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Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Diabetes Care

Published:April 24, 2018DOI:https://doi.org/10.1016/j.jand.2018.03.007

      Abstract

      There are 30.3 million people with diabetes and 86 million with prediabetes in the United States, underscoring the growing need for comprehensive diabetes care and nutrition for the management of diabetes and diabetes-related conditions. Management of diabetes is also critical for the prevention of diabetes-related complications such as cardiovascular and renal disease. The Diabetes Care and Education Dietetic Practice Group along with the Academy of Nutrition and Dietetics Quality Management Committee have updated the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitian Nutritionists (RDNs) in Diabetes Care. The SOP and SOPP for RDNs in Diabetes Care provide indicators that describe three levels of practice: competent, proficient, and expert. The SOP utilizes the Nutrition Care Process and clinical workflow elements for care and management of those with diabetes and prediabetes. The SOPP describes six domains that focus on professionalism: Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources. Specific indicators outlined in the SOP and SOPP depict how these standards apply to practice. The SOP and SOPP are complementary resources for RDNs caring for individuals with diabetes or specializing in diabetes care or practicing in other diabetes-related areas, including research. The SOP and SOPP are intended to be used for RDN self-evaluation for ensuring competent practice and for determining potential education and training needs for advancement to a higher practice level in a variety of settings.
      Editor’s note: Figures 1 and 2 that accompany this article are available at www.jandonline.org.
      Approved December 2017, by the Quality Management Committee of the Academy and the Executive Committee of DCE DPG. Scheduled review date: May 2024. Questions regarding the Revised 2017 SOP and SOPP for RDNs (Competent, Proficient, and Expert) in Diabetes Care may be addressed to Academy Quality Management Staff: Dana Buelsing, MS, manager, quality standards operations, and Sharon McCauley, MS, MBA, RDN, LDN, FADA, FAND, senior director, quality management, at [email protected].
      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). The two credentials have identical meanings. In this document, the authors have chosen to use RDN to refer to both RDs and RDNs.
      The Diabetes Care and Education Dietetic Practice Group (DCE DPG) of the Academy of Nutrition and Dietetics (Academy), under the guidance of the Academy Quality Management Committee, has revised the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitians (RDs) in Diabetes Care published in 2011.
      • Boucher J.L.
      • Evert A.
      • Daly A.
      • et al.
      American Dietetic Association Revised Standards of Practice and Standards of Professional Performance for Registered Dietitians (Generalist, Specialist, and Advanced) in Diabetes Care.
      The revised documents, Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (RDNs) (Competent, Proficient, and Expert) in Diabetes Care, reflect advances in diabetes practice during the past 6 years and replace the 2011 Standards. These documents build on the Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for RDNs.
      • Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists.
      The Academy/Commission on Dietetic Registration’s (CDR) Code of Ethics
      • American Dietetic Association/Commission on Dietetic Registration
      Code of Ethics for the Profession of Dietetics and process for consideration of ethics Issues.
      (revised and approved Code of Ethics available in 2018) along with the Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for RDNs
      • Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists.
      and Revised 2017 Scope of Practice for the Registered Dietitian Nutritionist,
      • Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Registered Dietitian.
      guide the practice and performance of RDNs in all settings.
      Scope of practice in nutrition and dietetics is composed of statutory and individual components, including codes of ethics (eg, Academy or other national organizations and/or employer code of ethics), and encompasses the range of roles, activities, practice guidelines, and regulations related to RDN performance. For credentialed practitioners, scope of practice is typically established within the practice act and interpreted and controlled by the agency or board that regulates the practice of the profession in a given state.
      • Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Registered Dietitian.
      An RDN’s statutory scope of practice can delineate the services an RDN is authorized to perform in a state where a practice act or certification exists. For more information see www.cdrnet.org/state/licensure-agency-list.
      An RDN’s individual scope of practice is determined by education, training, credentialing, experience, organizational policies and procedures, and demonstrating and documenting competence to practice. Individual scope of practice in nutrition and dietetics has flexible boundaries to capture the breadth of an individual’s professional practice. Professional advancement beyond the core education and supervised practice to qualify for the CDR RDN credential provides RDNs practice opportunities such as expanded roles within an organization based on specified training and certifications, if required; or additional credentials (eg, focus area CDR specialist certification, if applicable, or Advanced Practice Certification in Clinical Nutrition [RDN-AP], Certified Diabetes Educator [CDE], Board Certified-Advanced Diabetes Management [BC-ADM], Certified Case Manager [CCM], or Certified Professional in Health Care Quality [CPHQ]). The Scope of Practice Decision Tool (www.eatrightpro.org/scope), an online interactive tool, guides an RDN through a series of questions to determine whether a particular activity is within his or her scope of practice. This tool is designed to allow an RDN to critically evaluate his or her personal knowledge, skill, experience, judgment, and demonstrated competence using criteria resources.
      • Academy of Nutrition and Dietetics Quality Management Committee and Scope of Practice Subcommittee of the Quality Management Committee
      Academy of Nutrition and Dietetics Scope of Practice Decision Tool: A self-assessment guide.
      The Centers for Medicare and Medicaid Services (CMS), Department of Health and Human Services, Hospital

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State operations manual. Appendix A-survey protocol, regulations and interpretive guidelines for hospitals (Rev. 176, 12-29-17); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf. Accessed March 5, 2018.

      and Critical Access Hospital

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State operations manual. Appendix W-survey protocol, regulations and interpretive guidelines for critical access hospitals (CAHs) and swing-beds in CAHs (Rev. 165, 12-16-16); §485.635(a)(3)(vii) Dietary Services; §458.635 (d)(3) Verbal Orders. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_w_cah.pdf. Accessed March 5, 2018.

      Conditions of Participation now allows a hospital and its medical staff the option of including RDNs or other qualified nutrition professionals within the category of “non-physician practitioners” eligible for ordering privileges for therapeutic diets and nutrition-related services when it is consistent with state law and health care regulations. RDNs in hospital settings interested in obtaining ordering privileges must review state laws (eg, licensure, certification, and title protection) if applicable and health care regulations to determine whether there are any barriers or state-specific processes that must be addressed. For more information, review the Academy’s practice tips that outline the regulations and implementation steps for obtaining ordering privileges (www.eatrightpro.org/dietorders). For assistance, refer questions to the Academy’s State Affiliate organization.
      Medical staff oversight of an RDN(s) occurs in one of two ways. A hospital has the regulatory flexibility to appoint an RDN(s) to the medical staff and grant the RDN(s) specific nutrition ordering privileges, or can authorize the ordering privileges without appointment to the medical staff. To comply with regulatory requirements, an RDN’s eligibility to be considered for ordering privileges must be through the hospital’s medical staff rules, regulations, and bylaws, or other facility-specific process.

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. 42 CFR Parts 413, 416, 440 et al. Medicare and Medicaid Programs; regulatory provisions to promote program efficiency, transparency, and burden reduction; part II; final rule (FR DOC #2014-10687; pp 27105–27157). http://www.gpo.gov/fdsys/pkg/FR-2014-05-12/pdf/2014-10687.pdf. Accessed March 5, 2018.

      The actual privileges granted will be based on an RDN’s knowledge, skills, experience, and specialist certification, if required, and demonstrated and documented competence.
      The Long-Term Care Final Rule published October 4, 2016, in the Federal Register “allows the attending physician to delegate to a qualified dietitian or other clinically qualified nutrition professional the task of prescribing a resident’s diet, including a therapeutic diet, to the extent allowed by State law” and permitted by the facility’s policies.

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. 42 CFR parts 405, 431, 447, 482, 483, 485, 488, and 489 Medicare and Medicaid programs; reform of requirements for long-term care facilities. Final rule (FR DOC#2016; pp 68688-68872) – Federal Register October 4, 2016; 81(192):68688-68872; §483.30(f)(2) physician services (pp 65-66), §483.60 food and nutrition services (pp 89-94), §483.60 food and nutrition services (pp 177-178). https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities. Accessed March 5, 2018.

      The qualified professional must be acting within the scope of practice as defined by state law and is under the supervision of the physician that may include, for example, countersigning the orders written by the qualified dietitian or clinically qualified nutrition professional. RDNs who work in long-term care facilities should review the Academy’s updates on CMS that outline the regulatory changes to §483.60 Food and Nutrition Services (www.eatrightpro.org/quality). Review his or her state’s long-term care regulations to identify potential barriers to implementation and identify considerations for developing the facility’s process with the medical director and for orientation of attending physicians. The CMS State Operations Manual, Appendix PP--Guidance for Surveyors for Long-Term Care Facilities

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State operations manual-appendix PP-guidance to surveyors for long-term care facilities. (Rev. 173, 11-22-17); §483.30 physician services, §483.60 food and nutrition services. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf. Accessed March 5, 2018.

      contains the revised regulatory language (new revisions are italicized and in red color

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State operations manual-appendix PP-guidance to surveyors for long-term care facilities. (Rev. 173, 11-22-17); §483.30 physician services, §483.60 food and nutrition services. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf. Accessed March 5, 2018.

      ). CMS periodically revises the State Operations Manual Conditions of Participation; obtain the current information at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107Appendicestoc.pdf.

      Academy Quality and Practice Resources

      The Academy’s Revised 2017 SOP in Nutrition Care and SOPP for RDNs
      • Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists.
      reflect the minimum competent level of nutrition and dietetics practice and performance. The core standards serve as blueprints for the development of focus area SOP and SOPP for RDNs in competent, proficient, and expert levels of practice. The SOP in Nutrition Care is composed of four standards consistent with the Nutrition Care Process and clinical workflow elements as applied to the care of patients/clients/populations in all settings.
      • Swan W.I.
      • Vivanti A.
      • Hakel-Smith N.A.
      • et al.
      Nutrition Care Process and Model update: Toward realizing people-centered care and outcomes management.
      The SOPP consist of standards representing six domains of professional performance: Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources. The SOP and SOPP for RDNs are designed to promote the provision of safe, effective, efficient, and quality food and nutrition care and services; facilitate evidence-based practice; and serve as a professional evaluation resource.
      These focus area standards for RDNs in diabetes care provide a guide for self-evaluation and expanding practice, a means of identifying areas for professional development, and a tool for demonstrating competence in delivering diabetes care and dietetic services.
      Nutrition and Dietetics Diabetes Care and Services (for the purpose of the SOP and SOPP in Diabetes Care) encompasses medical nutrition therapy, counseling, both patient and professional education, support, research, and other diabetes nutrition-related services (eg, utilizing the Nutrition Care Process in nutrition planning, food preparation and modification, and lifestyle education).
      They are used by RDNs to assess their current level of practice and to determine the education and training required to maintain currency in their focus area and advancement to a higher level of practice. In addition, the standards can be used to assist RDNs in general clinical practice with maintaining minimum competence in the focus area and by RDNs transitioning their knowledge and skills to a new focus area of practice. Like the Academy’s core SOP in Nutrition Care and SOPP for RDNs,
      • Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists.
      the indicators (ie, measurable action statements that illustrate how each standard can be applied in practice) (see Figures 1 and 2, available at www.jandonline.org) for the SOP and SOPP for RDNs in Diabetes Care were revised with input and consensus of content experts representing diverse practice and geographic perspectives. The SOP and SOPP for RDNs in Diabetes Care were reviewed and approved by the Executive Committee of the Diabetes Care and Education Dietetic Practice Group and the Academy Quality Management Committee.

      Three Levels of Practice

      The Dreyfus model
      • Dreyfus H.L.
      • Dreyfus S.E.
      Mind over Machine: The Power of Human Intuition and Expertise in the Era of the Computer.
      identifies levels of proficiency (novice, advanced beginner, competent, proficient, and expert) (Figure 3) during the acquisition and development of knowledge and skills. The first two levels are components of the required didactic education (novice) and supervised practice experience (advanced beginner) that precede credentialing for nutrition and dietetics practitioners. Upon successfully attaining the RDN credential, a practitioner enters professional practice at the competent level and manages his or her professional development to achieve individual professional goals. This model is helpful in understanding the levels of practice described in the SOP and SOPP for RDNs in Diabetes Care. In Academy focus areas, the three levels of practice are represented as competent, proficient, and expert.
      Figure 3Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitian Nutritionists (RDNs) (Competent, Proficient, and Expert) in Diabetes Care.
      Standards of Practice (SOP) are authoritative statements that describe practice demonstrated through nutrition assessment, nutrition diagnosis (problem identification), nutrition intervention (planning and implementation), and outcomes monitoring and evaluation (four separate standards) and the responsibilities for which Registered Dietitian Nutritionists (RDNs) are accountable. The SOP for RDNs in Diabetes Care presuppose that the RDN uses critical thinking skills; analytical abilities; theories; best available research findings; current accepted nutrition, dietetics, and medical knowledge; and the systematic holistic approach of the nutrition care process as they relate to the application of the standards. The Standards of Professional Performance (SOPP) for RDNs in Diabetes Care are authoritative statements that describe behavior in the professional role, including activities related to quality in practice, competence and accountability, provision of services, application of research, communication and application of knowledge, and use and management of resources (six separate standards).
      SOP and SOPP are complementary standards and serve as evaluation resources. All indicators may not be applicable to all RDNs’ practice or to all practice settings and situations. RDNs operate within the directives of applicable federal and state laws and regulations, as well as policies and procedures established by the organization by which they are employed. To determine whether an activity is within the scope of practice of an RDN, the practitioner compares his or her knowledge, skill, experience, judgment, and demonstrated competence with the criteria necessary to perform the activity safely, ethically, legally, and appropriately. The Academy of Nutrition and Dietetics Scope of Practice Decision Tool, which is an online interactive tool, is specifically designed to assist practitioners with this process.
      The term patient/client is used in the SOP as a universal term because these Standards relate to direct provision of nutrition care and services. Patient/client could also mean client/patient, resident, participant, consumer, or any individual or group who receives diabetes care, education, and support services. Customer is used in the SOPP as a universal term. Customer could also mean client/patient, client/patient/customer, participant, consumer, or any individual, group, or organization to which the RDN provides services. These services are provided to individuals of all ages. These SOP and SOPP are not limited to the clinical setting. In addition, it is recognized that the family and caregiver(s) of patient/clients of all ages, including individuals with special health care needs, play critical roles in overall health and are important members of the team throughout the assessment and intervention process. The term appropriate is used in the standards to mean: Selecting from a range of best practice or evidence-based possibilities, one or more of which would give an acceptable result in the circumstances.
      Each standard is equal in relevance and importance and includes a definition, a rationale statement, indicators, and examples of desired outcomes. A standard is a collection of specific outcome-focused statements against which a practitioner’s performance can be assessed. The rationale statement describes the intent of the standard and defines its purpose and importance in greater detail. Indicators are measurable action statements that illustrate how each specific standard can be applied in practice. Indicators serve to identify the level of performance of competent practitioners and to encourage and recognize professional growth.
      Standard definitions, rationale statements, core indicators, and examples of outcomes found in the Academy of Nutrition and Dietetics: Revised 2017 SOP in Nutrition Care and SOPP for RDNs have been adapted to reflect three levels of practice (competent, proficient and expert) for RDNs in diabetes care (see image below). In addition, the core indicators have been expanded to reflect the unique competence expectations for an RDN providing diabetes care, education, and support services.
      Standards described as proficient level of practice in this document are not equivalent to the National Certification Board for Diabetes Educators certification, Certified Diabetes Educator (CDE). Rather, the designation recognizes the skill level of an RDN who has developed and demonstrated through successful completion of the certification examination, diabetes nutrition knowledge and application beyond the competent practitioner and demonstrates, at a minimum, proficient-level skills. An RDN with a CDE designation is an example of an RDN who has demonstrated additional knowledge, skills, and experience in diabetes nutrition by the attainment of a specialist credential and compliance with recertification requirements. Standards described as expert level of practice in this document are not equivalent to the American Association of Diabetes Educators certification, Board Certified-Advanced Diabetes Management (BC-ADM). Rather, the designation recognizes the skill level of an RDN who has developed additional diabetes nutrition knowledge and application beyond the proficient-level practitioner. An RDN with a BC-ADM designation is an example of an RDN who has demonstrated, at a minimum, expert level skills as presented in this document.

