In order to achieve the full value of the PCMH, each member of this team must be fully utilized to the extent of their training and license.
ROLE OF THE RDN The PCMH model of care emphasizes an integrated team approach to care, and that care is comprehensive and coordinated. The Medical Home Policy Statement calls for comprehensive health care that includes several nutrition-related services, including, “provision of primary care, including but not restricted to acute and chronic care and preventive services.”17 Many of the PCMH demonstration projects have focused on improving the care and outcomes for their patients with multiple morbidity, particularly for December 2014 Volume 114 Number 12
patients with type 2 diabetes and cardiovascular disease risk.18 In addition, primary care physicians report seeing the benefit of including RDNs as part of their health care teams, and studies have shown that physicians believe that nutrition is important for the care of their patients, yet they feel inadequately trained to provide optimal nutrition counseling.19 The Commission on Dietetic Registration defines the RDN as an individual who has met current minimum academic requirements with successful completion of both specified didactic education and supervised-practice experiences through programs accredited by the Accreditation Council for Education in Nutrition and Dietetics of the Academy of Nutrition and Dietetics and who has successfully completed the Registration Examination for Dietitians. To maintain the credential, the RDN must comply with continuing professional education requirements.20 RDNs have demonstrated efficacy through medical nutrition therapy (MNT) for improving health outcomes for type 2 diabetes, weight management, disorders of lipid metabolism, and hypertension,21 yet few RDNs are included as an integrated part of the PCMH model in primary care. Based on the outcomes and value of MNT for patients with multiple morbidities, PCMH primary care practices are not truly offering comprehensive care unless their health care team includes an RDN. A recent study conducted by the Pennsylvania Chronic Care Initiative showed that high-risk patients enrolled in nonpediatric primary care practices that adopted the PCMH model had significantly lower per-member, per-month medical costs and utilization per 1,000 members compared with nonePCMH practices.22 High-risk patients enrolled in the PCMH practices received care management services, which were often provided by an RDN, and included self-management support and goal monitoring. Canada offers an example of the value of including RDNs as part of integrated, patient-focused health care teams. The Canadian health care system in Ontario has been examining the implementation of “family health teams” into primary care.23 The family health team is an approach to primary health care that brings together
different health care providers to coordinate the highest possible quality of care for the patients. The family health team consists of physicians, nurses, nurse practitioners, social workers, RDNs, and other health care workers. The goal is for the entire family health team to work collaboratively with each other utilizing their experience and skills so that the patient receives the best care. Currently, there are 185 family health teams serving >3 million people in >200 communities across Ontario. A recent publication reviewing the current knowledge regarding family health team functioning found that patients and providers described improved health care access, greater satisfaction, and enhanced quality of health care using the family health team approach.23 In the United States, the Affordable Care Act’s Title III Section 3502 includes provisions specifically for the formation of community health teams to support the PCMH.24 The Affordable Care Act defines a community health team as “an interdisciplinary, interprofessional team of health care providers” and “may include medical specialists, nurses, pharmacists, dietitians, social workers, behavioral and mental health providers, doctors of chiropractic, licensed complementary and alternative medicine practitioners, and physicians’ assistants.” Some states, including North Carolina and Vermont, implemented programs that included the core principles of community health teams before the Affordable Care Act. Vermont implemented the Department of Health’s Blueprint for Health program, with goals to enhance high-quality preventive health care and for better management of chronic diseases.25 RDNs worked with patients who have diabetes and other patients who needed nutrition education and support.25 North Carolina implemented Community Care of North Carolina, an original pilot of eight networks of Medicaid beneficiaries, with the goal to provide primary care case management to improve quality of care.26 The network has been expanded to 14 networks, with each network employing a medical director, network manager, clinical care manager supervisor, care managers (including RDNs), pharmacists, and a psychiatrist. Preliminary results indicate that Community Care of North
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FROM THE ACADEMY Carolina saved $60 million in state fiscal year 2003, $124 million in state fiscal year 2004, and $231 million in state fiscal years 2005-2006, and health outcomes improved for patients with asthma and type 2 diabetes. Ongoing results from these two initiatives, and others like them, will be important to monitor, particularly around the role of the RDN. What does the PCMH mean for the RDN? For one, the data suggest that RDNs need to be an integrated and valued member of the PCMH team. RDNs have the knowledge, skills, and training to contribute to person-centered care by assuming a wide variety of roles and responsibilities. Specifically:
the RDN is an integrated part of the primary care team, providing MNT, patient self-management support, and care management services; the RDN is participating on the health care team and providing comprehensive and coordinated care for the patient; the RDN is managing diseaseprevention services and outreach to the practice’s patient population; the RDN is participating (and leading) continuous qualityimprovement efforts within the primary care practice; and the RDN is measuring and reporting on quality and effectiveness.
