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Nutrition Care Process and Model Part I: The 2008 Update

  • Writing Group of the Nutrition Care Process/Standardized Language Committee
      The Nutrition Care Process and Model (NCPM) is a systematic problem-solving method that food and nutrition professionals use to think critically and make decisions that address practice-related problems (
      • Lacey K.
      • Pritchett E.
      Nutrition Care Process and Model: ADA adopts road map to quality care and outcomes management.
      ). The NCPM provides a consistent structure and framework for food and nutrition professionals to use when delivering nutrition care and is designed for use with patients, clients, groups, and communities of all ages and conditions of health or disease (herein referred to as “patients/clients”). The original model was developed following a review of the literature and was intended to replace other nutrition care processes used in practice and education (
      • Lacey K.
      • Pritchett E.
      Nutrition Care Process and Model: ADA adopts road map to quality care and outcomes management.
      ).
      This update is the result of a planned, regularly scheduled review of the NCPM to ensure that it reflects current practice. It incorporates the results of a survey of American Dietetic Association groups experienced with the NCPM and incorporates decisions made by the Nutrition Care Process/Standardized Language Committee. Part II of this article, which will appear in an upcoming issue of the Journal, describes the official international dietetics and nutrition terminology as outlined in the International Dietetics and Nutrition Terminology (INDT) Reference Manual (
      International Dietetics and Nutrition Terminology (INDT) Reference Manual.
      ), which elaborates on and supports the NCPM. The information in Parts I and II of this article replaces previous information describing the NCPM.

      Background

      The NCPM contains four distinct but interrelated and connected steps: nutrition assessment, nutrition diagnosis, nutrition intervention, and nutrition monitoring and evaluation (described in Figure 1). In theory, each step informs the subsequent step. However, as new information is obtained, a registered dietitian (RD) may revisit previous steps of the process to reassess, add, or revise nutrition diagnoses, modify interventions, or adjust goals and monitoring parameters. The NCPM is designed to incorporate a scientific base that moves food and nutrition professionals beyond experience-based practice to evidence-based practice. If the NCPM is used consistently by all food and nutrition professionals, improved health outcomes should enhance recognition of RDs and dietetic technicians, registered (DTRs), as the preferred providers of nutrition services.
      Figure thumbnail gr1a
      Figure 1The four steps of the Nutrition Care Process and Model.
      Figure thumbnail gr1b
      Figure 1The four steps of the Nutrition Care Process and Model.

      The NCPM

      Figure 2 is a graphic representation of the NCPM. The outer ring of the Model influences how patients/clients receive nutrition information. The practice setting reflects rules and regulations governing practice, the age and health conditions of particular patients/clients, and how a food and nutrition professional's time is allocated. The health care system mandates the amount of time available to food and nutrition professionals, the type of services provided, and who provides the services. The social system reflects patients'/clients' health-related knowledge, values, and the time devoted to improving nutritional health. The economic aspect incorporates resources allocated to nutrition care, including the value of a food and nutrition professional's time in the form of salary and reimbursement.
      Figure thumbnail gr2
      Figure 2The four distinct but interrelated and connected steps of the Nutrition Care Process and Model.
      The middle ring of the Model distinguishes the unique professional attributes of food and nutrition professionals from those in other professions. The inner ring illustrates the four steps of the NCPM, which are described in Figure 2. The central core of the model depicts the essential and collaborative partnership with a patient/client. The model is intended to reflect the dynamic nature of relationships throughout the NCPM.

      Areas Outside the NCPM

      Screening and Referral System

      Screening has been defined as “a test or standardized examination procedure used to identify patients requiring special intervention” (
      US Preventive Services Task Force
      Guide to Clinical Preventive Services.
      ). Nutrition screening is a critical antecedent step of the NCPM that is not typically completed by food and nutrition professionals. Thus, it is not a part of the NCPM. RDs are capable of screening patients and are accountable for developing a screening process that is cost-effective and accurately identifies patients/clients who might have a nutrition problem.
      Referral is the act of sending a patient/client to another health professional for care beyond one's own expertise. The term “referral” may also apply to the actual document that authorizes a visit to another health professional and is also a legal requirement for billing purposes. In addition to correctly identifying clients who would benefit from nutrition care, a referral process ensures that patients/clients have identifiable methods of being linked to the RD who is ultimately responsible for the nutrition intervention. Referral mechanisms may be established based on specific medical diagnoses or other agreed upon criteria.