      Competent Practitioner

      In nutrition and dietetics, a competent practitioner is an RDN who is either just starting practice after having obtained RDN registration by CDR or an experienced RDN recently transitioning his or her practice to a new focus area of nutrition and dietetics. A focus area of nutrition and dietetics practice is a defined area of practice that requires focused knowledge, skills, and experience that applies to all levels of practice.

      Academy of Nutrition and Dietetics. Definition of terms. www.eatrightpro.org/scope. Accessed March 5, 2018.

      A competent practitioner who has achieved credentialing as an RDN and is starting in professional employment consistently provides safe and reliable services by employing appropriate knowledge, skills, behavior, and values in accordance with accepted standards of the profession; acquires additional on-the-job skills; and engages in tailored continuing education to further enhance knowledge, skills, and judgment obtained in formal education.

      Academy of Nutrition and Dietetics. Definition of terms. www.eatrightpro.org/scope. Accessed March 5, 2018.

      A general practice RDN can include responsibilities across several areas of practice, including but not limited to community, clinical, consultation and business, management, research, education, and food and nutrition systems. Because of the prevalence of prediabetes and/or diabetes in the population, nutrition care, as part of an interprofessional team for the management of individuals with diabetes along with other medical conditions, is an integral component of educational preparation and clinical practice for RDNs. To enhance competence in managing the care of individuals with a variety of medical diagnoses where diabetes is a comorbid condition, strengthening understanding of the disease process and treatment options, including medical nutrition therapy (MNT), will contribute to safe and quality care. Refer to the Academy’s Evidence Analysis Library practice guidelines for diabetes (www.andeal.org), and the American Diabetes Association’s Standards of Medical Care in Diabetes.

      American Diabetes Association. Standards of medical care in diabetes-2018. https://professional.diabetes.org/content-page/standards-medical-care-diabetes. Accessed March 5, 2018.

      Proficient Practitioner

      A proficient practitioner is an RDN who is generally 3 or more years beyond credentialing and entry into the profession and consistently provides safe and reliable service; has obtained operational job performance skills, and is successful in an RDN's chosen focus area of practice. The proficient practitioner demonstrates additional knowledge, skills, judgment, and experience in a focus area of nutrition and dietetics practice. An RDN may acquire specialist credentials, if available, to demonstrate proficiency in a focus area of practice.

      Academy of Nutrition and Dietetics. Definition of terms. www.eatrightpro.org/scope. Accessed March 5, 2018.

      A proficient-level practitioner in diabetes care has gained additional knowledge in diabetes care and management; work experience in delivering diabetes MNT counseling, education, and care; and may have obtained the CDE credential (www.ncbde.org). In 2017, the National Certification Board for Diabetes Educators reports that 41% of CDEs are RDNs, 50% are nurses, 7% are pharmacists, and 2% are from other disciplines (www.ncbde.org).

      Expert Practitioner

      An expert practitioner is an RDN who is recognized within the profession and has mastered the highest degree of skill in, and knowledge of, nutrition and dietetics. Expert level achievement is acquired through ongoing critical evaluation of practice and feedback from others. The individual at this level strives for additional knowledge, experience, and training. An expert has the ability to quickly identify “what” is happening and “how” to approach the situation. Experts easily use nutrition and dietetics skills to become successful through demonstrating quality practice and leadership, and to consider new opportunities that build upon nutrition and dietetics.

      Academy of Nutrition and Dietetics. Definition of terms. www.eatrightpro.org/scope. Accessed March 5, 2018.

      An expert practitioner may have an expanded or specialist role or both, and may possess an advanced credential(s). Generally, the practice is more complex and the practitioner has a high degree of professional autonomy and responsibility. An expert-level RDN in diabetes care and management has extensive knowledge and practice experiences in the care and management of individuals with prediabetes and diabetes and may have one or more certifications such as the CDE and/or BC-ADM credential (www.diabeteseducator.org/education-career/certification). These RDNs are recognized by others for their practice and professional contributions to further quality diabetes care, education, and research.
      These Standards, along with the Academy/CDR Code of Ethics,
      • American Dietetic Association/Commission on Dietetic Registration
      Code of Ethics for the Profession of Dietetics and process for consideration of ethics Issues.
      answer the questions: Why is an RDN uniquely qualified to provide diabetes care and related nutrition and dietetics services? What knowledge, skills, and competencies does an RDN need to demonstrate for the provision of safe, effective, and quality diabetes care and service at the competent, proficient, and expert levels?

      Overview

      According to the Centers for Disease Control and Prevention, in 2017 there were 86 million people with prediabetes and 30.3 million (9.4% of the United States population) with diabetes.

      Centers for Disease Control and Prevention. Diabetes 2017 report card. www.cdc.gov/diabetes. Accessed March 13, 2018.

      Approximately 50% of adults older than age 65 years have prediabetes. Due to the increasing numbers of people experiencing prediabetes and diabetes (type 1, type 2, gestational, and stress/or medication induced), diabetes care has become a specialized field for RDNs. Responding to the increasing demand for the screening, prevention, treatment, and management of persons with both prediabetes and diabetes is crucial throughout the life cycle (eg, children, adolescents, and adults). Due to the chronic nature of diabetes, the treatment approach has evolved from that of acute hospital/facility-based care to outpatient/ambulatory care settings using a patient-centered collaborative–integrative medical home model.
      • Raja S.
      • Hasnain M.
      • Vadakumchery T.
      • Hamad J.
      • Shah R.
      • Hoersch M.
      Identifying elements of patient-centered care in underserved populations: A qualitative study of patient perspectives.
      Under this model, individuals adopt a more proactive and participatory role in providing the needed care for themselves and their loved ones. According to the American Diabetes Association’s Standards of Medical Care in Diabetes, management for the person with diabetes should consist of a physician coordinated team, including a nurse, dietitian, physician assistant, pharmacist, and/or mental health professional.

      American Diabetes Association. Standards of medical care in diabetes-2018. https://professional.diabetes.org/content-page/standards-medical-care-diabetes. Accessed March 5, 2018.

      The Standards emphasize that MNT should be provided to all individuals with diabetes, with preference that this be provided by an RDN with the skill set and knowledge specific to diabetes care.
      Diabetes, like other chronic diseases, requires a multifaceted treatment approach. This includes lifestyle management (individualized eating and physical activity plan), considering a medication plan when applicable, as well as educational and behavioral support. Knowledge in the areas of actual and recommended health practices and outcomes is an essential component for patient/client involvement in the management of diabetes. There is strong evidence that type 2 diabetes can be delayed or prevented by altering lifestyle factors, specifically dietary pattern and physical activity.

      Academy of Nutrition and Dietetics. Prevention of type 2 diabetes evidence based nutrition practice guideline: Executive summary of recommendations 2014. http://andeal.org/topic.cfm?menu=5344&cat=5210. Accessed March 5, 2018.

      • Raynor H.A.
      • Davidson P.G.
      • Burns H.
      • et al.
      Medical nutrition therapy and weight loss questions for the evidence analysis library prevention of type 2 diabetes: Systematic reviews.
      Position of The Academy of Nutrition and Dietetics: The role of medical nutrition therapy and registered dietitian nutritionists in the prevention and treatment of prediabetes and type 2 diabetes.
      MNT provided by an RDN has been shown to enhance weight loss and improve clinical parameters, such as fasting and 2-hour postprandial blood glucose level, and waist circumference associated with development of type 2 diabetes.

      Academy of Nutrition and Dietetics. Prevention of type 2 diabetes evidence based nutrition practice guideline: Executive summary of recommendations 2014. http://andeal.org/topic.cfm?menu=5344&cat=5210. Accessed March 5, 2018.

      Along with MNT, weight loss of 5% to 7% has repeatedly been shown to be a strong predictor for reducing the risk of developing type 2 diabetes. For every 1 kg of weight loss, there is a 16% reduction in risk.
      • Perreault L.
      • Pan Q.
      • Mather K.J.
      • et al.
      Effect of regression from prediabetes to normal glucose regulation on long-term reduction in diabetes risk: Results from the Diabetes Prevention Program Outcomes Study.
      According to the Academy, MNT provided by an RDN should be included in an integrated collaborative health care program for improving metabolic outcomes such as glycated hemoglobin (hemoglobin A1c) level as well as preventing the progression or delay from prediabetes to diabetes and complications associated with diabetes.

      Academy of Nutrition and Dietetics. Prevention of type 2 diabetes evidence based nutrition practice guideline: Executive summary of recommendations 2014. http://andeal.org/topic.cfm?menu=5344&cat=5210. Accessed March 5, 2018.

      Academy of Nutrition and Dietetics. Adult weight management nutrition practice guideline: Executive summary of recommendations 2014. Academy of Nutrition and Dietetics Evidence Analysis Library. http://andeal.org/topic.cfm?menu=5276&cat=4690. Accessed March 5, 2018.

      • Franz M.J.
      • Macleod J.
      • Evert A.
      • Brown C.
      • Gradwell E.
      • Handu D.
      • et al.
      Academy of Nutrition and Dietetics nutrition practice guideline for type 1 and type 2 diabetes in adults: Systematic review of evidence for medical nutrition therapy effectiveness and recommendations for integration into the nutrition care process.
      • MacLeod J.
      • Franz M.J.
      • Handu D.
      • et al.
      Academy of Nutrition and Dietetics nutrition practice guideline for type 1 and type 2 diabetes in adults: Nutrition intervention evidence reviews and recommendations.
      • Marincic P.Z.
      • Hardin A.
      • Salazar M.V.
      • et al.
      Diabetes self-management education and medical nutrition therapy improve patient outcomes: A pilot study documenting the efficacy of registered dietitian nutritionist interventions through retrospective chart review.
      The RDN is positioned to empower patients/clients and provide nutrition counseling, education, and support. RDNs provide diabetes MNT and services in a variety of settings, including but not limited to outpatient collaborative care clinics, inpatient and outpatient health care facilities, diabetes education centers, and community health centers (eg, diabetes prevention program and diabetes self-management education and support [DSMES]
      • Beck J.
      • Greenwood D.A.
      • Blanton L.
      • et al.
      2017 National standards for diabetes self-management education and support.
      services). Medicare defines MNT as “nutritional diagnostic, therapy, and counseling services for the purpose of disease management which are furnished by a Registered Dietitian . . .” supporting that RDNs have the clinical skills, training, and education for providing diabetes-related nutrition services.

      US Code of Federal Regulation, Title 42. § 1395x. Social Security. (vv) Medical nutrition therapy services; registered dietitian or nutrition professional; subpart G—medical nutrition therapy. 42 C.F.R. 410.134. SOURCE: 66 FR 55331, Nov. 1, 2001, as amended at 72 FR 66400, Nov. 27, 2007. §410.130, 132, 134. http://www.ecfr.gov/cgi-bin/text-idx?rgn=div5;node=42%3A2.0.1.2.10#se42.2.410_1134. Accessed March 5, 2018.

      DSMES services have become an integral component and foundation for the development of an individual’s plan for diabetes care and national standards guide their provision. More importantly, these care plans should be individualized and consist of collaboration between the individual and the physician as well as other members of the diabetes care team, including the RDN providing MNT

      Academy of Nutrition and Dietetics. Prevention of type 2 diabetes evidence based nutrition practice guideline: Executive summary of recommendations 2014. http://andeal.org/topic.cfm?menu=5344&cat=5210. Accessed March 5, 2018.

      Academy of Nutrition and Dietetics. Diabetes mellitus type 1 and 2 systematic review and guideline. https://www.andeal.org/topic.cfm?menu=5305. Accessed March 5, 2018.