New Payment Models A barrier to the integration of the RDN into primary care has been an insufficient reimbursement model. The typical fee-for-service model only allows the RDN to bill for episodic MNT visits, often for limited diagnoses, despite evidence to support the effectiveness of MNT for a wide variety of medical conditions. Traditionally, reimbursement for noneface-to-face patient contact as well as care management services has been limited or nonexistent, although we are beginning to see third-party payers recognizing the value of such services in helping to achieve the Triple Aim. Several of the PCMH demonstration projects have implemented innovative payment models to allow for practices 2020
to provide the comprehensive and coordinated care that is not typically covered with fee for service. Several demonstration project payers offered a per-member, per-month payment to the practices to allow for nonevisitrelated services, such as proactive outreach and care management services, including self-management. The per-member, per-month payment model is an opportunity to integrate the RDN into the person-centered primary care team. The results from this payment model have been very positive, particularly for high-risk patients, as described in the Pennsylvania study.22 In addition, bundled payments, shared savings, and quality incentive programs offer other nonefee-for-service methods for covering nutrition services as the RDN contributes to improved outcomes and lower costs of care. Based on the results from PCMH demonstration projects, the Center for Medicare and Medicaid Innovation initiated the Comprehensive Primary Care Initiative in seven states and regions in 2012.27 The Comprehensive Primary Care Initiative is testing a different delivery model and primary care compensation structure with the goal of driving improvements for health care quality and financial outcomes. The aim of the Comprehensive Primary Care Initiative is to provide better health, better care, and lowered cost through practice improvement and payment reform. The payment model for the Comprehensive Primary Care Initiative is a blended one that includes fee for service; risk adjusted, per member, per month; and shared savings. Providers participating in the Comprehensive Primary Care Initiative are expected to incorporate five functions of primary care: managing care for patients with high health care needs, ensuring access to care, delivering preventive care, engaging patients and caregivers, and coordinating care across the medical neighborhood. The RDN’s skill set addresses most of the five functions for the Comprehensive Primary Care Initiative and inclusion of the RDN as part of the primary care team will be essential for the success of this initiative. At the onset of this initiative, few of the Comprehensive Primary Care Initiative practices are changing their typical staffing models to include the new model for care and, as such, the Comprehensive
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Primary Care Initiative may not be able to deliver comprehensive, coordinated care to patients at a sustainable cost.28 However, this is an opportunity for the RDN to be an essential part of the Comprehensive Primary Care Initiative, as the cost-effectiveness data support the value of the RDN. Significant change has occurred in the decade-plus since the initiation of the Future of Family Medicine project. In particular, there has been the implementation of new models of care, including the PCMH. As such, the American Academy of Family Physicians has convened a working party to respond to the changing health care landscape and revisit the Future of Family Medicine project. The working party will be focusing on changing payment models and making recommendations to move away from fee for service and toward a value-based payment structure. If this happens, RDNs will need to be ready to respond and integrate as part of a primary care health care team.
CALL TO ACTION We believe that in order to meet the needs of a population that is changing, with older individuals who have more chronic diseases, the composition and roles of the person-centered care team needs to change. With these changes, the role of the RDN in providing MNT will become even more crucial for effective management of this population. All stakeholders within the health care system need to more fully recognize and embrace the value and multidimensional role of the RDN on this team. To encourage the true meaning of the Joint Principles of the PatientCentered Medical Home, the Academy of Nutrition and Dietetics asserts a new set of goals for the PCMH and other population health management models of care:
“Patient-centered care” should mean person-centered care. As a patient, one is defined by a diagnosis rather than by their needs. Whereas a diagnosis may call for certain treatment modalities, personhood calls for recognition of not only diagnoses, but also of social, emotional, spiritual, and other needs. The importance December 2014 Volume 114 Number 12
FROM THE ACADEMY
of the team focus on the person cannot be overstated. Team care can only be achieved by a highly functioning group of professionals who are skilled in their own discipline and work cooperatively to coordinate efforts to meet the person’s needs. RDNs play an important role in care for many acute and almost all chronic diseases. In addition, these professionals can be invaluable in asserting the principles of preventive care that all health care champions. RDNs are considered an essential and valued member of the primary care team and the PCMH and other population health management models of care include nutrition and lifestyle management as a primary tenet. The role of the RDN is essential in the PCMH’s “orbits” for patients. RDNs have demonstrated value and efficacy for improved patient outcomes throughout the cycle of life, including prenatal nutrition, child and adolescent nutrition, as well as chronic disease, such as type 2 diabetes, weight management, disorders of lipid metabolism, and hypertension manifested in adults and seniors. The education and training of all physicians and RDNs should incorporate participation in multidisciplinary care teams consisting of professionals skilled in management of special aspects of care. Paramount in this training is the integration and coordination of care with sharing of information and collaboration of all aspects of the patient’s care. RDNs are proactive in their communities to promote nutrition services as an essential and valued part of the PCMH and population health management models of care.
necessary to integrate the RDN into the permanent orbit of the patient. RDNs are qualified to perform expanding roles essential to person-centered care that include case-management and quality-improvement leadership. Of immediate importance is defining and validating the value proposition RDNs represent to patients across the continuum. Responding to the emergence of the PCMH and population health models of care, in 2013 the Academy convened a Patient-Centered Medical Home/Accountable Care Organization Workgroup, as a subgroup of the Coding and Coverage Committee. The charge to this group was to develop recommendations for Academy leadership to advance the role of RDNs in the PCMH/population health management models of care, develop an Academy strategy for engaging members to become involved with the opportunities within the PCMH/population health management models of care, and identify new resources for member education about the PCMH/ population health management, with the ultimate goal of positioning the RDN as an integral part of these emerging models. Their final report, the “PCMH/Population Health Management Models Workgroup Report” (available at www.eatright.org/ coverage), was published in June 2014 and defines five specific strategies: 1.