      Outcomes Management System

      Outcomes management is based on accumulated data that are collected, analyzed, compared with standards or benchmarks, and the results used to adjust and improve performance. Outcomes management requires an infrastructure to aggregate and manage data documented throughout the NCPM. Results from a large series of patients/clients can be used to determine the effectiveness of intervention strategies and the influence of nutrition care in improving the overall health of individuals and groups. Because an outcomes management system involves data from multiple patients/clients and possibly multiple food and nutrition professionals or sites, it is outside the NCPM.

      Distinction Between Medical Nutrition Therapy (MNT) and The NCPM

      MNT is a term widely used in dietetics. It was defined in the 2001 Medicare benefit legislation as “nutritional diagnostic, therapy, and counseling services for the purpose of disease management, which are furnished by a registered dietitian or nutrition professional” (

      Medicare Program; Revisions to Payment Policies and Five Year Review of and Adjustments to the Relative Values Units Under the Physician Fee Schedule for Calendar Year 2002; Final Rule. Subpart G—Medical nutrition therapy. 66 Federal Register 55331 (2001) (codified at 42 CFR §405, 410, 411, 414, and 415).

      ). MNT is not synonymous with the NCPM, but is one specific type of nutrition care. The NCPM is used to provide MNT, but also in other forms of nutrition care such as obtaining feeding assistance or referring to another practitioner.

      Clarification for Practitioners

      This revised description of the NCPM in Figure 1 makes the following points for practitioners.
      • Nutrition assessment has been redefined and the nutrition assessment section has been reformatted to aid in clustering signs and symptoms according to the nutrition diagnoses reference sheets.
      • Early examples of nutrition diagnoses included the terminology “potential for” and “risk of” as modifiers of the diagnoses. However, in the absence of data documenting a cause-and-effect relationship between nutritional risk and nutrition diagnoses, these modifiers are no longer recommended and should not be used.
      • The original article on this topic recognized that patients/clients may have more than one nutrition diagnosis. The NCPM continues to accommodate more than one nutrition diagnosis. A nutrition intervention and nutrition monitoring strategy should accompany each nutrition diagnosis.

      Future Implications

      The NCPM has already begun to influence practice, education, and credentialing of RDs and DTRs, as well as research in the United States and abroad. For example, the American Dietetic Association has developed standards of practice and standards of professional performance that incorporate the NCPM (
      • Kieselhorst K.J.
      • Skates J.
      • Pritchett E.
      American Dietetic Association: Standards of practice in nutrition care and updated standards of professional performance.
      ). Several groups within the profession have developed practice-specific standards that incorporate the NCPM. The 2008 revised standards of practice in nutrition care for DTRs (
      The American Dietetic Association 2007-2008 and 2006-2007 Quality Management Committees
      American Dietetic Association Revised Standards for Dietetic Practice and Professional Performance: 2008 Standards of Practice for Registered Dietitians in Nutrition Care; 2008 Standards of Professional Performance for Registered Dietitians; 2008 Standards of Practice for Dietetic Technicians, Registered in Nutrition Care; 2008 Standards of Professional Performance for Dietetic Technicians, Registered.
      ) will more clearly define the role of DTRs relative to the NCPM.
      The NCPM is a prominent component of the Commission on Accreditation of Dietetics Education standards released in March 2008 (
      Commission on Accreditation for Dietetics Education
      2008 eligibility requirements and accreditation standards for didactic programs in dietetics.
      ,
      Commission on Accreditation of Dietetics Education
      2008 eligibility requirements and accreditation standards for dietetic internships.
      ). It remains to be seen whether educators will reorganize course content to align with the NCPM, but beginning in March 2009, all types of dietetics education programs are required to incorporate NCPM content. Graduates of the Commission on Accreditation for Dietetics Education–accredited programs should be prepared to assume an appropriate role in nutritional assessment but also in nutrition diagnosis and nutrition intervention, monitoring, and evaluation.
      RDs entering the profession since 2006 have taken a revised and updated Registration Examination for Dietitians. The nutrition assessment, nutrition diagnosis, nutrition intervention, and nutrition monitoring and evaluation steps of the NCPM comprise 40% of the examination (). NCPM education for practicing food and nutrition professionals has been made available at affiliate meetings in almost all states. A number of educational materials are available to American Dietetic Association members at no charge from the American Dietetic Association Web site (www.eatright.org). In addition, the Commission on Dietetic Registration has developed a continuing education module available to all food and nutrition professionals.