      in any care setting. There have been a number of studies underscoring the importance of educating patients/clients in diabetes self-care, now known as DSMES, for improving metabolic control, and in turn, decreasing the incidence and progression of many of the diabetes-associated complications.
      • Saaristo T.
      • Moilanen L.
      • Korpi-Hyövälti E.
      • et al.
      Lifestyle intervention for prevention of type 2 diabetes in primary health care: One-year follow-up of the Finnish National Diabetes Prevention Program (FIN-D2D).
      • Eriksson J.
      • Lindström J.
      • Valle T.
      • et al.
      Prevention of type II diabetes in subjects with impaired glucose tolerance: The Diabetes Prevention Study (DPS) in Finland.
      • Vinall M.
      • Matthews D.
      Review and update of the United Kingdom Prospective Diabetes Study Trials.
      • Diabetes Control and Complications Trial Research Group
      The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus.
      The goals of DSMES services, using a patient-centered collaborative/integrated medical home, are to: empower the patient/client with diabetes to obtain the knowledge on what to do; attain the skills to do it; gain confidence and the desire to perform the self-care behaviors; and cultivate problem-solving and coping skills for dealing with the barriers of self-care behaviors for obtaining metabolic goals.
      Technology advances such as continuous glucose monitoring (CGM) share capabilities through the cloud, mobile applications, and crowdsourcing, provide timely feedback in the care of a person with diabetes and has been shown to enhance diabetes self-management skills and patient satisfaction.
      • Diabetes Control and Complications Trial Research Group
      The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus.
      • Tuomilehto J.
      • Lindström J.
      • Eriksson J.G.
      • et al.
      Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance.
      • Hortensius J.
      • Kars M.C.
      • Wierenga W.S.
      • et al.
      Perspectives of patients with type 1 or insulin-treated type 2 diabetes on self-monitoring of blood glucose: A qualitative study.
      • Ammenwerth E.
      • Schnell-Inderst P.
      • Hoerbst A.
      The impact of electronic patient portals on patient care: A systematic review of controlled trials.
      However, there are a multitude of factors influencing metabolic outcomes, including the patient’s knowledge, cultural background, psychosocial and social factors, treatment team, and medication regimens.
      • Beck J.
      • Greenwood D.A.
      • Blanton L.
      • et al.
      2017 National standards for diabetes self-management education and support.
      Endocrine Society Practice Guidelines underscore the role of the experienced RDN as part of the care team for providing individualized MNT diabetes care plans for those receiving continuous sustained insulin infusion (CSII) and CGM.
      • Peters A.L.
      • Ahmann A.J.
      • Battelino T.
      • et al.
      Diabetes technology – Continuous subcutaneous insulin infusion (CSII) therapy and continuous glucose monitoring (CGM) in adults: An Endocrine Society clinical practice guideline.
      Research demonstrates that there is a need to improve and maintain patient engagement in self-care and DSMES.
      • Polonsky W.H.
      • Fisher W.
      • Schikman C.H.
      • et al.
      Structured self-monitoring of blood glucose significantly reduces A1C levels in poorly controlled, non-insulin treated type 2 diabetes: Results from the Structured Testing Program study.
      Computer-based interactive tools, social media, and telehealth technologies can help improve self-care practices and patient engagement.
      • Ammenwerth E.
      • Schnell-Inderst P.
      • Hoerbst A.
      The impact of electronic patient portals on patient care: A systematic review of controlled trials.
      • Mamykina L.
      • Levine M.E.
      • Davidson P.G.
      • Smaldone A.
      • Elhadad N.
      • Albers J.A.
      Data-driven health management: Reasoning about personally generated data in diabetes with information technologies.
      It is important for nutrition and dietetics practitioners in any setting providing diabetes and nutrition education to be aware of and skilled at using the available diabetes technology resources for ensuring that evidenced-based care is being provided. Due to health disparities and barriers to DSMES, telehealth is being used increasingly as an alternative for providing education.
      • Mclendon S.F.
      Interactive video telehealth models to improve access to diabetes specialty care and education in the rural setting: A systematic review.
      • Siminerio L.
      • Ruppert K.
      • Huber K.
      • Toledo F.G.S.
      Telemedicine for reach, education, access, and treatment (TREAT): Linking telemedicine with diabetes self-management education to improve care in rural communities.
      The Joint Position Statement of the American Diabetes Association, American Association of Diabetes Educators (AADE) and the Academy emphasizes the importance of DSMES at four critical times. This position paper provides DSMES algorithms to be initiated and implemented by collaborative health care teams, with RDNs being the preferred providers of MNT for people with diabetes.
      Position of The Academy of Nutrition and Dietetics: The role of medical nutrition therapy and registered dietitian nutritionists in the prevention and treatment of prediabetes and type 2 diabetes.
      • Powers M.
      • Bardsley J.
      • Cypress M.
      • et al.
      Diabetes self-management education and support in type 2 diabetes: A joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics.
      • Evert A.B.
      • Boucher J.L.
      • Cypress M.
      • et al.
      American Diabetes Association. Nutrition therapy recommendations for the management of adults with diabetes.
      The four critical points include at the time of a new diagnosis, annually, with treatment changes or complicating conditions (eg, hospitalization), and in transitions of care to assess and provide DSMES. The SOP and SOPP include resources for expanding knowledge and encourages RDNs providing care to individuals with diabetes and other comorbid conditions to continuously assess their skills for providing care and advancing practice (eg, competent, proficient, and expert levels of practice) (Figure 4). The education algorithm included in the Joint Position Statement along with the SOP and SOPP in Diabetes Care can be used by an RDN and the interprofessional team for gauging how, what, and when to deliver diabetes education and nutrition services (Figure 5). RDNs whose professional practice focuses in diabetes who are not working in direct care settings such as in academia, research, federal or state agencies, or in positions of professional organizations (eg, American Diabetes Association and AADE) should regularly reference the SOP and SOPP for assessing their skills, advancing practice, and application in their work settings.
      Figure 4Diabetes nutrition resources (not all inclusive).
      ResourceAddressDescription
      Academy
      Academy=Academy of Nutrition and Dietetics.
      Cultural Competency for Nutrition Professionals
      www.eatrightstore.org/product/E2EBE1F2-A38E-49AB-B5B6-D1D432585F17This online publication provides an overview of various cultures and food practices with the goal of supporting care and services for diverse populations.
      Academy Diabetes Care and Education Dietetics Practice Groupwww.dce.org/This Academy practice group strives to empower its members to be leaders in food, nutrition, and diabetes care and prevention.
      Academy Diabetes Mellitus Toolkitwww.eatrightstore.org/product/10BFB22D-2301-428C-8446-CA38C10D832DThe toolkit is designed to assist RDNs
      RDN=registered dietitian nutritionist.
      in applying the Academy Diabetes Mellitus Management Evidence-Based Nutrition Practice Guidelines.
      Academy EAL
      EAL=Evidence Analysis Library.
      Diabetes Mellitus Types 1 and 2 Systematic Review and Guideline
      www.andeal.org/topic.cfm?menu=5305The focus of the EAL guideline is on MNT
      MNT=medical nutrition therapy.
      for adults with type 1 and type 2 diabetes.
      Academy EAL Gestational Diabetes Mellitus Guideline and Supporting Systematic Reviewwww.andeal.org/topic.cfm?menu=5288This resource focuses on the treatment of women with gestational diabetes and provides evidence-based MNT recommendations for management of gestational diabetes mellitus.
      Academy EAL Prevention of Type 2 Diabetes Projectwww.andeal.org/topic.cfm?menu=5344This EAL resource focuses on MNT for individuals who are at high risk for type 2 diabetes, such as individuals with prediabetes.
      Academy Gestational Diabetes Toolkitwww.eatrightstore.org/product/70EC4F6C-A75D-40F0-85F6-9E0ACEA47FE7The toolkit is designed to assist an RDN in applying the Academy Gestational Diabetes Evidence-Based Nutrition Practice Guidelines.
      Academy Making Choices Meal Planning for Diabetes and Chronic Kidney Diseasewww.eatrightstore.org/product/87A0732F-B41D-4A58-9D15-2105C0CF397BThis resource is designed to help health care professionals counsel patients/clients with both diabetes (type 1 or type 2) and chronic kidney disease stage 3 or 4.
      Academy Pocket Guide to Lipid Disorders, Hypertension, Diabetes, and Weight Managementwww.eatrightstore.org/product/65068CB9-A25C-497F-BF73-302CA684A0CBThis resource integrates evidence-based nutrition practice guidelines into nutrition care for patients/clients who have one or more medical diagnoses.
      Academy Pocket Guide to Pediatric Weight Management, 2nd editionwww.eatrightstore.org/product/DDCCA4CB-DADE-445F-A09C-3F620BF3B6C9This pocket guide describes interventions that will help reduce the risk of health complications in children and adolescents with overweight and obesity issues.
      American Association of Clinical Endocrinologistswww.aace.comA health care association that specializes in endocrinology, diabetes, and metabolism which provides individuals with resources such as guidelines and algorithms for diabetes care.
      American Association of Diabetes Educatorswww.diabeteseducator.org/homeA professional membership organization with the goal of improving diabetes care through education, management, and support. The organization also offers the Board Certified-Advanced Diabetes Management (BC-ADM) credential, which is its certification for advanced-level practitioners.
      American College of Obstetricians and Gynecologistswww.acog.orgA nonprofit organization that produces practice guidelines and other educational material for the American Congress of Obstetricians and Gynecologists.
      American Diabetes Association Guide to Nutrition Therapy for Diabetes, 3rd editionwww.ada.orgA comprehensive compilation of evidence-based information for providing medical nutrition therapy and nutrition interventions for the spectrum of diabetes care.
      American Diabetes Association’s Standards of Medical Care in Diabetesprofessional.diabetes.org/content-page/standards-medical-care-diabetesThese standards, updated annually, are aimed at providing individuals with the components of diabetes care, general treatment goals, and tools to evaluate quality care for all populations and a variety of settings.
      Centers for Disease Control and Preventionwww.cdc.gov/diabetesA place for resources such as data and statistics, programs and initiatives, research, and publications on diabetes.
      Diabetes Self-Management Education and Support in Type 2 Diabetes: A Joint Position Statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dieteticswww.eatrightpro.org/resource/practice/position-and-practice-papers/position-papers/academy-position-papers-indexThis joint position statement focuses on the position that all individuals with diabetes receive diabetes self-management education and support.
      Guiding Principles for the Care of People with or at Risk for Diabeteswww.niddk.nih.gov/health-information/communication-programs/ndep/health-professionals/guiding-principles-care-people-risk-diabetesPrinciples that aim to help guide primary care providers and health care teams deliver quality diabetes care to adults with or at risk for diabetes.
      National Certification Board for Diabetes Educatorswww.ncbde.org/An organization with a mission to promote quality diabetes education by developing and maintaining certification and credentialing process for Certified Diabetes Educators (CDEs).
      National Standards for Diabetes Self-Management Education and Supportwww.diabeteseducator.org/practice/practice-documents/national-standards-for-dsmesGuidelines for operating a diabetes self-management education and support program that are updated every 5 years.
      a Academy=Academy of Nutrition and Dietetics.
      b RDN=registered dietitian nutritionist.
      c EAL=Evidence Analysis Library.
      d MNT=medical nutrition therapy.
      Figure thumbnail gr5a
      Figure 5Diabetes self-management education and support for adults with type 2 diabetes: Algorithm of care.
      • Powers M.
      • Bardsley J.
      • Cypress M.
      • et al.
      Diabetes self-management education and support in type 2 diabetes: A joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics.
      Figure thumbnail gr5b
      Figure 5Diabetes self-management education and support for adults with type 2 diabetes: Algorithm of care.
      • Powers M.
      • Bardsley J.
      • Cypress M.
      • et al.
      Diabetes self-management education and support in type 2 diabetes: A joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics.
      In specific instances, the practice of some RDNs has evolved to include care beyond diabetes MNT. In accordance with demonstrated competence and organization-approved protocols, some RDNs now provide instruction for self-monitoring blood glucose, insulin administration, adjusting diabetes medication, as well as provide training on CSII and CGM devices. It is important to note that neither the CDE nor BC-ADM credential authorizes an individual to perform tasks outside of his or her professional scope of practice, but an RDN, after competency is demonstrated, can teach a patient/client to self-administer his or her own insulin injections or perform an invasive procedure and adjust medications when using provider or organization-approved protocols.
      The Academy supports a variety of DPGs such as the DCE DPG. The DCE DPG is for those interested in diabetes information, networking, and for those working in the diabetes focus area. Membership has maintained a steady growth with more than 5,400 members. The mission of the DCE DPG further emphasizes the role of RDNs in diabetes care by empowering its members “to be leaders in food, nutrition, diabetes care, and prevention” with the vision of “optimizing the health of people impacted by diabetes using food, nutrition and self-management education.”

      About DCE. Diabetes Care and Education Dietetic Practice Group website. https://www.dce.org/about-us/. Accessed March 28, 2018.

      The DCE DPG provides numerous opportunities for professional growth by promoting clinical/educational research, offering continuing education through its newsletter and webinars, collaborations with diabetes organizations and industry, proactively advocating for diabetes legislation, and providing diabetes educational tools and publications for both professional use and for people with diabetes available through the DPG’s website at www.dce.org/.

      Academy Revised 2017 SOP and SOPP for RDNs (Competent, Proficient, And Expert) In Diabetes Care

      An RDN can use the Academy Revised 2017 SOP and SOPP for RDNs (Competent, Proficient, and Expert) in Diabetes Care (see Figures 1 and 2, available at www.jandonline.org, and Figure 3) to:
      • identify the competencies needed to provide diabetes nutrition and dietetics care and services;
      • self-evaluate whether he or she has the appropriate knowledge, skills, and judgment to provide safe and effective diabetes care, and other nutrition and dietetics diabetes-related services for their level of practice;
      • identify the areas in which additional knowledge, skills, and experience are needed to practice at the competent, proficient, or expert level of diabetes nutrition and dietetics practice;
      • provide a foundation for public and professional accountability in diabetes nutrition and dietetics care and services;
      • support efforts for strategic planning, performance improvement, outcomes reporting, and assist management in the planning and communicating of diabetes nutrition care, dietetics services, research, and resources;
      • enhance professional identity and skill in communicating the nature of diabetes nutrition and dietetics care and services;
      • guide the development of diabetes nutrition and dietetics-related education and continuing education programs, job descriptions, practice guidelines, competence evaluation tools, and career pathways; and
      • assist educators and preceptors in teaching students and interns the knowledge, skills, and competencies needed to work and specialize in diabetes nutrition and dietetics, and the understanding of the full scope of this focus area of practice.

      Application to Practice

      All RDNs, even those with significant experience in other practice areas, must begin at the competent level when practicing in a new setting or new focus area of practice. At the competent level, an RDN in diabetes care is learning the principles that underpin this focus area and is developing knowledge and skills, and judgment for safe and effective diabetes nutrition and dietetics practice. This RDN, who may be new to the profession or may be an experienced RDN, has a breadth of knowledge in nutrition and dietetics and may have proficient or expert knowledge/practice in another focus area. However, an RDN new to the focus area of diabetes care must accept the challenge of becoming familiar with the body of knowledge, practice guidelines, and available resources to support and ensure quality diabetes-related nutrition and dietetics practice.
      At the proficient level, an RDN has progressed to a more in-depth understanding of diabetes practice, and is more skilled at adapting and applying evidence-based guidelines and best practices than at the competent level. This RDN is able to modify practice to meet individualized needs (eg, integrating care of multiple comorbid diabetes-related conditions, cultural and population health factors, and psychosocial concerns). In addition, an RDN at this level understands the interrelationship of MNT, blood glucose monitoring, physical activity, and medication adjustments in the overall treatment plan for the individual with diabetes. RDNs at the proficient level may possess a CDE or other specialist credential(s). Indicators described as proficient level of practice in this document are not equivalent to the CDE or other specialist credential(s). Rather, the CDE or other specialist credential(s) refer to an RDN who has developed and demonstrated, through successful completion of the certification examination and compliance with recertification requirements, diabetes nutrition, care and management knowledge, skill, and application beyond the competent practitioner. An RDN practicing at this level may obtain certification to provide education and training on the use of diabetes technology (eg, CSII, CSII integrated with continuous glucose monitoring, hybrid-closed loop CSII, or stand-alone CGM).
      At the expert level, RDNs think even more critically about diabetes nutrition and dietetics care and services, demonstrate a more intuitive understanding of diabetes care and service, display a range of highly developed clinical knowledge and technical skills, and formulate judgments acquired through a combination of education, experience, and critical thinking. Essentially, practice at the expert level requires the application of advanced nutrition and diabetes care knowledge, with practitioners drawing not only on their practice experience, but also on the experience of RDNs providing diabetes care and services in various disciplines and practice settings. Expert RDNs, with their extensive experience and ability to see the significance and meaning of diabetes nutrition and diabetes within a contextual whole, are flexible and have considerable autonomy in practice. In addition, they may hold a specialist credential such as BC-ADM or CDE. They not only develop and implement diabetes nutrition and diabetes care services, but they also manage, drive, and direct clinical care; conduct and collaborate in research and advocacy; accept organization leadership roles; engage in scholarly work; guide interprofessional teams; and lead the advancement of diabetes nutrition and dietetics practice. An RDN practicing at this level may assist with the development of organization-approved protocols for making adjustments to diabetes-related medications based on analysis of the nutrition assessment and biochemical parameters or research pertaining to diabetes care and management.
      Indicators for the SOP and SOPP for RDNs in Diabetes Care are measurable action statements that illustrate how each standard can be applied in practice (Figures 1 and 2, available at www.jandonline.org). Within the SOP and SOPP for RDNs in Diabetes Care, an “X” in the competent column indicates that an RDN who is caring for patients/clients is expected to complete this activity and/or seek assistance to learn how to perform at the level of the standard. For example, a competent RDN in diabetes care could be an RDN starting practice after registration or an experienced RDN who cares for patients with a wide variety of medical diagnoses, including diabetes, who collaborates with RDN experienced with care of individuals with diabetes and/or CDE in ambulatory care to provide care for inpatients requiring intensified diabetes treatment such as CSII and/or CGM after discharge.
      An “X” in the proficient column indicates that an RDN who performs at this level has a deeper understanding of diabetes care and related services and has the ability to modify or guide therapy to meet the needs of patients/clients in various situations (eg, caring for clients with multiple diabetes-related comorbidities and acute/complex issues such as trauma/injury/illness, or serves as outpatient diabetes educator, or coordinator of a diabetes self-management education and support program).
      An “X” in the expert column indicates that the RDN who performs at this level possesses a comprehensive understanding of diabetes care and related services, or role and responsibilities in the diabetes focus area (eg, research); and a highly developed range of skills and judgments acquired through a combination of experience and education (eg, provides MNT for clients referred for counseling, making medical recommendations to providers, education on adjusting for meals, physical activity, illness, other complex situations or utilizing diabetes technology, and/or developing organizational policies related to diabetes care). The expert RDN builds and maintains the highest level of knowledge, skills, and behaviors, including leadership, vision, and credentials.
      Standards and indicators presented in Figure 1 and Figure 2 (available at www.jandonline.org) in boldface type originate from the Academy’s Revised 2017 SOP in Nutrition Care and SOPP for RDNs
      • Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists.
      and should apply to RDNs in all three levels. Additional indicators not in boldface type developed for this focus area are identified as applicable to all levels of practice. Where an “X” is placed in all three levels of practice, it is understood that all RDNs in diabetes care are accountable for practice within each of these indicators. However, the depth with which an RDN performs each activity will increase as the individual moves beyond the competent level. Several levels of practice are considered in this document; thus, taking a holistic view of the SOP and SOPP for RDNs in Diabetes Care is warranted. It is the totality of individual practice that defines a practitioner’s level of practice and not any one indicator or standard.
      RDNs should review the SOP and SOPP in Diabetes Care at determined intervals to evaluate their individual focus area knowledge, skill, and competence. Consistent self-evaluation is important because it helps identify opportunities to improve and enhance practice and professional performance, and set goals for professional development. This self-appraisal also enables RDNs providing diabetes care, nutrition counseling and education to better utilize these Standards as part of the Professional Development Portfolio recertification process,
      • Weddle D.O.
      • Himburg S.P.
      • Collins N.
      • Lewis R.
      The professional development portfolio process: Setting goals for credentialing.
      which encourages CDR-credentialed nutrition and dietetics practitioners to incorporate self-reflection and learning needs assessment for development of a learning plan for improvement, and commitment to lifelong learning. CDR’s updated system implemented with the 5-year recertification cycle that began in 2015 incorporates the use of essential practice competencies for determining professional development needs.
      • Worsfold L.
      • Grant B.L.
      • Barnhill C.
      The essential practice competencies for the Commission on Dietetic Registration’s credentialed nutrition and dietetics practitioners.
      In the new three-step process, a credentialed practitioner accesses an online Goal Wizard (step 1), which uses a decision algorithm to identify essential practice competency goals and performance indicators relevant to an RDN’s area(s) of practice (essential practice competencies and performance indicators replace the learning need codes of the previous process). The Activity Log (step 2) is used to log and document continuing professional education over the 5-year period. The Professional Development Evaluation (step 3) guides self-reflection and assessment of learning and how it is applied. The outcome is a completed evaluation of the effectiveness of the practitioner’s learning plan and continuing professional education. The self-assessment information can then be used in developing the plan for the practitioner’s next 5-year recertification cycle. For more information, see www.cdrnet.org/competencies-for-practitioners.
      RDNs are encouraged to pursue additional knowledge, skills, and training, regardless of practice setting, to maintain currency and to expand individual scope of practice within the limitations of the legal scope of practice as defined by state law. RDNs are expected to practice only at the level at which they are competent, and this will vary depending on education, training, and experience.
      • Gates G.R.
      • Amaya L.
      Ethics opinion: Registered dietitian nutritionists and nutrition and dietetics technicians, registered are ethically obligated to maintain personal competence in practice.
      RDNs should collaborate with other RDNs in diabetes care as learning opportunities and to promote consistency in practice, performance, and continuous quality improvement. See Figure 6 for role examples of how RDNs in different roles and at different levels of practice may use the SOP and SOPP in Diabetes Care.
      Figure 6Role examples of Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitian Nutritionists (RDNs) (Competent, Proficient, and Expert) in Diabetes Care.
      RoleExamples of use of SOP and SOPP documents by RDNs in different practice roles
      Clinical practitioner–