Advocacy: Impact federal, state, and local laws and regulations to support inclusion of and payment for RDN-provided services in the PCMH/population health management models of care.
2.
Positioning: Demonstrate to decision makers the value of RDN participation in the PCMH/ population health management models as the team member to optimize health through food and nutrition; and drive and support activities of state affiliates and Dietetic Practice Groups to promote the RDN’s value as part of the PCMH/ population health management model. Collaboration: Leverage existing and new partnerships to demonstrate to decision makers the value of RDN participation
Next Steps It is imperative that the Academy and RDNs fully understand and embrace the opportunities and challenges that the new health care delivery and payment models present, and be prepared and empowered to lead changes December 2014 Volume 114 Number 12
3.
4.
5.
in the PCMH/population health management models. Development: Empower current and future RDNs to advocate for inclusion in the PCMH and population health management models as the team member to optimize health through food and nutrition; and incorporate the PCMH/population health management model in all applicable aspects of dietetics education programs to prepare faculty/students to understand and participate in these models of care. Resources: Provide Academy resources to enhance current and future RDNs’ knowledge, skills, and involvement as proactive participants in the PCMH and population health management care team.
Specific tactics for each strategy are detailed in the report, along with additional recommendations. This report provides a framework for the Academy, members, and key partners to understand the value and importance of integration of the RDN into these delivery and payment models. The overall health of our population depends on the nutrition community taking action and providing coordinated and comprehensive care that focuses on the needs of the individual. RDNs are uniquely experienced and positioned to be one of the critical health care professionals in our US health care model of today and the future. Building on the efforts of the Academy and RDNs, decision makers within health care delivery and payment, both in the public and private sectors, must create policies and systems that recognize the contributions of RDNs toward achieving the Triple Aim.
References 1.
Berwick D, Nolan T, Whittington J. The Triple Aim: Care, cost, and quality. Health Affairs. 2008;27(3):759-769.
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Mitchell P, Wynia M, Golden R, et al. Core principles & values of effective team-based health care. Discussion Paper. Washington, DC: Institute of Medicine. www.iom. edu/tbc. Accessed April 15, 2014.
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The Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: Institute of Medicine; March 2001.
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FROM THE ACADEMY 4.
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Martin JC, Avant RF, Bowman MA, et al. The future of family medicine: A collaborative project of the family medicine community. Ann Fam Med. 2004;(2 suppl 1):S3-S32. American College of Physicians. The Advanced Medical Home: A PatientCentered, Physician-Guided Model of Health Care. http://www.acponline.org/ advocacy/current_policy_papers/assets/ adv_med.pdf. Accessed April 15, 2014.
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Starfield B. Is primary care essential? Lancet. 1994;344(8930):1129-1133.
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Delnoij D, Van Merode G, Paulus A, Groenewegen P. Does general practitioner gatekeeping curb health care expenditure? J Health Serv Res Pol. 2000; 5(1):22-26.
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Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970-1998. Health Serv Res. 2003;38(3):831-865.
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Friedberg MW, Coltin KL, Pearson SD, Kleinman KP, Zheng J, Singer JA. Does affiliation of physician groups with one another produce higher quality primary care? J Gen Intern Med. 2007;22(10): 1385-1392.
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Sans-Corrales M, Pujol-Ribera E, GeneBadia J, Pasarin-Rua MI, Iglesias-Perez B, Casajuana-Brunet J. Family medicine attributes related to satisfaction, health, and costs. Fam Pract. 2006;23(3):308-316.
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Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457502.
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McClellan M, McKethan AN, Lewis JL, Roski J, Fisher ES. A national strategy to put accountable care into practice. Health Aff (Millwood). 2010;29(5):982-990.
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Patient Protection and Affordable Care Act, 42 U.S.C. § 18001 (2010). Mostashari F, Sanghavi D, McClellan M. Health Reform and physician-led accountable care: The paradox of primary care physician leadership. JAMA. 2014;311(18): 1855-1856.
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The Joint Principles of the PatientCentered Medical Home. http://www. aafp.org/dam/AAFP/documents/practice_ management/pcmh/initiatives/PCMHJoint. pdf. Accessed April 17, 2014.
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Association of American Medical Colleges, Center for Workforce Studies. Physician Shortages to Worsen Without Increases in Residency Training. June 2010. https:// www.aamc.org/download/153160/data/ physician_shortages_to_worsen_without_ increases_in_residency_tr.pdf. Accessed June 2, 2014.
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Kahn RF. Continuing medical education in nutrition. Am J Clin Nutr. 2006;83:981S-984S.
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Patient-centered medical home cost and quality results, 2010-2013. PatientCentered Primary Care Collaborative. http://www.pcpcc.org/resource/summarypatient-centered-medical-home-cost-andquality-results-2010-e-2013. Accessed June 12, 2014.
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Adams KM, Lindell KC, Kohlmeier M, Zeisel SH. Status of nutrition education in medical schools. Am J Clin Nutr. 2006; 83(4):9441S-9944S.
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Academy of Nutrition and Dietetics. Definitions of terms list. http://www.eatright. org/HealthProfessionals/content.aspx?id_ 6866. Accessed June 12, 2014.