      Evidence-Based Practice and the NCPM

      Evidence-based practice involves using the highest quality of available information to make practice decisions. It combines the experience of clinicians with a critical evaluation of primary and secondary knowledge sources to support the decision-making process. The American Dietetic Association's electronic Evidence Analysis Library (www.adaevidencelibrary.com) contains thousands of documents that support the steps of the NCPM. These documents have been rigorously evaluated by trained evidence analysts, ranked for quality, and compiled into Evidence-Based Guidelines and Toolkits. The Guidelines and Toolkits elaborate the NCPM as it applies in adult and pediatric weight management, critical illness, disorders of lipid metabolism, and other topics are in preparation. The Dietetics Practice-Based Research Network has been involved in validating nutrition diagnosis terms and will no doubt participate in further studies incorporating and elaborating the NCPM.

      Conclusions

      Since it was accepted by the House of Delegates, the NCPM has been elaborated, refined, and updated to reflect current practice. The NCPM is being incorporated into education, credentialing, and materials supporting evidence-based practice. As these initiatives continue, the NCPM will be more widely understood and adopted within the profession.
      The writing group was composed of: Jennifer Bueche, PhD, RD; Pam Charney, PhD, RD; Jessie Pavlinac, MS, RD, CSR; Annalynn Skipper, PhD, RD, FADA; Elizabeth Thompson, MPH, RD; and Esther Myers, PhD, RD, FADA.
      Additional members of the Nutrition Care Process/Standardized Language Committee were: Nancy Lewis, PhD, RD—Chair; Elise Smith, MA, RD—Vice-Chair; Donna Israel, PhD, RD, FADA; Judy Beto, PhD, RD, FADA; Claudia A. Conkin, MS, RD; Melinda Zook-Weaver, MS, RD; and Constance J. Geiger, PhD, RD.

      References

        • Lacey K.
        • Pritchett E.
        Nutrition Care Process and Model: ADA adopts road map to quality care and outcomes management.
        J Am Diet Assoc. 2003; 103: 1061-1071
      1. International Dietetics and Nutrition Terminology (INDT) Reference Manual.
        American Dietetic Association, Chicago, IL2007
        • US Preventive Services Task Force
        Guide to Clinical Preventive Services.
        2nd ed. US Department of Health and Human Services, Office of Disease Prevention and Health Promotion, Washington, DC1996
      2. Medicare Program; Revisions to Payment Policies and Five Year Review of and Adjustments to the Relative Values Units Under the Physician Fee Schedule for Calendar Year 2002; Final Rule. Subpart G—Medical nutrition therapy. 66 Federal Register 55331 (2001) (codified at 42 CFR §405, 410, 411, 414, and 415).

        • Kieselhorst K.J.
        • Skates J.
        • Pritchett E.
        American Dietetic Association: Standards of practice in nutrition care and updated standards of professional performance.
        J Am Diet Assoc. 2005; 105: 641-645
        • The American Dietetic Association 2007-2008 and 2006-2007 Quality Management Committees
        American Dietetic Association Revised Standards for Dietetic Practice and Professional Performance: 2008 Standards of Practice for Registered Dietitians in Nutrition Care; 2008 Standards of Professional Performance for Registered Dietitians; 2008 Standards of Practice for Dietetic Technicians, Registered in Nutrition Care; 2008 Standards of Professional Performance for Dietetic Technicians, Registered.
        (American Dietetic Association Web site) (Accessed May 12, 2008)
        • Commission on Accreditation for Dietetics Education
        2008 eligibility requirements and accreditation standards for didactic programs in dietetics.
        (American Dietetic Association Web site) (Accessed March 19, 2008)
        • Commission on Accreditation of Dietetics Education
        2008 eligibility requirements and accreditation standards for dietetic internships.
        (American Dietetic Association Web site) (Accessed March 19, 2008)
      3. Registration examination for dietitians.
        (Commission on Dietetic Registration Web site) (Accessed January 4, 2007)