      inpatient care
      A community hospital recently employed a newly credentialed Registered Dietitian Nutritionist (RDN) for the adult general medicine units. The RDN observes that diabetes is a common medical diagnosis. To strengthen knowledge and skills in diabetes management and education, the RDN reviews the SOP and SOPP in Diabetes Care to evaluate skills and competencies for providing care to individuals with diabetes and sets professional goals to improve competency in this area of practice. The RDN meets with the RDN in the Diabetes Education Center to learn about the program and referral process, and obtain advice on continuing education options for inclusion in a professional development plan. The RDN uses other staff RDNs as mentors and consults when patients have complex management needs beyond the RDN’s experience/level of competence.
      Clinical practitioner–

      ambulatory care
      An experienced RDN working in a primary care clinic routinely provides medical nutrition therapy counseling and education for patients with diabetes (or comorbid condition) because there is not a community diabetes education program. The RDN would like to qualify for the Certified Diabetes Educator (CDE) credential. The RDN uses the SOP and SOPP for Diabetes Care, the Academy Evidence Analysis Library guidelines and resources from diabetes organizations to demonstrate best practices in diabetes self-management education and support activities. The RDN uses the SOP and SOPP for self-evaluation of current level of practice in determining areas to strengthen with the goal of achieving the proficient practice level. The RDN reviews the criteria for the CDE certification examination to update professional development plan for successful CDE credential attainment.
      Clinical practitioner–diabetes education programAn RDN who is a CDE practicing in a diabetes education program, is trained in quality improvement, and is eligible for the quality coordinator position. The role would entail leading the interprofessional diabetes care team to develop and manage the program’s quality improvement processes for data collection, analysis, presentation of results, and adjusting services to achieve quality outcomes. Resources to assist with accomplishing the role tasks are the SOP and SOPP for RDNs in Diabetes Care and other disciplines’ standards. The RDN reviews current professional development plan and updates essential practice competencies to add continuing education activities in Lean/Six Sigma, quality improvement-related training and quality management outcomes measures development process.
      Clinical nutrition managerA clinical nutrition manager who manages inpatient and outpatient nutrition services, and the accredited diabetes education center refers to the focus area SOP and SOPP as support tools for developing position descriptions, competence standards, and assessment tools. The RDN also uses the SOP and SOPP as a resource to help guide self-evaluation and professional development activities with RDN staff. The clinical nutrition manager refers to the SOP and SOPP for RDNs in Diabetes Care, standards of practice for the diabetes nurse educator, and diabetes organization standards of care (eg, American Diabetes Association Standards of Medical Care in Diabetes,

      American Diabetes Association. Standards of medical care in diabetes-2018. https://professional.diabetes.org/content-page/standards-medical-care-diabetes. Accessed March 5, 2018.

      and diabetes self-management education and support Algorithm of Care
      • Powers M.
      • Bardsley J.
      • Cypress M.
      • et al.
      Diabetes self-management education and support in type 2 diabetes: A joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics.
      ) as key resources for ensuring a quality program and compliance with accreditation program standards.
      Long-term care/

      skilled nursing practitioner
      An RDN working in a skilled nursing and long-term care facility observes increases in the number of new residents having more complex diabetes-related management requirements. The RDN refers to the SOP and SOPP in Diabetes Care for reviewing knowledge and skills needed to provide quality diabetes care and identifies areas for continuing education. The RDN makes the case for why an RDN, CDE consultation would be beneficial for individualized resident care to the facility's administrator, medical director, and/or director of nursing. The RDN uses the information and resources in discussions with the interprofessional team for care plan development and diet order and/or meal plan adjustments.
      Telehealth practitionerAn RDN in a hospital offers telehealth services providing nutrition consultations to patients/clients with diabetes. The RDN considers the SOP and SOPP in Diabetes Care when determining expertise needed. The RDN routinely monitors all relevant state laws and regulations, the Academy of Nutrition and Dietetics telehealth resources, and organization policies regarding the practice of telehealth specifically considering requirements in the case that a patient/client lives in another state. The RDN uses the SOP SOPP in Diabetes Care to evaluate level of competence and identify areas for additional knowledge and/or skills in diabetes self-management education and support. The review assists the RDN recognizing when a referral is needed including, but not limited to, an RDN, CDE with more extensive diabetes management experience in dealing with complex medical and diabetes issues.
      In some instances, components of the SOP and SOPP for RDNs in Diabetes Care do not specifically differentiate between proficient-level and expert-level practice. In these areas, it remains the consensus of the content experts that the distinctions are subtle, captured in the knowledge, experience, and intuition demonstrated in the context of practice at the expert level, which combines dimensions of understanding, performance, and value as an integrated whole.
      • Chambers D.W.
      • Gilmore C.J.
      • Maillet J.O.
      • Mitchell B.E.
      Another look at competency-based education in dietetics.
      A wealth of knowledge is embedded in the experience, discernment, and practice of expert-level RDN practitioners. An experienced practitioner observes events, analyzes them to make new connections between events and ideas, and produces a synthesized whole. The knowledge and skills acquired through practice will continually expand and mature. The SOP and SOPP indicators are updated with each review of these standards, and includes input from expert-level RDNs who systematically record and document their experiences, often through use of exemplars. Exemplary actions of individual RDNs in diabetes care in practice settings and professional activities that enhance patient/client care and/or services can be used to illustrate outstanding practice models and serve as benchmarks for practitioners who aspire to advance their professional skills to the expert level. One such example is the leadership role that RDNs took to guide the development of the DSMES Algorithm of Care and the AADE7 Self-Care Behaviors system.
      • Raynor H.A.
      • Davidson P.G.
      • Burns H.
      • et al.
      Medical nutrition therapy and weight loss questions for the evidence analysis library prevention of type 2 diabetes: Systematic reviews.
      • Siminerio L.
      • Ruppert K.
      • Huber K.
      • Toledo F.G.S.
      Telemedicine for reach, education, access, and treatment (TREAT): Linking telemedicine with diabetes self-management education to improve care in rural communities.
      • Powers M.
      • Bardsley J.
      • Cypress M.
      • et al.
      Diabetes self-management education and support in type 2 diabetes: A joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics.

      Future Directions

      The SOP and SOPP for RDNs in Diabetes Care are innovative and dynamic documents. Future revisions will reflect changes and advances in practice, changes to dietetics education standards, regulatory changes, outcomes of practice audits, and the refinement of the expectation of entry-level vs advanced practice in an integrative collaborative health care environment. Continued clarity and differentiation of the three practice levels in support of safe, effective, and quality practice in diabetes care remains an expectation of each revision to serve tomorrow's practitioners and their patients, clients, and customers.

      Summary

      RDNs face complex situations every day. Addressing the unique needs of each situation and applying standards appropriately is essential to providing safe, timely, person-centered quality care and service. All RDNs are advised to conduct their practice based on the most recent edition of the Code of Ethics, the Scope of Practice for RDNs, and the SOP in Nutrition Care and SOPP for RDNs, along with applicable federal and state regulations and facility/program accreditation standards. The SOP and SOPP for RDNs in Diabetes Care are complementary documents and are key resources for RDNs and others, including regulators and accrediting organizations. These standards can and should be used by RDNs in daily practice who provide care to individuals with diabetes to consistently improve and appropriately demonstrate competence and value as providers of safe, effective, and quality nutrition and dietetics care and services. These standards also serve as a professional resource for self-evaluation and professional development for RDNs specializing in diabetes care practice. Just as a professional’s self-evaluation and continuing education process is an ongoing cycle, these standards are also a work in progress and will be reviewed and updated every 7 years. Current and future initiatives of the Academy as well as advances in diabetes care and services will provide information to use in future updates and in further clarifying and documenting the specific roles and responsibilities of RDNs at each level of practice. As a quality initiative of the Academy and the DCE DPG, these standards are an application of continuous quality improvement and represent an important collaborative endeavor.
      These standards have been formulated for use by individuals in self-evaluation, practice advancement, development of practice guidelines and specialist credentials, and as indicators of quality. These standards do not constitute medical or other professional advice, and should not be taken as such. The information presented in the standards is not a substitute for the exercise of professional judgment by a nutrition and dietetics practitioner. These standards are not intended for disciplinary actions, or determinations of negligence or misconduct. The use of the standards for any other purpose than that for which they were formulated must be undertaken within the sole authority and discretion of the user.

      Acknowledgements

      The authors thank Alison Evert, MS, RD, CDE; Anne Daly, MS, RD, BC-ADM, CDE; and Karmeen Kulkarni, MS, RD, BC-ADM, CDE, who gave willingly of their time to review these standards, and to the Diabetes Care and Education Dietetic Practice Group’s Executive Committee. The authors also thank all who were instrumental in the process for the revisions of the article and the Academy of Nutrition and Dietetics staff, in particular Carol Gilmore, MS, RDN, LD, FADA, FAND; Dana Buelsing, MS; and Sharon McCauley, MS, MBA, RDN, LDN, FADA, FAND, who supported and facilitated the development of these Standards of Practice and Standards of Professional Performance.

      Author Contributions

      Each author contributed to editing the components of the article and reviewed all drafts of the manuscript.

      Supplementary Materials

      Figure 1Standards of Practice (SOP) for Registered Dietitian Nutritionists (RDNs) in Diabetes Care. The terms patient, client, customer, individual, person, group, or population are used interchangeably with the actual term used in a given situation dependent on the setting and the population receiving care or services.
      Standards of Practice for Registered Dietitian Nutritionists in Diabetes Care

      Standard 1: Nutrition Assessment

      The registered dietitian nutritionist (RDN) uses accurate and relevant data and information to identify nutrition-related problems.

      Rationale:

      Nutrition screening is the preliminary step to identify individuals who require a nutrition assessment performed by an RDN. Nutrition assessment is a systematic process of obtaining and interpreting data to make decisions about the nature and cause of nutrition-related problems and provides the foundation for nutrition diagnosis. It is an ongoing, dynamic process that involves not only initial data collection, but also reassessment and analysis of patient/client or community needs. Nutrition assessment is conducted using validated tools based in evidence, the five domains of nutrition assessment and comparative standards. Nutrition assessment may be performed via in-person, or facility/practitioner assessment application, or Health Insurance Portability and Accountability Act-compliant video conferencing telehealth platform.
      Indicators for Standard 1: Nutrition Assessment
      Bold Font Indicators are Academy Core RDN Standards of Practice IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      1.1Patient/client/population history: Assesses current and past information related to personal, medical, family, and psychosocial/social historyXXX
      1.1AEvaluates diabetes history, including assessment of diabetes education, support, skills, and behaviors considering EAL
      EAL=Academy of Nutrition and Dietetics Evidence Analysis Library. Review EAL list of guidelines as there are multiple guidelines that relate to diabetes (Gestational, Type 1 and Type 2 in Adults, Prevention Type 2), and comorbidities (eg, Chronic Kidney Disease; Hypertension; Obesity/Overweight, Adult and Childhood).
      diabetes-related guidelines and AADE7
      AADE7=American Association of Diabetes Educators 7 Self Care Behaviors (www.diabeteseducator.org).
      and DSMES
      DSMES=diabetes self-management education and support (https://professional.diabetes.org/content-page/standards-medical-care-diabetes).
      guidelines
      XXX
      1.1A1Evaluates diabetes, nutrition history, and intensity of diabetes management (eg, DSMES, CSII,
      CSII=continuous sustained insulin infusion (ie, insulin pump).
      and/or use of CGM
      CGM=continuous glucose monitoring.
      )
      XX
      1.1BEvaluates medical history of health, disease conditions, and other comorbidities (eg, CVD
      CVD=cardiovascular disease.
      , lipid disorders, hypertension, overweight/obesity, kidney disease, cancer, metabolic/bariatric surgery, stroke, chronic obstructive pulmonary disease, and heart failure)
      XXX
      1.1B1Assesses history of past and recurrent sleep disturbances, insomnia (eg, night eating, hormonal changes, and blood glucose variability)XX
      1.1B2Assesses history of problems with ingestion, digestion, absorption, and metabolism of macronutrients and micronutrients potentially impacted as a consequence of diabetes or other comorbiditiesXX
      1.1CEvaluates family history (eg, diabetes, CVD, lipid disorders, hypertension, overweight/obesity, kidney disease, cancer, peripheral vascular disease, and stroke)XXX
      1.1DEvaluates associated autoimmune comorbidities (eg, thyroid conditions, Addison’s disease, celiac disease, cystic fibrosis-related diabetes, pernicious anemia)XXX
      1.1EDetermines history of tobacco (eg, cigarettes, e-cigarettes, or smokeless tobacco), alcohol, illicit drug useXXX
      1.1FEvaluates psychosocial factors or issues, including family and significant others and social support, cognitive impairment support, diabetes distress/depression/anxiety, disordered eating, or eating disorderXXX
      1.1F1Assesses nutrition-related patient/client-centered measures, including nutrition quality of life and activities of daily livingXXX
      1.1F2Assesses perception of his or her nutrition and diabetes care (eg, cultural, ethnic, religious, and lifestyle factors)XXX
      1.1F3Screens for signs/symptoms of diabetes distressXX
      1.1F4Assesses history of past and current impacts of trauma/stress on dietary intake and diabetes management (eg, mental health technology phobia, fear of SMBG
      SMBG=self-monitoring blood glucose.
      , fear of hypoglycemia, and health anxiety)
      X
      1.1F5Assesses history of or signs/symptoms for depressionX
      1.1GEvaluates preventive care strategies and behaviors (eg, lifestyle prevention practices and screening family members for diabetes risk)XXX
      1.2Anthropometric assessment: Assesses anthropometric indicators (eg, height, weight, body mass index, waist circumference, and arm circumference), comparison to reference data (eg, percentile ranks/z scores), and individual patterns and historyXXX
      1.2AIdentifies appropriate adult and pediatric reference standards for comparisonXXX
      1.2A1Estimates and modifies anthropometric measurements, as appropriate (eg, amputations and pregnancy)XXX
      1.2A2Identifies and interprets trends in anthropometric indexes (eg, for suboptimal growth and development or overweight/obesity in children, adolescents, and teens)XX
      1.3Biochemical data, medical tests, and procedure assessment: Assesses laboratory profiles (eg, acid-base balance, renal function, endocrine function, inflammatory response, vitamin/mineral profile, lipid profile), and medical tests and procedures (eg, gastrointestinal study and metabolic rate)XXX
      1.3AEvaluates nutrition implications of diagnostic tests:
      • diagnosis of diabetes, pre-diabetes, or gestational diabetes
      • laboratory data for diabetes-related complications such as lipids, glucose, renal function, and other nutrition-related biochemical parameters
      • blood pressure and carotid ultrasound
      • neuropathy or retinopathy
      XXX
      1.3A1Evaluates and interprets other diabetes nutrition-related biochemical parameters (eg, long-term metformin use and vitamin B 12, or celiac disease) and lab tests associated with definitive diagnosis of diabetes type (eg, c-peptide, insulin antibodies)X
      1.3BEvaluates patient’s/client’s food records, SMBG data, and/or medication regimen for pattern managementXXX
      1.3B1Applies decision making to interpret food intake, labs (eg, HbA1c
      HbA1c=glycated hemoglobin.
      ), and glucose monitoring data (eg, SMBG, CGM, device settings, and/or electronically generated data reports) for pattern management evaluation
      XX
      1.3B2Evaluates and interprets food intake, glucose monitoring (eg, SMBG, CGM, device settings, and/or electronically generated data reports) and procedures (eg, in/outpatient surgery, MRI
      MRI=magnetic resonance imaging.
      or CT
      CT=computed tomography scan.
      ) for more complex decisions in pattern management and medication adjustments
      X
      1.4Nutrition-focused physical examination (NFPE) may include visual and physical examination: Obtains and assesses findings from NFPE (eg, indicators of vitamin/mineral deficiency/toxicity, edema, muscle wasting, subcutaneous fat loss, altered body composition, oral health, feeding ability [suck/swallow/breathe], appetite, and affect)XXX
      1.4AReviews screening data or screens for nutrition risk (eg, malnutrition, food security) using evidence-based screening tools for the setting and/or population (adult or pediatric)XXX
      1.4BPerforms NFPE that includes, but is not limited to the inspection of injection, CSII and sensor sites; oral health; monofilament foot exams; body areas or skin for signs of irritation or dry or cracked at risk of ulcer; conditions related to diabetes (eg, nonhealing wound, acanthosis nigricans, foot exams, or vitiligo)XX
      1.4CUtilizes evidence-based recommendations for guiding the NFPE and evaluating the physical or clinical findings (eg, AMA–PQRI
      AMA-PQRI=American Medical Association-Physician Quality Reporting Initiative (https://assets.ama-assn.org/resources/doc/cqi-templates/pqri-sort.shtml).
      Measures and ADA
      ADA=American Diabetes Association (www.diabetes.org).
      Standards of Medical Care in Diabetes [www.diabetes.org])
      X
      1.4DAssess clinical signs of malnutrition, undernutrition, disordered eating, or eating disorder (eg, muscle wasting, dry, brittle, or thinning hair and nails, sarcopenia, and cachexia) to identify a nutrition diagnosis and developing a plan of care/interventionX
      1.5Food and nutrition-related history assessment (ie, dietary assessment):

      Evaluates:
      XXX
      1.5AFood and nutrient intake, including the composition and adequacy, meal and snack patterns, and appropriateness related to food allergies and intolerancesXXX
      1.5A1Assesses fluid intake, appetite, and dietary pattern changes (eg, oral issues-chewing and swallowing, gastrointestinal problems, or comorbid conditions), and any changes for potential impact on diabetes management; seeks guidance as neededXXX
      1.5A2Assesses changes in appetite or usual intake resulting from illness, sports, travel, medical conditions, and/or psychological issues (eg, stress, trauma, depression, or disordered eating) for impact on diabetes managementXX
      1.5A3Assesses daily fluid needs for health, physical activity, fitness level, and environmental conditions, and comorbid conditions (eg, renal or heart failure)XX
      1.5A4Assess food and nutrient intake considering the following:
      • type and distribution of macronutrient intake (eg, carbohydrate, protein, and fat), and fiber
      • micro- and macronutrient intake using appropriate tools, and comparing with evidence-based nutrition recommendations for individuals with diabetes across the life cycle (eg, vitamins and minerals)
      • adequacy of nutrition intake to maintain energy balance under various conditions throughout the life cycle (eg, physical activity or comorbid conditions)
      • history of food allergies/intolerances (eg, gluten sensitivity or intolerance, lactose intolerance)
      • understanding of dietary modifications superimposed with comorbidities (eg, heart failure, renal, CVD)
      XX
      1.5BFood and nutrient administration, including current and previous diets and diet prescriptions and food modifications, eating environment, and enteral and parenteral nutrition administrationXXX
      1.5B1Evaluates diet experience and current meal planning approach (eg, carbohydrate counting, calorie counting, plate method, carbohydrate controlled, previous diabetes/nutrition education/counseling, or weight management attempts)XXX
      1.5B2Evaluates eating environment, access, and cultural influences or differences (eg, location, atmosphere, family/caregiver/companion, eats alone, and types/preparation of cuisine)XX
      1.5B3Considers complex issues (eg, recovery from surgery/

      trauma/injury/illness) or changes in severity of comorbid conditions (eg, steroid- or chemically-induced diabetes) related to food intake and clinical complications; seeks assistance from experienced practitioner, if needed
      X
      1.5B4Considers complex diabetes management issues (eg, recovery from major surgery/trauma/injury/illness, nutrition support) related to food intake, changes in comorbid conditions, and medication managementX
      1.5CMedication and dietary supplement use including prescription and OTC
      OTC=over the counter.
      medications, and integrative and functional medicine products
      XXX
      1.5C1Evaluates prescriptions and adherence to oral diabetes medications, other injectables, and/or insulin (eg, type, dosage, effect, and duration); seeks assistance if neededXX
      1.5C1iAssesses current and coordinates regimen of all medications, including diabetes-related (injectables and/or oral), comorbid conditions (eg, hypertension, CVD, and renal), and other disease-related medications (eg, thyroid, Addison’s disease, posttransplant, cancer) in relation to food intake and timing of administration (eg, insulin to carbohydrate ratios, ISF
      ISF=insulin sensitivity factor.
      , exercise, and antibiotics)
      X
      1.5C1iiAssesses overall medication management in the context of integrated disease state management (eg, end-stage renal disease or heart failure)X
      1.5C2Assesses safety and efficacy of OTC medications and dietary supplements, including herbalsXXX
      1.5C3Reviews relationships between prescription, OTC, and dietary supplements, including herbals and medicinal spices used and their potential influence on blood glucose levelsXX
      1.5C4Observes and evaluates administration technique of insulin, other injectable or medication delivery systems, and their appropriateness and use (eg, CSII, syringe, or pen); glucagon administration technique; and urine and blood ketone testing when appropriateXX
      1.5C5Evaluates blood glucose monitoring equipment selection, use, techniques, and reports either self-reported or electronically generated (eg, SMBG or CGM)X
      1.5DKnowledge, beliefs, and attitudes (eg, understanding of nutrition-related concepts, emotions about food/nutrition/health, body image, preoccupation with food and/or weight, readiness to change nutrition- or health-related behaviors, and activities and actions influencing achievement of nutrition-related goals)XXX
      1.5D1Assesses behavioral mediators (or antecedents) related to living with diabetes/chronic disease and dietary intake (eg, attitudes, self-efficacy, knowledge, intentions, readiness and willingness to change, and perceived social support)XXX
      1.5D2Evaluates nutrition and self-care skills, behaviors, health care knowledge/beliefs/attitudes from the patient’s/client’s/caregiver’s perspective (eg, experience self-adjusting the treatment plan and culture)XXX
      1.5D3Evaluates lifestyle behaviors related to diabetes, its complications and congruency with patient-centered management goals (eg, self-reported adherence, appointments, recall of nutrition or diabetes-related goals, self-monitoring, and self-management as agreed upon)XX
      1.5D4Evaluates various influences (eg, language, physical activity, social networks, culture, ethnicity, and religion) that relate to the potential impact on behavior changeXX
      1.5D5Determines readiness of patient/client for intensifying glycemic control to prevent or reduce the progression of chronic complications and/or comorbiditiesX
      1.5D6Assesses risk/history of eating disorders and/or disordered eating pattern or factors (eg, medication adjustments/omissions, food issues, and physical activity) such as:
      • bingeing and purging eating behavior and antecedents (eg, goes into bathroom immediately after eating or exercises or misses medication doses)
      • abnormal mealtime behaviors (eg, drinking in place of eating, spitting out food, or restrictive behaviors such as limiting carbohydrates)
      • insulin omissions for weight control (eg, teens)
      • avoidance behavior (eg, eats alone, avoids social situations)
      • obsessive behaviors regarding meal composition
      X
      1.5EFood security defined as factors impacting access to a sufficient quantity of safe, healthful food and water, as well as food/nutrition-related suppliesXXX
      1.5E1Assesses food and water safety, access, and availability of healthy food/meals:
      • for appropriate food preparation resources (eg, financial, food markets/grocery stores, and equipment for cooking, serving, and safe food storage),
      • food environment or access (eg, use of food pantry, meal programs, homeless shelter), and
      • plans for emergency situations/disaster events (eg, food and water availability and supply of medications)
      XXX
      1.5FPhysical activity, cognitive and physical ability to engage in developmentally appropriate nutrition-related tasks (eg, mobility, self-feeding, and other ADLs
      ADL=activities of daily living.
      ), instrumental ADLs (eg, shopping and food preparation), and breastfeeding
      XXX
      1.5F1Assesses health literacy and numeracy (eg, ability to read, write, and perform calculations)XXX
      1.5F2Identifies and uses evidenced-based quality-of-life surveys for performing ADLs related to nutrition interventionsXX
      1.5GOther factors affecting intake and nutrition and health status (eg, cultural, ethnic, religious, lifestyle influencers, psychosocial, and social determinants of health)XXX
      1.5G1Assesses patient’s/client’s/family’s/caregiver’s understanding of health condition(s) and nutrition-related effects and implications as it relates to cultural, ethnic, and religious beliefs and traditionsXXX
      1.5G2Identifies and evaluates other influences (eg, nonmedical friend/family advice, commercial influences such as the Internet/media) that relate to diabetes management or nutrition therapyXX
      1.6Comparative standards: Uses reference data and standards to estimate nutrient needs and recommended body weight, body mass index, and desired growth patternsXXX
      1.6AIdentifies the most appropriate reference data and/or standards (eg, international, national, state, institutional, and regulatory) based on practice setting, and patient-/client-specific factors (eg, age and disease state)XXX
      1.6A1Compares nutrition assessment data to appropriate criteria, relevant norms, population-based surveys, standards (eg, Academy
      Academy=Academy of Nutrition and Dietetics (www.eatrightpro.org).
      , Dietitians of Canada, ADA, IDF
      IDF=International Diabetes Federation (www.idf.org).
      , The National Academies of Sciences, Engineering, and Medicine: Health and Medicine Division) positions for determining nutrition- and diabetes-related recommendations:
      • energy needs/balance
      • macronutrient and micronutrient needs
      • fluid and electrolyte balance
      XX
      1.6BEvaluates implications of data, reference standards, and practice guidelines for determining diabetes care and management approach through the life cycleX
      1.7Physical activity habits and restrictions: Assesses physical activity, history of physical activity, and physical activity trainingXXX
      1.7AEvaluates current diabetes treatment plan for appropriate physical activity prescription according to current guidelinesXXX
      1.7BAssess physical activity limitations (eg, vision, mobility, dexterity, and medication contraindications) and physical inactivity (eg, television/screen and other sedentary activity time)XXX
      1.7CAssesses factors influencing access to physical activity (eg, environmental safety [eg, physical and climatic], walkability of neighborhood, proximity to parks/green space, access to physical activity facilities/programs)XXX
      1.7DAssesses ability to perform physical activity in the presence of suboptimal blood glucose control (eg, hypo- or hyperglycemia) and specific long-term complications of diabetes (eg, retinopathy and neuropathy) in accordance with the current ADA Standards of Medical Care in Diabetes recommendationsXX
      1.8Collects data and reviews collected and/or documented data by the nutrition and dietetics technician, registered (NDTR), other health care practitioners(s), patient/client, or staff for factors that influence nutrition and health statusXXX
      1.8AAssesses risk of developing acute complications (eg, hypoglycemia and fall risk, hyperglycemia, DKA
      DKA=diabetic ketoacidosis.
      )
      XXX
      1.8BReviews collected data from all sources to identify factors that impact nutrition and health status and diabetes care and management:
      • frequency, severity, and consequences of hypoglycemia/hyperglycemia, and prevention/treatment
      • patient/client/advocate
        Advocate: An advocate is a person who provides support and/or represents the rights and interests at the request of the patient/client. The person may be a family member or an individual not related to the patient/client who is asked to support the patient/client with activities of daily living or is legally designated to act on behalf of the patient/client, particularly when the patient/client has lost decision making capacity. (Adapted from definitions within The Joint Commission Glossary of Terms12 and the Centers for Medicare and Medicaid Services, Hospital Conditions of Participation6).
        understanding of the most common precipitants of DKA and behaviors leading to DKA and hypoglycemia
      • results of preventive screenings for diabetes lifestyle prevention practices and diabetes complications (eg, immunizations, eye, foot, circulation, kidney function-microalbumin, HbA1c, lipid levels, and blood pressure)
      • actual risk of developing chronic macrovascular CVD and microvascular complications (eg, neuropathy, diabetic kidney disease, or retinopathy)
      • preventive care behaviors (eg, foot care, annual influenza immunization, pneumococcal immunization, annual dilated eye, and dental exams) based on the recommendations of the ADA Standards of Medical Care in Diabetes
      XX
      1.8CDirects nutrition management of long-term complications of diabetes within the context of interprofessional
      Interprofessional: Interprofessional is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physicians, nurses, dietitian nutritionists, pharmacists, diabetes educators, psychologists, social workers, and occupational and physical therapists), depending on the needs of the patient/client. Interprofessional could also mean interdisciplinary or multidisciplinary.
      care and referrals
      X
      1.9Uses collected data to identify possible problem areas for determining nutrition diagnosesXXX
      1.9AAssesses and prioritizes nutrition-related problems (eg, intake, behavior change, and weight change) for factors that influence nutrition and health statusXXX
      1.9BAssesses more complex issues related to food intake and clinical complications (eg, presence of nutrition risk factors and multiple complications) for prioritizing nutrition diagnosesXX
      1.9CAssesses complex food-related issues, clinical complications, and current or anticipated treatment options (eg, surgery or medical management adjustments) in prioritizing nutrition problems in collaboration with the interprofessional teamX
      1.10Documents and communicates:XXX
      1.10ADate and time of assessmentXXX
      1.10BPertinent data (eg, medical, social, and behavioral)XXX
      1.10CComparison to appropriate standardsXXX
      1.10DPatient/client/population perceptions, values, and motivation related to presenting nutrition and diabetes management-related problemsXXX
      1.10EChanges in patient/client/population perceptions, values and motivation related to presenting nutrition and diabetes management-related problemsXXX
      1.10FReason for discharge/discontinuation or referral, if appropriateXXX
      Examples of Outcomes for Standard 1: Nutrition Assessment
      • Appropriate assessment tools and procedures are used in valid and reliable ways
      • Appropriate and pertinent data are collected
      • Effective interviewing methods are used
      • Data are organized and categorized in a meaningful framework that relates to nutrition problems
      • Use of assessment data leads to the determination that a nutrition diagnosis/problem does or does not exist
      • Problems that require consultation with or referral to another provider are recognized
      • Documentation and communication of assessment are complete, relevant, accurate, and timely
      Standard 2: Nutrition Diagnosis

      The registered dietitian nutritionist (RDN) identifies and labels specific nutrition problem(s)/diagnosis(es) that the RDN is responsible for treating in diabetes care and management.