21.
Academy of Nutrition and Dietetics Evidence Analysis Library. What is the evidence to support the cost-effectiveness, cost benefit or economic savings of outpatient MNT services provided by an RDN? http://
andevidencelibrary.com/conclusion.cfm? conclusion_statement_id¼251001&high light¼MNT%20for%20weight%20manage ment%20diabetes&home¼1. Accessed June 14, 2014. 22.
Wang QC, Chawla R, Colombo CM, Snyder RL, Nigam S. Patient-centered medical home impact on health plan members with diabetes. J Public Health Manage Pract. 2014;20(5):E12E20.
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Rosser WW, Colwill JM, Kasperski J, Wilson L. Progress of Ontario’s family health team model: A patient-centered medical home. Ann Fam Med. March/April 2011;9(2):165171.
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Office of the Legislative Counsel. Compilation of Patient Protection and Affordable Care Act. http://docs.house.gov/energy commerce/ppacacon.pdf. Published May 2010. Accessed May 15, 2014.
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Bielaszka-DuVernay C. Vermont’s Blueprint for medical homes, community health teams, and better health at lower cost. Health Aff (Millwood). 2011;30(3): 383-386.
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Community Care of North Carolina—Program impact. http://www.communitycarenc.com/ our-results/. Accessed June 20, 2014.
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Centers for Medicare and Medicaid Innovation. Fact Sheet. Comprehensive Primary Care Initiative. http://innovation.cms.gov/ Files/fact-sheet/Comprehensive-PrimaryCare-Initiative-Fact-Sheet.pdf. Accessed June 12, 2014.
28.
Peikes DN, Reid RJ, Day TJ, et al. Staffing patterns of primary care practices in the comprehensive primary care initiative. Ann Fam Med. 2014;12(2): 142-149.
AUTHOR INFORMATION B. T. Jortberg is an assistant professor, Department of Family Medicine, University of Colorado School of Medicine, Aurora. M. O. Fleming is chief medical officer, Amedisys, Inc, Baton Rouge, LA; clinical assistant professor of family medicine, Louisiana State University, School of Medicine, Shreveport; and clinical assistant professor of family and community medicine, Tulane University Medical School, New Orleans, LA. Address correspondence to: Bonnie T. Jortberg, PhD, RD, Department of Family Medicine, University of Colorado School of Medicine, 12631 E 17th Ave, Mail Stop F496, Aurora, CO 80045-0508. E-mail: [email protected]
STATEMENT OF POTENTIAL CONFLICT OF INTEREST No potential conflict of interest was reported by the authors.
FUNDING/SUPPORT There is no funding to disclose.
2022
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Registered Dietitian Nutritionists Bring Value to Emerging Health Care Delivery Models Bonnie T. Jortberg, PhD, RD; Michael O. Fleming, MD, FAAFP ABSTRACT Health care in the United States is the most expensive in the world; however, most citizens do not receive quality care that is comprehensive and coordinated. To address this gap, the Institute for Healthcare Improvement developed the Triple Aim (ie, improving population health, improving the patient experience, and reducing costs), which has been adopted by patient-centered medical homes and accountable care organizations. The patient-centered medical home and other population health models focus on improving the care for all people, particularly those with multiple morbidities. The Joint Principles of the Patient-Centered Medical Home, developed by the major primary care physician organizations in 2007, recognizes the key role of the multidisciplinary team in meeting the challenge of caring for these individuals. Registered dietitian nutritionists (RDNs) bring value to this multidisciplinary team by providing care coordination, evidence-based care, and quality-improvement leadership. RDNs have demonstrated efficacy for improvements in outcomes for patients with a wide variety of medical conditions. Primary care physicians, as well as several patient-centered medical home and population health demonstration projects, have reported the benefits of RDNs as part of the integrated primary care team. One of the most significant barriers to integrating RDNs into primary care has been an insufficient reimbursement model. Newer innovative payment models provide the opportunity to overcome this barrier. In order to achieve this integration, the Academy of Nutrition and Dietetics and RDNs must fully understand and embrace the opportunities and challenges that the new health care delivery and payment models present, and be prepared and empowered to lead the necessary changes. All stakeholders within the health care system need to more fully recognize and embrace the value and multidimensional role of the RDN on the multidisciplinary team. The Academy’s Patient-Centered Medical Home/Accountable Care Organizations Workgroup Report provides a framework for the Academy, its members, and key partners to use to achieve this goal. J Acad Nutr Diet. 2014;114:2017-2022.
T
HE ULTIMATE GOAL OF ALL health care is meeting the needs of the individual patient. In a world of limited resources, viewed through the lens of a changing population, rapid advances in knowledge, and increasingly complex needs, the concept of value—quality outcomes relative to costs (see Figure)—becomes paramount. This white paper defines the role of the registered dietitian nutritionist (RDN) in achieving value in the context of several of the new payment models. Health care in the United States is the most expensive in the world, accounting for 17% of the gross national product, and estimates put that percentage to 20% by 2020.1 Although the United States spends a significant amount of money on health care, most of our citizens do not receive quality care that is comprehensive and coordinated. To 2212-2672/Copyright ª 2014 by the Academy of Nutrition and Dietetics. http://dx.doi.org/10.1016/j.jand.2014.08.025
ª 2014 by the Academy of Nutrition and Dietetics.
address this gap, the Institute for Healthcare Improvement developed the Triple Aim—defined as simultaneously improving population health, improving the patient experience of care, and reducing per-capita cost—as a goal for new health systems that contribute to the overall health of populations while reducing costs.1 Both the patientcentered medical home (PCMH) and the concept of the accountable care organization (ACO) have adopted the Triple Aim as a fundamental notion in improving health care.
Considering the complexities of providing quality care and meeting patients’ health care needs, it is difficult to imagine any clinician providing care in isolation. The incorporation of multiple perspectives of various disciplines offers the benefit of diverse knowledge and experience. Therefore, a high-performing multidisciplinary team is now widely recognized as an essential tool for constructing a more patient-centered, coordinated, and effective health care delivery system.2
THE PCMH AND ACO All registered dietitians are nutritionists, but not all nutritionists are registered dietitians. The Academy’s Board of Directors and Commission on Dietetic Registration have determined that those who hold the credential Registered Dietitian (RD) may optionally use “Registered Dietitian Nutritionist” (RDN) instead. The two credentials have identical meanings. In this document, the term RDN is used to refer to both registered dietitians and registered dietitian nutritionists.
The concept of patient-centeredness was identified as one of the six aims of quality in the Institute of Medicine’s 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Approved August 2014 by the Coding and Coverage Committee of the Academy of Nutrition and Dietetics and the PCMH/ ACO Workgroup of the Coding and Coverage Committee.
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FROM THE ACADEMY Value ¼
Quality Outcomesa Costsb
a
Person’s needs and goals met. Not just dollar costs, but also reputational costs and market share.
b
Figure. Definition of “value” in health care. Century.3 The Institute of Medicine stated that patient-centeredness is defined as “providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.” In 2002, a group of national family medicine organizations launched The Future of Family Medicine Project. This project culminated with the publication of “The Future of Family Medicine: A Collaborative Project of the Family Medicine Community.”4 The final recommendations of this report would prove to be prescient, recognizing the needs of the American population in a changing world. It stated: “The leadership of US family medicine organizations is committed to a transformative process. In partnership with others, this process has the potential to integrate health care to improve the health of all Americans. This process should include taking steps to ensure that every American has a personal medical home.” Following in the footsteps of this report, the American College of Physicians published a policy paper, “The Advanced Medical Home: A PatientCentered, Physician-Guided Model of Health Care” 5 that proposed fundamental changes in the way primary care is delivered. The PCMH is a philosophy of primary care that is focused on the individual. It delivers comprehensive, team-based, coordinated, and accessible care, and it continually strives toward the six aims of quality. It is a philosophy of health care delivery that encourages providers and care teams to work together to meet the needs of the individual and their families, where people are treated with respect, dignity, and compassion, and enable strong and trusting relationships with all members of the care team. Above all, the medical home is not a final destination; instead, it is a model for achieving primary care excellence. The 2018
medical neighborhood is an important part of the PCMH, as it includes other health care services for the patient, including the RDN, community and social service organizations, and state and local public health agencies. The goals of improving population health and managing costs have been consistent across countries and populations. There is a strong correlation between primary care and population health. Several studies have compared primary care internationally and within the United States. These have provided evidence of the benefits of strong primary care, in terms of better opportunities to control costs, improved quality of care, better population health, and less socioeconomic inequality in health.6-8 Studies have shown that regions with a higher primary care physician density, but not a higher specialist density, have a healthier population than regions with a higher specialist and lower primary care physician density.9-11 Both the structure of care and the coordination and comprehensiveness of primary care have a positive relationship with health outcomes for individuals with chronic disease, such as ischemic heart disease, cerebrovascular disease, diabetes, asthma, bronchitis, and emphysema. ACOs are essentially defined as a coalescence of providers who are jointly held accountable for achieving measured quality improvements and reductions in the rate of spending growth for a defined population of patients.12 These health care organizations may involve a variety of provider configurations, ranging from integrated delivery systems and primary care medical groups to hospital-based systems and virtual networks of physicians, such as independent practice associations. RDNs are active and valuable resources within and for these systems. Many of these ACOs encompass primary care practices that are recognized as PCMHs. With the enactment of the Patient Protection and Affordable Care Act of 2010 (the Patient Protection and Affordable Care Act of 2010 includes a number of provisions that establish ACOs in Medicare and other federal programs and that encourage public-private collaboration for accountable care. These include a “shared savings” accountable care program in Section 3022 and
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additional flexibility for implementing accountable care in Section 10307),13 the concept of ACOs as an alternative to the current volume-based system now has the official imprimatur of health reform. Consumers and health care professionals alike have anticipated change in both the effectiveness and clinical efficiency of a damaged system. However, despite some encouraging reports, to date the ACOs have not demonstrated the significant savings originally envisioned.14 Regardless of the outcomes of ACOs in particular, the overall concept of population health management remains critical to the success of achieving the Triple Aim. Concomitant to this goal, teams that include RDNs must be part of any care-delivery strategy focused on managing the health of populations. Implementation of ACOs is likely to be more effective if it can be aligned with a range of other reforms that also increase the emphasis on and support for improving quality and reducing costs. This is particularly true for primary careeoriented reforms, such as the PCMH.12
ROLE OF THE PRIMARY CARE PHYSICIAN The Joint Principles of the PatientCentered Medical Home,15 as adopted by the Patient-Centered Primary Care Collaborative, includes the following principles:
The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients. The personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care, chronic care, preventive services, and end-oflife care. Care is coordinated and/or integrated across all elements of the complex health care system (eg, nutrition services, subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (eg, December 2014 Volume 114 Number 12
FROM THE ACADEMY family, public, and private community-based services). Therefore, the ultimate expression of this philosophy of care is an integrated care team led by a primary care physician whose role is to meet all of the health care needs of each person for whom they care by coordinating this care across the multiple sites and disciplines. One way to view this philosophy is as a “solar system” that places the person in the center. There may be a number of satellites in motion in the system, some moving in and out based on need, but the care team of the PCMH is in a permanent “orbit” around that center, with the trajectory and radius of that orbit defined by the individual person’s needs. As the individual ages or develops chronic diseases, the orbit and the makeup of the team change to meet the needs. However, the central premise is to always meet these patient-specific needs. This vision of an integrated team requires careful coordination and inclusion of the right health care professional to provide the right care for the patient. However, challenges exist. According to the Association of American Medical College’s Center for Workforce Studies, by 2010 there will be 45,000 too few primary care physicians.16 This looming shortage shines the spotlight on the other members of this team, and suggests the notion of effectively expanding the new model team to include other health care professionals, such as RDNs. In order to achieve the full value of the PCMH, each member of this team must be fully utilized to the extent of their training and license.