      Rationale:

      Analysis of the assessment data leads to identification of nutrition problems and a nutrition diagnosis(es), if present. The nutrition diagnosis(es) is the basis for determining outcome goals, selecting appropriate interventions, and monitoring progress. Diagnosing nutrition problems is the responsibility of the RDN.
      Indicators for Standard 2: Nutrition Diagnosis
      Bold Font Indicators are Academy Core RDN Standards of Practice IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      2.1Diagnoses nutrition problems based on evaluation of assessment data and identifies supporting concepts (ie, etiology, signs, and symptoms)XXX
      2.1AUses evidence-based guidelines and protocols to organize and group data consisting of intake, clinical, physical function, behavioral, environmental, and other assessmentsXXX
      2.1BConsiders complex information related to food intake and clinical factors (eg, metabolic/bariatric surgery, gestational diabetes/high-risk pregnancy, hyperlipidemia, hypertension, disordered eating or eating disorder, developmental disability, or psychiatric illness) when deriving the nutrition diagnosis(es)XX
      2.1CIntegrates complex information related to food intake, biochemical data, therapeutic procedures, and clinical complications and their management within an interprofessional environment (eg, uncontrolled diabetes, diabetic kidney disease, and neuropathy) when formulating a nutrition diagnosis(es)X
      2.2Prioritizes the nutrition problems(s)/diagnosis(es) based on severity, safety, patient/client needs and preferences, ethical considerations, likelihood that nutrition intervention/plan of care will influence the problem, discharge/transitions of care needs, and patient/client/advocate perception of importanceXXX
      2.2APrioritizes nutrition diagnoses in order of importance or urgency using evidence-based protocols and guidelines for diabetes careXXX
      2.2BPrioritizes nutrition diagnoses based on diabetes disease states and/or status (eg, at diagnosis, illness, or transition of care), complications, protocols, and guidelines for diabetes careXX
      2.2CPrioritizes nutrition diagnoses using advanced clinical reasoning and judgment for diabetes and other-related complicationsX
      2.3Communicates, providing evidence as necessary, and confirms the nutrition diagnosis(es) to patients/clients/advocates, community, family members, or other health care professionals when possible and appropriateXXX
      2.3ACommunicates and confirms the diagnosis(es) using clinical judgment skills (eg, consideration of the prevention of micro- and macrovascular complications)XX
      2.3BCommunicates and confirms the diagnosis(es) using advanced clinical reasoning and judgment as part of an interprofessional team (ie, addressing diabetes as a complex metabolic disorder)X
      2.4Documents the nutrition diagnosis(es) using standardized terminology and clear, concise written statement(s) (eg, using Problem [P], Etiology [E], and Signs and Symptoms [S] [PES statement(s)] or Assessment [A], Diagnosis [D], Intervention [I], Monitoring [M], and Evaluation [E] [ADIME statements(s)])XXX
      2.5Re-evaluates and revises nutrition diagnosis(es) when additional assessment data become availableXXX
      Examples of Outcomes for Standard 2: Nutrition Diagnosis

      • Nutrition Diagnostic Statements that are:
      • Clear, concise, accurate, and prioritized
      • Specific to patient/client (eg, community and/or culturally centered)
      • Based on reliable and accurate assessment data
      • Documentation of nutrition diagnosis(es) is relevant, accurate, and timely

      • Documentation of nutrition diagnosis(es) is revised as additional assessment data become available
      Standard 3: Nutrition Intervention/Plan of Care

      The registered dietitian nutritionist (RDN) identifies and implements appropriate, person-centered interventions designed to address nutrition-related problems, behaviors, risk factors, environmental conditions, or aspects of health status for an individual, target group, or the community at large.

      Rationale:

      Nutrition intervention consists of two interrelated components—planning and implementation.
      • Planning involves prioritizing the nutrition diagnoses, conferring with the patient/client and others, reviewing practice guidelines, protocols and policies, setting goals, and defining the specific nutrition intervention strategy.
      • Implementation is the action phase that includes carrying out and communicating the intervention/plan of care, continuing data collection, and revising the nutrition intervention/plan of care strategy, as warranted, based on change in condition and/or the patient/client/population response.
      An RDN implements the interventions or assigns components of the nutrition intervention/plan of care to professional, technical, and support staff in accordance with knowledge/skills/judgment, applicable laws and regulations, and organization policies. The RDN collaborates with or refers to other health care professionals and resources. The nutrition intervention/plan of care is ultimately the responsibility of the RDN.
      Indicators for Standard 3: Nutrition Intervention/Plan of Care
      Bold Font Indicators are Academy Core RDN Standards of Practice IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      Plans the Nutrition Intervention/Plan of Care:
      3.1Addresses the nutrition diagnosis(es) by determining and prioritizing appropriate interventions for the plan of careXXX
      3.1APrioritizes considering one or more of the following based on type of diabetes, ie, gestational diabetes, prediabetes, type 1 diabetes, or type 2 diabetes:
      • survival skills (eg, meal timing and composition, physical activity, SBGM, action and timing of medication[s], and prevention and treatment of hypo-/hyperglycemia)
      • DSMES/DSMT
        DSMT=diabetes self-management training (https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/DSMT-Accreditation-Program.html).
        needs (eg, National DSMES Standards and Algorithm of Care, AADE7 Self-Care Behaviors, and ADA Standards of Medical Care in Diabetes)
      • patient’s/client’s ability or willingness to implement and adhere to the nutrition plan
      • presence of comorbid diseases or conditions (eg, CVD, gastrointestinal disorders, renal function, and altered weight/growth status)
      XXX
      3.1BConsiders medical issues, treatment goals, patient/client/advocate goals including quality of life in determining appropriateness for intensive glycemic control to prevent or reduce progression of comorbidities, including need for hospitalizations and/or surgeryXX
      3.2Bases intervention/plan of care on best available research/evidence and information, evidence-based guidelines, and best practicesXXX
      3.2AUses EAL diabetes-related guidelines (eg, type 1 diabetes, type 2 diabetes, gestational diabetes, and prevention type 2) and ADA Nutrition recommendations
      • Evert A.B.
      • Boucher J.L.
      • Cypress M.
      • et al.
      American Diabetes Association. Nutrition therapy recommendations for the management of adults with diabetes.
      XXX
      3.2BAdjusts application of the diabetes education guidelines/protocols (National Standards for DSMES, AADE-7 Behaviors) based on the individual needs of the person with diabetes and progress of intervention in collaboration with the interprofessional teamXX
      3.2CRecognizes when it is appropriate to utilize adjusted intervention

      guidelines (eg, intellectual or developmental disabilities, hypoglycemic unawareness, cognitive changes, or emotional factors such as anxiety, clinical depression, or medications influencing glucose management)
      X
      3.3Refers to policies and procedures, protocols, and program standardsXXX
      3.4Collaborates with patient/client/advocate/population, caregivers, interprofessional team, and other health care professionalsXXX
      3.4AOrganizes and leads communication with patient/client, caregiver, family, or designee, and acts as case manager to coordinate and organize care in collaboration with interprofessional teamXX
      3.5Works with patient/client/advocate/population and caregivers to identify goals, preferences, discharge/transitions of care needs, plan of care, and expected outcomesXXX
      3.5ADevelops goals and outcomes with patient/client participation using clear, concise, and measurable termsXXX
      3.5BIdentifies, evaluates, and addresses readiness to change and barriers to successful implementation of patient-/client-centered goals and outcomes (eg, adherence, food availability and preparation issues, social support, readiness to change, financial considerations, realistic expectations, food knowledge and duration of treatment, commitment to process)XXX
      3.5CDevelops and implements strategies to address lapses in self-care management or behaviors and identifies recovery strategiesXX
      3.5DDirects nutrition management of long-term complications within the context of integrated care (eg, pregnancy, renal disease, heart failure, and surgery)X
      3.6Develops the nutrition prescription and established measurable patient-/client-focused goals to be accomplishedXXX
      3.6ADevelops or adjusts the nutrition prescription and diabetes self-management plan, as appropriate, considering:
      • medical conditions, including food restrictions and intolerances and treatment goals
      • nutrition diagnosis(es)–priority
      • physical activity and work schedule, if applicable
      • medication plan, if applicable
      • educational needs, including health literacy and numeracy
      • cultural, religious, and other influences and/or beliefs
      • food access and preparation skills
      • psychological and behavioral factors influencing diabetes management and support
      XXX
      3.6BReviews and determines need for initiation and/or adjustment of pharmacotherapy, considering nutrition, physical activity, growth, medication, blood glucose and/or CGM data, and physical exam (eg, intensification of medication management [adjusting dose/timing], discontinuation of medications based on progression of the disease or macronutrient impact), as part of an interprofessional teamXX
      3.7Defines time and frequency of care, including intensity, duration, and follow-upXXX
      3.7AUses guidelines established for medical nutrition therapy (eg, EAL diabetes-related guidelines [eg, type 1 diabetes and type 2 diabetes, gestational diabetes, and prevention type 2]), and DSMES (eg, DSMES Algorithm of Care) to determine duration and follow-upXXX
      3.8Uses standardized terminology for describing interventionsXXX
      3.9Identifies resources and referrals neededXXX
      3.9AIdentifies resources and tools to assist patient/client with managing food intake and glucose management (eg, food guides, mobile apps, portion guides, community support groups, fitness facilities, or other outpatient programs) to support behavior change goalsXXX
      3.9BIdentifies referrals to programs and/or providers (eg, behavioral health, ophthalmologist, podiatrist, physical therapist, personal trainer, and dentist) as appropriate and based on individual patient/client needsXXX
      3.9CIdentifies resources/initiates referrals for complex needs (eg, behavioral, communication ability, digestive changes, skills training for care providers/family, food security, transportation, and access)XX
      Implements the Nutrition Intervention/Plan of Care:
      3.10Collaborates with colleagues, interprofessional team, and other health care professionalsXXX
      3.10AProvides ongoing follow-up documentation to referring physician or midlevel providers (eg, physician assistants and advance practice nurses) and collaborates with interprofessional teams outside the immediate diabetes care team (eg, CVD, renal disease, obstetrics, cystic fibrosis, or posttransplant) for potential changes to plan of care (eg, medications)XXX
      3.10BRecommends to health care provider when medication adjustment is warranted (eg, based on glucose monitoring data or availability of payer coverage)XX
      3.10CPartners or collaborates within an interprofessional diabetes team and other providers to recommend changes to the diabetes protocols consistent with facility policies to manage nutrition-related conditions and support therapiesXX
      3.10DInitiates and/or leads planning and discussion of nutrition components of DSMES with the interprofessional team and other stakeholdersX
      3.11Communicates and coordinates the nutrition intervention/plan of careXXX
      3.11ACommunicates plan of care to health care professionals involved in implementation of the planXXX
      3.11A1Communicates, coordinates, and confirms understanding of care plan components with members of the health care team (eg, physician, pharmacist, nurse, nurse educator, mental/behavioral health practitioner, or bariatric coordinator)XX
      3.11BVerifies patient/client and, if applicable, family/significant others/caregivers, understand and can articulate goals and other relevant plan of care aspectsXX
      3.12Initiates the nutrition intervention/plan of careXXX
      3.12AUses approved clinical privileges, physician/non-physician practitioner
      Non-physician practitioner: A non-physician practitioner may include a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse-midwife, clinical social worker, clinical psychologist, anesthesiologist’s assistant, qualified dietitian, or nutrition professional. Disciplines considered for privileging by a facility’s governing body and medical staff must be in accordance with state law.6,7 The term privileging is not referenced in the Centers for Medicare and Medicaid Services Long-Term Care Regulations. With publication of the Final Rule revising the Conditions of Participation for Long Term Care Facilities effective November 2016, post-acute care settings, such as skilled and long-term care facilities, may now allow a resident’s attending physician the option of delegating order writing for therapeutic diets, nutritional supplements, or other nutrition-related services to the qualified dietitian or clinically qualified nutrition professional, if consistent with state law and organization policies.9,10
      -driven orders (ie, delegated orders), protocols, or other facility-specific processes for order writing or for provision of nutrition-related services consistent with applicable specialized training, competence, medical staff, and/or organizational policy
      XXX
      3.12A1Implements, initiates, or modifies orders for therapeutic diets, pharmacotherapy management, or nutrition-related services (eg, medical foods/nutrition/dietary supplements, food texture modifications, enteral and parenteral nutrition, intravenous fluid infusions, laboratory tests, medications, and education and counseling)XXX
      3.12A2Manages nutrition support therapies (eg, formula selection, rate adjustments, addition of designated medications and vitamin/mineral supplements to parenteral nutrition solutions or supplemental water for enteral nutrition)XXX
      3.12A2iManages enteral/parenteral nutrition and specialized nutrition support therapy, including formula selection and adjustment based on patient/client laboratory results, using provider-approved protocols, clinical privileges for order writing, or similar documents consistent with organization policies (eg, adjusting insulin dosage or pump settings)XX
      3.12A3Initiates and performs nutrition-related services (eg, beside swallow screenings, inserting and monitoring nasoenteric feeding tubes, and indirect calorimetry measurements, or other permitted services)XXX
      3.12A3iPlans and reviews selection and initiation of glucose monitoring equipment (eg, blood glucose meters, CGM systems, and sensor-augmented pumps)XX
      3.12A3iiProvides education and training with required CSII and CGM certification according to institution or organization protocol or approved clinical privilegesXX
      3.12BUtilizes appropriate behavior change theories (eg, motivational interviewing, behavior modification, and modeling) to facilitate individualized self-management self-care strategies and nutrition prescription and meal plan based on:
      • meal and pharmacotherapy interventions
      • physical activity and work schedules, if applicable
      • acute and chronic complications
      • sick days
      • SMBG frequency
      • growth and development
      XXX
      3.12CEducates patient/client on glucose regulation to support setting realistic self-management goals (eg, age, stress, or pregnancy)XX
      3.12DEducates using multiple intervention approaches as appropriate to guide decision making for patient/client in complicated, unpredictable, and dynamic situations (eg, trauma, acute diabetes-related complications) considering cultural and psychosocial factorsXX
      3.12EEducates using experiential and current body of advanced knowledge of patient/client population to individualize the treatment strategy for complex interventions (eg, culture, psychosocial, belief structure, and practices)X
      Provides DSMES for the following topics in 3.12F-3.12J as applicable to patient/client/advocate needs:
      3.12FDiscusses medication plan, if applicableXXX
      3.12F1Reviews actions, duration, and side effects of medications commonly used in diabetes management (eg, oral, injectable, inhaled, and patches)XX
      3.12F2Provides instruction on medication delivery systems (eg, syringes, pens, CSII, or patch), use and storage, reducing risk of bloodborne pathogens, and sharps disposalXX
      3.12F3Uses advanced judgment and reasoning, including laboratory monitoring, to adjust and implement pharmacotherapy plan following provider and/or facility approved protocols and policiesX
      3.12F4Discusses integrative and functional medicine strategies when medically appropriate, including potential interactionsX
      3.12GDiscusses acute complications such as treatment of hyper- and hypoglycemiaXXX
      3.12G1Reviews basic information and provides instruction on prevention and treatment for hyper- and hypoglycemiaXXX
      3.12G2Provides instruction on treatment of severe hypoglycemia, including glucagon administrationXX
      3.12HDiscusses sick day guidelines (eg, food and liquid intake)XXX
      3.12H1Provides information for sick day guidelines beyond food intake (eg, medication adjustment, urine or blood ketone testing, and adequate hydration)XX
      3.12IReviews glucose monitoring data (eg, CGM or home) for pattern related to physical activity and food intake following adjustment algorithms or protocolsXX
      3.12I1Provides instruction for adjusting the food, physical activity, and/or diabetes medication plan based on glucose data (eg, calculation and explanation of ICR
      ICR=insulin to carbohydrate ratio.
      and ISF)
      X
      3.12I2Provides instruction on trending of glucose, use of personal data management tools (eg, monitoring and health apps), and interpreting glucose patterns at homeX
      3.12JDiscusses reducing risk of chronic complications (eg, foot care, monitoring blood pressure; annual eye, dental, and lipid level evaluations) addressing the “ABCs of Diabetes Care” (http://www.diabetes.org/living-with-diabetes/complications/heart-disease/healthy-abcs.html)XXX
      3.12J1Reviews components of NFPE (eg, foot/wound care, skin/nail care, dental, and neurological) for prevention and when to contact medical providerXX
      3.13Assigns activities to nutrition and dietetics technician, registered (NDTR), and other professional, technical, and support personnel in accordance with qualifications, organization policies/protocols, and applicable laws and regulationsXXX
      3.13ASupervises professional, technical, and support personnelXXX
      3.13BProvides support personnel with information and guidance needed to complete assigned activitiesXXX
      3.14Continues data collectionXXX
      3.14AIdentifies and records specific data collection for patient/client, including weight change, biochemical, behavioral, and lifestyle factors using prescribed/standardized formatXXX
      3.14BAnalyzes data trends to modify plan, if indicated; consults with more experienced practitioner or interprofessional team as neededXXX
      3.15Documents:
      3.15ADate and timeXXX
      3.15BSpecific and measurable treatment goals and expected outcomesXXX
      3.15CRecommended interventionsXXX
      3.15DPatient/client/advocate/caregiver/community receptivenessXXX
      3.15EReferrals made and resources usedXXX
      3.15FPatient/client/advocate/caregiver/community comprehensionXXX
      3.15GBarriers to changeXXX
      3.15HOther information relevant to providing care and monitoring progress over timeXXX
      3.15IPlans for follow up and frequency of careXXX
      3.15JRationale for discharge or referral if applicableXXX
      Examples of Outcomes for Standard 3: Nutrition Intervention
      • Goals and expected outcomes are appropriate and prioritized
      • Patient/client/advocate/population, caregivers, and interprofessional teams collaborate and are involved in developing nutrition intervention/plan of care
      • Appropriate individualized patient-/client-centered nutrition intervention/plan of care, including nutrition prescription, is developed
      • Nutrition interventions/plans of care is delivered and actions are carried out as intended
      • Discharge planning/transitions of care needs are identified and addressed
      • Documentation of nutrition intervention/plan of care is:
        • Specific
        • Measurable
        • Attainable
        • Relevant
        • Timely
        • Comprehensive
        • Accurate
        • Dated and timed
        • Ongoing, revised, and updated
      Standard 4: Nutrition Monitoring and Evaluation