ROLE OF THE RDN The PCMH model of care emphasizes an integrated team approach to care, and that care is comprehensive and coordinated. The Medical Home Policy Statement calls for comprehensive health care that includes several nutrition-related services, including, “provision of primary care, including but not restricted to acute and chronic care and preventive services.”17 Many of the PCMH demonstration projects have focused on improving the care and outcomes for their patients with multiple morbidity, particularly for December 2014 Volume 114 Number 12
patients with type 2 diabetes and cardiovascular disease risk.18 In addition, primary care physicians report seeing the benefit of including RDNs as part of their health care teams, and studies have shown that physicians believe that nutrition is important for the care of their patients, yet they feel inadequately trained to provide optimal nutrition counseling.19 The Commission on Dietetic Registration defines the RDN as an individual who has met current minimum academic requirements with successful completion of both specified didactic education and supervised-practice experiences through programs accredited by the Accreditation Council for Education in Nutrition and Dietetics of the Academy of Nutrition and Dietetics and who has successfully completed the Registration Examination for Dietitians. To maintain the credential, the RDN must comply with continuing professional education requirements.20 RDNs have demonstrated efficacy through medical nutrition therapy (MNT) for improving health outcomes for type 2 diabetes, weight management, disorders of lipid metabolism, and hypertension,21 yet few RDNs are included as an integrated part of the PCMH model in primary care. Based on the outcomes and value of MNT for patients with multiple morbidities, PCMH primary care practices are not truly offering comprehensive care unless their health care team includes an RDN. A recent study conducted by the Pennsylvania Chronic Care Initiative showed that high-risk patients enrolled in nonpediatric primary care practices that adopted the PCMH model had significantly lower per-member, per-month medical costs and utilization per 1,000 members compared with nonePCMH practices.22 High-risk patients enrolled in the PCMH practices received care management services, which were often provided by an RDN, and included self-management support and goal monitoring. Canada offers an example of the value of including RDNs as part of integrated, patient-focused health care teams. The Canadian health care system in Ontario has been examining the implementation of “family health teams” into primary care.23 The family health team is an approach to primary health care that brings together
different health care providers to coordinate the highest possible quality of care for the patients. The family health team consists of physicians, nurses, nurse practitioners, social workers, RDNs, and other health care workers. The goal is for the entire family health team to work collaboratively with each other utilizing their experience and skills so that the patient receives the best care. Currently, there are 185 family health teams serving >3 million people in >200 communities across Ontario. A recent publication reviewing the current knowledge regarding family health team functioning found that patients and providers described improved health care access, greater satisfaction, and enhanced quality of health care using the family health team approach.23 In the United States, the Affordable Care Act’s Title III Section 3502 includes provisions specifically for the formation of community health teams to support the PCMH.24 The Affordable Care Act defines a community health team as “an interdisciplinary, interprofessional team of health care providers” and “may include medical specialists, nurses, pharmacists, dietitians, social workers, behavioral and mental health providers, doctors of chiropractic, licensed complementary and alternative medicine practitioners, and physicians’ assistants.” Some states, including North Carolina and Vermont, implemented programs that included the core principles of community health teams before the Affordable Care Act. Vermont implemented the Department of Health’s Blueprint for Health program, with goals to enhance high-quality preventive health care and for better management of chronic diseases.25 RDNs worked with patients who have diabetes and other patients who needed nutrition education and support.25 North Carolina implemented Community Care of North Carolina, an original pilot of eight networks of Medicaid beneficiaries, with the goal to provide primary care case management to improve quality of care.26 The network has been expanded to 14 networks, with each network employing a medical director, network manager, clinical care manager supervisor, care managers (including RDNs), pharmacists, and a psychiatrist. Preliminary results indicate that Community Care of North
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FROM THE ACADEMY Carolina saved $60 million in state fiscal year 2003, $124 million in state fiscal year 2004, and $231 million in state fiscal years 2005-2006, and health outcomes improved for patients with asthma and type 2 diabetes. Ongoing results from these two initiatives, and others like them, will be important to monitor, particularly around the role of the RDN. What does the PCMH mean for the RDN? For one, the data suggest that RDNs need to be an integrated and valued member of the PCMH team. RDNs have the knowledge, skills, and training to contribute to person-centered care by assuming a wide variety of roles and responsibilities. Specifically:
the RDN is an integrated part of the primary care team, providing MNT, patient self-management support, and care management services; the RDN is participating on the health care team and providing comprehensive and coordinated care for the patient; the RDN is managing diseaseprevention services and outreach to the practice’s patient population; the RDN is participating (and leading) continuous qualityimprovement efforts within the primary care practice; and the RDN is measuring and reporting on quality and effectiveness.
New Payment Models A barrier to the integration of the RDN into primary care has been an insufficient reimbursement model. The typical fee-for-service model only allows the RDN to bill for episodic MNT visits, often for limited diagnoses, despite evidence to support the effectiveness of MNT for a wide variety of medical conditions. Traditionally, reimbursement for noneface-to-face patient contact as well as care management services has been limited or nonexistent, although we are beginning to see third-party payers recognizing the value of such services in helping to achieve the Triple Aim. Several of the PCMH demonstration projects have implemented innovative payment models to allow for practices 2020
to provide the comprehensive and coordinated care that is not typically covered with fee for service. Several demonstration project payers offered a per-member, per-month payment to the practices to allow for nonevisitrelated services, such as proactive outreach and care management services, including self-management. The per-member, per-month payment model is an opportunity to integrate the RDN into the person-centered primary care team. The results from this payment model have been very positive, particularly for high-risk patients, as described in the Pennsylvania study.22 In addition, bundled payments, shared savings, and quality incentive programs offer other nonefee-for-service methods for covering nutrition services as the RDN contributes to improved outcomes and lower costs of care. Based on the results from PCMH demonstration projects, the Center for Medicare and Medicaid Innovation initiated the Comprehensive Primary Care Initiative in seven states and regions in 2012.27 The Comprehensive Primary Care Initiative is testing a different delivery model and primary care compensation structure with the goal of driving improvements for health care quality and financial outcomes. The aim of the Comprehensive Primary Care Initiative is to provide better health, better care, and lowered cost through practice improvement and payment reform. The payment model for the Comprehensive Primary Care Initiative is a blended one that includes fee for service; risk adjusted, per member, per month; and shared savings. Providers participating in the Comprehensive Primary Care Initiative are expected to incorporate five functions of primary care: managing care for patients with high health care needs, ensuring access to care, delivering preventive care, engaging patients and caregivers, and coordinating care across the medical neighborhood. The RDN’s skill set addresses most of the five functions for the Comprehensive Primary Care Initiative and inclusion of the RDN as part of the primary care team will be essential for the success of this initiative. At the onset of this initiative, few of the Comprehensive Primary Care Initiative practices are changing their typical staffing models to include the new model for care and, as such, the Comprehensive
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Primary Care Initiative may not be able to deliver comprehensive, coordinated care to patients at a sustainable cost.28 However, this is an opportunity for the RDN to be an essential part of the Comprehensive Primary Care Initiative, as the cost-effectiveness data support the value of the RDN. Significant change has occurred in the decade-plus since the initiation of the Future of Family Medicine project. In particular, there has been the implementation of new models of care, including the PCMH. As such, the American Academy of Family Physicians has convened a working party to respond to the changing health care landscape and revisit the Future of Family Medicine project. The working party will be focusing on changing payment models and making recommendations to move away from fee for service and toward a value-based payment structure. If this happens, RDNs will need to be ready to respond and integrate as part of a primary care health care team.
CALL TO ACTION We believe that in order to meet the needs of a population that is changing, with older individuals who have more chronic diseases, the composition and roles of the person-centered care team needs to change. With these changes, the role of the RDN in providing MNT will become even more crucial for effective management of this population. All stakeholders within the health care system need to more fully recognize and embrace the value and multidimensional role of the RDN on this team. To encourage the true meaning of the Joint Principles of the PatientCentered Medical Home, the Academy of Nutrition and Dietetics asserts a new set of goals for the PCMH and other population health management models of care:
“Patient-centered care” should mean person-centered care. As a patient, one is defined by a diagnosis rather than by their needs. Whereas a diagnosis may call for certain treatment modalities, personhood calls for recognition of not only diagnoses, but also of social, emotional, spiritual, and other needs. The importance December 2014 Volume 114 Number 12
FROM THE ACADEMY
of the team focus on the person cannot be overstated. Team care can only be achieved by a highly functioning group of professionals who are skilled in their own discipline and work cooperatively to coordinate efforts to meet the person’s needs. RDNs play an important role in care for many acute and almost all chronic diseases. In addition, these professionals can be invaluable in asserting the principles of preventive care that all health care champions. RDNs are considered an essential and valued member of the primary care team and the PCMH and other population health management models of care include nutrition and lifestyle management as a primary tenet. The role of the RDN is essential in the PCMH’s “orbits” for patients. RDNs have demonstrated value and efficacy for improved patient outcomes throughout the cycle of life, including prenatal nutrition, child and adolescent nutrition, as well as chronic disease, such as type 2 diabetes, weight management, disorders of lipid metabolism, and hypertension manifested in adults and seniors. The education and training of all physicians and RDNs should incorporate participation in multidisciplinary care teams consisting of professionals skilled in management of special aspects of care. Paramount in this training is the integration and coordination of care with sharing of information and collaboration of all aspects of the patient’s care. RDNs are proactive in their communities to promote nutrition services as an essential and valued part of the PCMH and population health management models of care.