      The registered dietitian nutritionist (RDN) monitors and evaluates indicators and outcomes data directly related to the nutrition diagnosis, goals, preferences, and intervention strategies to determine the progress made in achieving desired results of nutrition care and whether planned interventions should be continued or revised.

      Rationale:

      Nutrition monitoring and evaluation are essential components of an outcomes management system in order to ensure quality, patient-/client-/population-centered care, and to promote uniformity within the profession in evaluating the efficacy of nutrition interventions. Through monitoring and evaluation, the RDN identifies important measures of change or patient/client/population outcomes relevant to the nutrition diagnosis and nutrition intervention/plan of care; describes how best to measure these outcomes, and intervenes when intervention/plan of care requires revision.
      Indicators for Standard 4: Nutrition Monitoring and Evaluation
      Bold Font Indicators are Academy Core RDN Standards of Practice IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      4.1Monitors progress:XXX
      4.1AAssesses patient/client/advocate/population understanding and compliance with nutrition intervention/plan of careXXX
      4.1A1Evaluates congruency of nutrition intervention/diabetes management plan (eg, eating plan and portion and/or calorie controlled) to diabetes/nutrition prescriptionXXX
      4.1A2Evaluates nutrition intervention that includes patient-/client-centered S.M.A.R.T.
      S.M.A.R.T.=specific, measurable, attainable, realistic, and timely goals.
      goals
      XXX
      4.1A3Reassesses patient’s/client’s stage of behavior change and learning style to evaluate need to revise nutrition interventionXX
      4.1BDetermines whether the nutrition intervention/plan of care is being implemented as prescribedXXX
      4.1B1Evaluates nutrition intervention/plan of care to identify and address barriers to diabetes management and nutrition interventionXXX
      4.1B2Evaluates nutrition intervention in the face of complex clinical situations (eg, pre- and postmetabolic/bariatric surgery; managing weight with complex conditions such as comorbid conditions, multiple medications, food allergies and intolerances, and cultural factors)XX
      4.1B3Tailors tools and methods to ensure desired outcomes reflect the patient’s/client’s social, physical, environmental factors, and diabetes nutrition goalsX
      4.2Measures outcomes:XXX
      4.2ASelects the standardized nutrition care measurable outcome indicator(s):XXX
      4.2A1Anthropometric measures (eg, weight, body mass index, waist circumference, rate of weight change, growth, and development)XXX
      4.2A2Body composition measures (eg, fat mass and lean)XXX
      4.2A3Laboratory measures (eg, HbA1c, lipid panel, comprehensive metabolic panel, and renal panel)XXX
      4.2A4Behavioral measures (eg, activity level, eating behaviors, cognitive functioning, and goal attainment)XXX
      4.2A4iTreatment outcomes (eg, possible barriers, mood and cognitive function changes, treatment delays, signs of relapse, and need for more advanced/involved treatment options)XX
      4.2A5Quality of life measures (eg, activity and daily living)XXX
      4.2A6Health care utilization for achieving nutrition and diabetes management outcomes (eg, consistent, adequate delivery or access to care; incidence of infections and hospitalizations; and resource utilization)X
      4.2BIdentifies positive or negative outcomes, including impact on potential needs for discharge/transitions of careXXX
      4.2B1Documents progress in meeting desired goals (eg, eating patterns, weight loss/maintenance, blood pressure, blood lipids, and blood glucose [ie, HbA1c goal]; and improved physical capabilities, such as activity level and sleep patterns)XXX
      4.2B2Identifies unintended consequences (eg, excessive rate of weight loss or extreme blood glucose variability), or the use of inappropriate methods of achieving goals (eg, insulin omission or self-imposed dietary restrictions and personal beliefs)XX
      4.2B3Addresses underlying factors interfering with meeting the diabetes and nutrition intervention goals (eg, access to resources, lack of insurance, cost of medications)XX
      4.3Evaluates outcomes:XXX
      4.3ACompares monitoring data with nutrition prescription and established goals or reference standard (eg, EAL for diabetes-related guidelines [eg, type 1 diabetes and type 2 diabetes, gestational diabetes, and prevention type 2], ADA Nutrition Recommendations
      • Siminerio L.
      • Ruppert K.
      • Huber K.
      • Toledo F.G.S.
      Telemedicine for reach, education, access, and treatment (TREAT): Linking telemedicine with diabetes self-management education to improve care in rural communities.
      )
      XXX
      4.3BEvaluates impact of sum of all interventions on overall patient/client/population health outcomes and goalsXXX
      4.3B1Completes comprehensive analysis of indicators for each identified problem compared with protocols and reference standards for impact on patient/client health outcomes and goalsXX
      4.3B2Completes a detailed trending analysis of the indicators and how they correlate with each other, to determine and evaluate the complexity of problems and influence on patient/client/population health outcomes and goalsX
      4.3CEvaluates progress or reasons for lack of progress related to problems and interventionsXXX
      4.3C1Determine whether outcomes meet expectationsXXX
      4.3C2Elicits feedback from patient/client/advocate about success with behavior change (eg, food and physical activity and health outcome goals)XXX
      4.3C2iElicits feedback from patient/client/advocate about challenges/barriers with behavior change (eg, monitoring, taking medications, problem solving, healthy coping, and reducing risks)XX
      4.3C3Adjusts plan with patient/client/caregiver to overcome obstacles to change and achieving goalsXXX
      4.3C4Modifies nutrition intervention based on patient/client tolerance, response, environmental limitations (eg, food security and economic status), and outcome measuresXX
      4.3DEvaluates evidence that nutrition intervention/plan of care is maintaining or influencing a desirable change in patient/ client/population behavior or statusXXX
      4.3D1Evaluates patient/client outcomes in relation to nutrition plan and goals (eg, laboratory data; physical, social, cognitive, environmental factors, ADLs, and growth and development)XXX
      4.3D2Evaluates and analyzes underlying factors interfering with intervention outcomes and access to services (eg, prognosis, psychological factors, or use/lack of resources) for impact on health outcomes, nutrition plan, and goalsXX
      4.3D3Reassesses, modifies, and coordinates, if applicable, action plan in complex cases based on effects of all interventions on patient’s/client’s complications, comorbid conditions, and overall health outcomesX
      4.3ESupports conclusions with evidence (eg anthropometric, biochemical, clinical, SMBG, and dietary data)XXX
      4.3E1Clearly documents outcomes and processesXXX
      4.4Adjusts nutrition intervention/plan of care strategies, if needed, in collaboration with patient/client/population/advocate/caregiver and interprofessional teamXXX
      4.4AImproves or adjusts intervention/plan of care strategies based on outcomes data, trends, best practices, and comparative standardsXXX
      4.4BModifies intervention strategies as needed (eg, culture, psychosocial, change in living/care situation, progress/change in goal, change in health status); seeks assistance as neededXXX
      4.4CModifies intervention strategies as appropriate to address patient/client needs and complex situations (comorbidities and complications [eg, gastroparesis or steroid-induced diabetes])XX
      4.4DArranges for additional resources and support services (eg, training of direct care providers, collaboration with health care professionals) for implementing nutrition intervention/plan of care in patients/clients balancing multiple situations (eg, emergency situations, and/or clinical complications)XX
      4.4EAdjusts in complicated situations (eg, glycemic variability or comorbidities) and when combining multiple intervention approachesX
      4.4FAdjusts in complicated situations by drawing on practice experience, knowledge, clinical judgment, and evidence-based practice about the patient/client population in complicated, unpredictable, and dynamic situations (eg, critical care, wound management, and factors related to comorbid conditions/complications)X
      4.5Documents:XXX
      4.5ADate and timeXXX
      4.5BIndicators measured, results, and method for obtaining measurement (eg, HbA1c, lipid levels, height, weight, vitamin B 12 level, and vitamin D level)XXX
      4.5CCriteria to which indicator is compared (eg, nutrition prescription/goal or a reference standard)XXX
      4.5DFactors facilitating or hampering progressXXX
      4.5EOther positive or negative outcomesXXX
      4.5FAdjustments to the nutrition intervention/plan of care, if indicatedXXX
      4.5GFuture plans for nutrition care, nutrition monitoring and evaluation, follow-up, referral, or dischargeXXX
      Examples of outcomes for Standard 4: Nutrition Monitoring and Evaluation
      • The patient/client/community outcome(s) directly relate to nutrition diagnosis and goals established in the nutrition intervention/plan of care. Examples include, but are not limited to:
        • Nutrition outcomes (eg, change in knowledge, behavior, food, or nutrient intake)
        • Clinical and health status outcomes (eg, change in laboratory values, body weight, blood pressure, risk factors, signs and symptoms, clinical status, infections, complications, morbidity, and mortality)
        • Patient-/client-/population-centered outcomes (eg, quality of life, satisfaction, self-efficacy, self-management, functional ability)
        • Health care utilization and cost-effectiveness outcomes (eg, change in medication, special procedures, planned/unplanned clinic visits, preventable hospital admissions, length of hospitalizations, prevented or delayed nursing home admissions, morbidity, and mortality)
      • Nutrition intervention/plan of care and documentation is revised, if indicated
      • Documentation of nutrition monitoring and evaluation is:
        • Specific
        • Measurable
        • Attainable
        • Relevant
        • Timely
        • Comprehensive
        • Accurate
        • Dated and timed
        • Ongoing, revised, and updated
      a EAL=Academy of Nutrition and Dietetics Evidence Analysis Library. Review EAL list of guidelines as there are multiple guidelines that relate to diabetes (Gestational, Type 1 and Type 2 in Adults, Prevention Type 2), and comorbidities (eg, Chronic Kidney Disease; Hypertension; Obesity/Overweight, Adult and Childhood).
      b AADE7=American Association of Diabetes Educators 7 Self Care Behaviors (www.diabeteseducator.org).
      c DSMES=diabetes self-management education and support (https://professional.diabetes.org/content-page/standards-medical-care-diabetes).
      d CSII=continuous sustained insulin infusion (ie, insulin pump).
      e CGM=continuous glucose monitoring.
      f CVD=cardiovascular disease.
      g SMBG=self-monitoring blood glucose.
      h HbA1c=glycated hemoglobin.
      i MRI=magnetic resonance imaging.
      j CT=computed tomography scan.
      k AMA-PQRI=American Medical Association-Physician Quality Reporting Initiative (https://assets.ama-assn.org/resources/doc/cqi-templates/pqri-sort.shtml).
      l ADA=American Diabetes Association (www.diabetes.org).
      m OTC=over the counter.
      n ISF=insulin sensitivity factor.
      o ADL=activities of daily living.
      p Academy=Academy of Nutrition and Dietetics (www.eatrightpro.org).
      q IDF=International Diabetes Federation (www.idf.org).
      r DKA=diabetic ketoacidosis.
      s Advocate: An advocate is a person who provides support and/or represents the rights and interests at the request of the patient/client. The person may be a family member or an individual not related to the patient/client who is asked to support the patient/client with activities of daily living or is legally designated to act on behalf of the patient/client, particularly when the patient/client has lost decision making capacity. (Adapted from definitions within The Joint Commission Glossary of Terms
      • The Joint Commission
      Glossary.
      and the Centers for Medicare and Medicaid Services, Hospital Conditions of Participation

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State operations manual. Appendix A-survey protocol, regulations and interpretive guidelines for hospitals (Rev. 176, 12-29-17); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf. Accessed March 5, 2018.

      ).
      t Interprofessional: Interprofessional is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physicians, nurses, dietitian nutritionists, pharmacists, diabetes educators, psychologists, social workers, and occupational and physical therapists), depending on the needs of the patient/client. Interprofessional could also mean interdisciplinary or multidisciplinary.
      v Non-physician practitioner: A non-physician practitioner may include a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse-midwife, clinical social worker, clinical psychologist, anesthesiologist’s assistant, qualified dietitian, or nutrition professional. Disciplines considered for privileging by a facility’s governing body and medical staff must be in accordance with state law.

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State operations manual. Appendix A-survey protocol, regulations and interpretive guidelines for hospitals (Rev. 176, 12-29-17); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf. Accessed March 5, 2018.