necessary to integrate the RDN into the permanent orbit of the patient. RDNs are qualified to perform expanding roles essential to person-centered care that include case-management and quality-improvement leadership. Of immediate importance is defining and validating the value proposition RDNs represent to patients across the continuum. Responding to the emergence of the PCMH and population health models of care, in 2013 the Academy convened a Patient-Centered Medical Home/Accountable Care Organization Workgroup, as a subgroup of the Coding and Coverage Committee. The charge to this group was to develop recommendations for Academy leadership to advance the role of RDNs in the PCMH/population health management models of care, develop an Academy strategy for engaging members to become involved with the opportunities within the PCMH/population health management models of care, and identify new resources for member education about the PCMH/ population health management, with the ultimate goal of positioning the RDN as an integral part of these emerging models. Their final report, the “PCMH/Population Health Management Models Workgroup Report” (available at www.eatright.org/ coverage), was published in June 2014 and defines five specific strategies: 1.
Advocacy: Impact federal, state, and local laws and regulations to support inclusion of and payment for RDN-provided services in the PCMH/population health management models of care.
2.
Positioning: Demonstrate to decision makers the value of RDN participation in the PCMH/ population health management models as the team member to optimize health through food and nutrition; and drive and support activities of state affiliates and Dietetic Practice Groups to promote the RDN’s value as part of the PCMH/ population health management model. Collaboration: Leverage existing and new partnerships to demonstrate to decision makers the value of RDN participation
Next Steps It is imperative that the Academy and RDNs fully understand and embrace the opportunities and challenges that the new health care delivery and payment models present, and be prepared and empowered to lead changes December 2014 Volume 114 Number 12
3.
4.
5.
in the PCMH/population health management models. Development: Empower current and future RDNs to advocate for inclusion in the PCMH and population health management models as the team member to optimize health through food and nutrition; and incorporate the PCMH/population health management model in all applicable aspects of dietetics education programs to prepare faculty/students to understand and participate in these models of care. Resources: Provide Academy resources to enhance current and future RDNs’ knowledge, skills, and involvement as proactive participants in the PCMH and population health management care team.
Specific tactics for each strategy are detailed in the report, along with additional recommendations. This report provides a framework for the Academy, members, and key partners to understand the value and importance of integration of the RDN into these delivery and payment models. The overall health of our population depends on the nutrition community taking action and providing coordinated and comprehensive care that focuses on the needs of the individual. RDNs are uniquely experienced and positioned to be one of the critical health care professionals in our US health care model of today and the future. Building on the efforts of the Academy and RDNs, decision makers within health care delivery and payment, both in the public and private sectors, must create policies and systems that recognize the contributions of RDNs toward achieving the Triple Aim.
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Berwick D, Nolan T, Whittington J. The Triple Aim: Care, cost, and quality. Health Affairs. 2008;27(3):759-769.
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Sans-Corrales M, Pujol-Ribera E, GeneBadia J, Pasarin-Rua MI, Iglesias-Perez B, Casajuana-Brunet J. Family medicine attributes related to satisfaction, health, and costs. Fam Pract. 2006;23(3):308-316.
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Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457502.
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The Joint Principles of the PatientCentered Medical Home. http://www. aafp.org/dam/AAFP/documents/practice_ management/pcmh/initiatives/PCMHJoint. pdf. Accessed April 17, 2014.
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Kahn RF. Continuing medical education in nutrition. Am J Clin Nutr. 2006;83:981S-984S.
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Academy of Nutrition and Dietetics Evidence Analysis Library. What is the evidence to support the cost-effectiveness, cost benefit or economic savings of outpatient MNT services provided by an RDN? http://
andevidencelibrary.com/conclusion.cfm? conclusion_statement_id¼251001&high light¼MNT%20for%20weight%20manage ment%20diabetes&home¼1. Accessed June 14, 2014. 22.
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AUTHOR INFORMATION B. T. Jortberg is an assistant professor, Department of Family Medicine, University of Colorado School of Medicine, Aurora. M. O. Fleming is chief medical officer, Amedisys, Inc, Baton Rouge, LA; clinical assistant professor of family medicine, Louisiana State University, School of Medicine, Shreveport; and clinical assistant professor of family and community medicine, Tulane University Medical School, New Orleans, LA. Address correspondence to: Bonnie T. Jortberg, PhD, RD, Department of Family Medicine, University of Colorado School of Medicine, 12631 E 17th Ave, Mail Stop F496, Aurora, CO 80045-0508. E-mail: [email protected]
STATEMENT OF POTENTIAL CONFLICT OF INTEREST No potential conflict of interest was reported by the authors.
FUNDING/SUPPORT There is no funding to disclose.
2022
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