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State operations manual. Appendix W-survey protocol, regulations and interpretive guidelines for critical access hospitals (CAHs) and swing-beds in CAHs (Rev. 165, 12-16-16); §485.635(a)(3)(vii) Dietary Services; §458.635 (d)(3) Verbal Orders. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_w_cah.pdf. Accessed March 5, 2018.

      The term privileging is not referenced in the Centers for Medicare and Medicaid Services Long-Term Care Regulations. With publication of the Final Rule revising the Conditions of Participation for Long Term Care Facilities effective November 2016, post-acute care settings, such as skilled and long-term care facilities, may now allow a resident’s attending physician the option of delegating order writing for therapeutic diets, nutritional supplements, or other nutrition-related services to the qualified dietitian or clinically qualified nutrition professional, if consistent with state law and organization policies.

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. 42 CFR parts 405, 431, 447, 482, 483, 485, 488, and 489 Medicare and Medicaid programs; reform of requirements for long-term care facilities. Final rule (FR DOC#2016; pp 68688-68872) – Federal Register October 4, 2016; 81(192):68688-68872; §483.30(f)(2) physician services (pp 65-66), §483.60 food and nutrition services (pp 89-94), §483.60 food and nutrition services (pp 177-178). https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities. Accessed March 5, 2018.

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State operations manual-appendix PP-guidance to surveyors for long-term care facilities. (Rev. 173, 11-22-17); §483.30 physician services, §483.60 food and nutrition services. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf. Accessed March 5, 2018.

      w ICR=insulin to carbohydrate ratio.
      x S.M.A.R.T.=specific, measurable, attainable, realistic, and timely goals.
      Figure 2Standards of Professional Performance (SOPP) for Registered Dietitian Nutritionists (RDNs) in Diabetes Care. Customer is used in this evaluation resource as a universal term. Customer could also mean client/patient, client/patient/customer, family, participant, consumer, or any individual, group, or organization to which an RDN provides service.
      Standards of Professional Performance for Registered Dietitian Nutritionists in Diabetes Care

      Standard 1: Quality in Practice

      The registered dietitian nutritionist (RDN) provides quality services using a systematic process with identified ethics, leadership, accountability, and dedicated resources.

      Rationale:

      Quality practice in nutrition and dietetics is built on a solid foundation of education and supervised practice, credentialing, evidence-based practice, demonstrated competence, and adherence to established professional standards. Quality practice requires systematic measurement of outcomes, regular performance evaluations, and continuous improvement.
      Indicators for Standard 1: Quality in Practice
      Bold Font Indicators are Academy Core RDN Standards of Professional Performance IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      1.1Complies with applicable laws and regulations as related to his/her area(s) of practice (eg, HIPAA
      HIPAA=Health Insurance Portability and Accountability Act.
      , sharps disposal, and food safety)
      XXX
      1.1AComplies with state licensure or certification laws and regulations, if applicable, including telehealth and continuing education requirementsXXX
      1.1BComplies with relevant regulatory, accreditation standards, and reimbursement policies for providers and institutionsXXX
      1.2Performs within individual and statutory scope of practice and applicable laws and regulationsXXX
      1.2AReflects scope of practice as defined by state and federal rules and regulations, accreditation, or other applicable standards in diabetes practiceXXX
      1.2BFollows any scope of practice requirements related to additional credentialing or position (eg, CDE
      CDE=Certified Diabetes Educator (www.ncbde.org).
      , BC-ADM
      BC-ADM=Board Certified-Advanced Diabetes Management (www.diabeteseducator.org).
      , or certified diabetes technology clinician)
      XXX
      1.2CReviews and ensures that job description complies with defined scope of practice and assigned duties and professional responsibilitiesXXX
      1.2DAdheres to provider or organization-approved protocols and/or privileges for including in scope of work: interpreting and adjusting treatment (eg, adjusting medication doses, evaluating electronic blood glucose or CGM
      CGM=continuous glucose monitoring.
      records, and obtaining insulin pump training, and making pump adjustments)
      XX
      1.2EAdheres to provider or organization-approved protocols (eg, to initiate/titrate medications for management of diabetes and basic cardiovascular disease preventive medical regimen and associated lab orders)X
      1.3Adheres to sound business and ethical billing practices applicable to the role and settingXXX
      1.3AEnsures ethical and accurate reporting of diabetes nutrition services (eg, billing codes for payer; ie, group or individual visit)XXX
      1.3BDevelops/presents training for staff and team members on ethics and best practices for billing proceduresXX
      1.3CCollaborates with billing services and establishes protocols/algorithms to guide decision making to ensure professional/ethical billing practicesX
      1.4Uses national quality and safety data (eg, National Academies of Sciences, Engineering, and Medicine: Health and Medicine Division, National Quality Forum, Institute for Healthcare Improvement, American Diabetes Association (ADA), American Association of Clinical Endocrinologists, and American College of Obstetricians and Gynecologists) to improve the quality of services provided and to enhance customer-centered servicesXXX
      1.4AParticipates and/or leads organization, and local/state/national quality initiatives to identify need for changes related to diabetes nutrition management (eg, monitoring and medication protocols)XX
      1.4BAnticipates changes to local, state, and national quality initiatives and leads performance improvement initiatives in the organization to support diabetes care and related services to facilitate improved outcomesX
      1.5Uses a systematic performance improvement model that is based on practice knowledge, evidence, research, and science for delivery of the highest quality servicesXXX
      1.5AIdentifies and participates in using an appropriate organization-approved performance improvement model(s)/process(es) (eg, Six Sigma and LEAN Thinking)XXX
      1.5BIdentifies performance improvement criteria to monitor effectiveness of servicesXXX
      1.5CObtains training and mentors members of the interprofessional
      Interprofessional: Interprofessional is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physicians, nurses, dietitian nutritionists, pharmacists, diabetes educators, psychologists, social workers, and occupational and physical therapists), depending on the needs of the customer. Interprofessional could also mean interdisciplinary or multidisciplinary.
      team on the organization performance improvement model(s) and leads performance improvement initiatives
      XX
      1.5DDevelops implementation strategies for quality improvement activities (eg, identification/adaptions of evidence-based practice guidelines/protocols, skills training/reinforcement, and organizational support/incentives)X
      1.5ELeads interprofessional performance improvement initiatives across the organization or systemX
      1.6Participates in or designs an outcomes-based management system to evaluate safety, effectiveness, quality, person-centeredness, equity, timeliness, and efficiency of practiceXXX
      1.6AInvolves colleagues and others, as applicable, in systematic outcomes managementXXX
      1.6A1Collaborates with the interprofessional team to define the role of various team membersXXX
      1.6BDefines expected outcomesXXX
      1.6B1Identifies quality outcomes to measure (eg, CMS
      CMS=Centers for Medicare and Medicaid Services (www.cms.gov).
      , National Quality Forum, ADA, American Association of Clinical Endocrinologists, and American College of Obstetricians and Gynecologists, NCQA
      NCQA=National Committee for Quality Assurance.
      , or institution-specific measures)
      XX
      1.6CUses indicators that are specific, measurable, attainable, realistic, and timely (S.M.A.R.T.)XXX
      1.6C1Selects criteria for data collection, and advocates for and participates in the development of data collection tools (eg, clinical, operational, and financial)XX
      1.6C2Serves in leadership role to evaluate benchmarks of diabetes care based on public health and population-based indicators (eg, HEDIS
      HEDIS=Healthcare Effectiveness Data and Information Set.
      and national diabetes quality improvement measure sets) to improve outcomes
      X
      1.6DMeasures quality of services in terms of structure, process, and outcomesXXX
      1.6D1Uses and/or develops systematic quality improvement approach to collect and organize data to measure performance against desired outcomes using data from multiple sourcesXXX
      1.6D2Routinely assesses current services using culturally competent engagement processes and in accordance with established performance criteria to change practice for improving diabetes nutrition careXX
      1.6D3Develops and/or uses systematic processes to monitor and analyze diabetes-related pooled data/aggregate data against expected outcomesX
      1.6EIncorporates electronic clinical quality measures to evaluate and improve care of patients/clients at risk for malnutrition or with malnutrition (www.eatrightpro.org/emeasures)XXX
      1.6FDocuments outcomes and patient reported outcomes (eg, PROMIS
      PROMIS: The Patient-Reported Outcomes Measurement Information System (PROMIS) (https://commonfund.nih.gov/promis/index) is a reliable, precise measure of patient-reported health status for physical, mental, and social well-being. It is a web-based resource and is publicly available.
      )
      XXX
      1.6F1Documents outcomes per selected protocol and participates in evaluation and reportingXXX
      1.6F2Evaluates patient/client and service outcomes using identified metrics to reinforce current practices or implement changes in program/servicesXX
      1.6F3Synthesizes and publishes effectiveness outcomes on programs and servicesX
      1.6GParticipates in, coordinates, or leads program participation in local, regional, or national registries and data warehouses used for tracking, benchmarking, and reporting service outcomesXXX
      1.6G1Actively promotes the inclusion of RDN-provided MNT
      MNT=medical nutrition therapy (www.eatrightpro.org/scope > Definition of terms).
      and DSMES
      DSMES=diabetes self-management education and support (https://professional.diabetes.org/content-page/standards-medical-care-diabetes).
      service components in local, regional, and/or national diabetes data registries
      XX
      1.6G2Analyzes and uses information for long range strategic planning (eg, program and service efficacy)X
      1.7Identifies and addresses potential and actual errors and hazards in provision of services or brings to attention of supervisors and team members as appropriateXXX
      1.7AEvaluates and ensures safe diabetes care; seeks assistance as neededXXX
      1.7A1Identifies and educates patients/clients/families and other health care professionals regarding potential drug-food/nutrient interactionsXXX
      1.7A2Refers patients/clients to appropriate services when error/hazard is outside of practitioner’s scope of practiceXXX
      1.7BCollaborates with provider and other members of the diabetes team (eg, pharmacist) to recognize potential drug to drug (prescribed and over the counter) nutrient and drug–dietary supplement (eg, vitamin, mineral, or herbal) interactionsXX
      1.7CMaintains awareness of problematic product names (eg, insulin products, oral diabetes medications, other injectables) and error prevention recommendations provided by Institute for Safe Medication Practices (www.ismp.org), Food and Drug Administration (www.fda.gov), and US Pharmacopeial (www.usp.org)XX
      1.7DContributes to developing systems to problem solve and prevent errors (eg, medication, sharps disposal, bloodborne pathogens and infection control, and hyper- and hypoglycemia) in collaboration with other health care providersX
      1.7EImplements and evaluates a reporting mechanism to capture, report, and intervene in sentinel events and near misses (eg, incorrect medication administration such as inpatient insulin dosing and subsequent hypoglycemia)X
      1.8Compares actual performance to performance goals (ie, Gap Analysis, SWOT Analysis [strength, weaknesses, opportunities, and threats], PDCA Cycle [plan, do, check, act], DMAIC [define, measure, analyze, improve, control])XXX
      1.8AReports and documents action plan to address identified gaps in care and/or service performanceXXX
      1.8BCompares and evaluates individual and departmental/organizational performance with nutrition and diabetes-related care and services to goals and expected outcomes; prepares and reports action plan to address identified gapsX
      1.8CBenchmarks departmental/organizational performance with national programs and standardsX
      1.9Evaluates interventions and workflow process(es) and identifies service and delivery improvementsXXX
      1.9AAnalyzes data and success of action plans in reaching patient/client and program outcome goalsXX
      1.9BSynthesizes results and communicates to key stakeholdersX
      1.9CGuides the development, testing, and redesign of program evaluation systemsX
      1.10Improves or enhances patient/client/population care and/or services working with others based on measured outcomes and established goalsXXX
      1.10AUses data and outcomes to implement changes in processes and/or practices or seeks assistance as neededXX
      1.10BLeads in creating and evaluating systems, processes, and programs that support institutional nutrition and diabetes-related core values and evidence-based guidelines for safe, quality careX
      1.10CDevelops or investigates and shares systems, processes, and programs that support best practices in diabetes nutrition care and services; publishes outcomes and best practicesX
      Examples of outcomes for Standard 1: Quality in Practice
      • Actions are within scope of practice and applicable laws and regulations
      • National quality standards and best practices are evident in customer-centered services
      • Performance improvement program specific to program(s)/service(s) is established and updated as needed; is evaluated for effectiveness in providing desired outcomes data and striving for excellence in collaboration with other team members
      • Performance indicators are specific, measurable, attainable, realistic, and timely (S.M.A.R.T.)
      • Aggregate outcomes results meet pre-established criteria
      • Quality improvement results direct refinement and advancement of practice
      Standard 2: Competence and Accountability

      The registered dietitian nutritionist (RDN) demonstrates competence in and accepts accountability and responsibility for ensuring safe, quality practice and services.

      Rationale:

      Competence and accountability in practice includes continuous acquisition of knowledge, skills, experience, and judgment in the provision of safe, quality customer-centered service.
      Indicators for Standard 2: Competence and Accountability
      Bold Font Indicators are Academy Core RDN Standards of Professional Performance IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      2.1Adheres to the code(s) of ethics (eg, Academy/CDR, other national organizations, and/or employer code of ethics)XXX
      2.2Integrates the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) into practice, self-evaluation, and professional developmentXXX
      2.2AIntegrates applicable focus area SOP and SOPP into practice (www.eatrightpro.org/sop)XXX
      2.2BUses the current SOP and SOPP for RDNs in Diabetes Care to assess performance at the appropriate level of practice and for developing a professional development plan, advancing skills, and practice (competent, proficient, or expert)XXX
      2.2CDevelops corporate/institutional policies, guidelines, human resource materials (eg, job descriptions, job-related competencies, career ladders, acceptable performance level) using the SOP and SOPP for RDNs in Diabetes Care as a guide when in a management roleXX
      2.2DUses advanced practice experience and knowledge to define specific actions for levels of practice (competent, proficient, or expert) reflecting the SOP and SOPP for RDNs in Diabetes CareX
      2.3Demonstrates and documents competence in practice and delivery of customer-centered service(s)XXX
      2.3ADocuments examples of expanded professional responsibility reflective of a proficient practice role (eg, evaluates the delivery of customer-centered services provided and recommends changes)XX
      2.3BDocuments examples of expanded professional responsibility reflective of an expert practice role (eg, evaluates and develops practice and delivery models for customer-centered services)X
      2.4Assumes accountability and responsibility for actions and behaviorsXXX
      2.4AIdentifies, acknowledges, and corrects errorsXXX
      2.4BExhibits professionalism and strives for improvement in practice (eg, manages change effectively; demonstrates assertiveness, listening, and conflict resolution skills; and demonstrates ability to build coalitions)XXX
      2.4CDevelops and directs diabetes nutrition-related policies and procedures that ensure staff accountability and responsibility when serving in a management roleXX
      2.4DIs active in promoting the specialty of nutrition and diabetes careXX
      2.4ELeads by example; exemplifies professional integrity as a leader in diabetes careX
      2.5Conducts self-evaluation at regular intervalsXXX
      2.5AIdentifies needs for professional developmentXXX
      2.5BCompares individual performance to self-directed goals and for consistency with best practices in diabetes care to identify areas for professional developmentXXX
      2.6Designs and implements plans for professional developmentXXX
      2.6ADevelops plan and documents professional development activities in career portfolio (eg, organizational policies and procedures, credentialing agency[ies])XXX
      2.6A1Engages in continuing education opportunities in nutrition and diabetes management and related areas according to his/her professional development plan and career goalsXXX
      2.6A2Develops and implements plan for professional growth in proficient practice areas of diabetes care (eg, participates in scholarly review of professional articles or serves as a reviewer or editorial board associate, including but not limited to, diabetes professional articles, chapters, or books)XX
      2.6A3Develops and implements plan for professional growth for expert practice areas (eg, leading an editorial board for scholarly review)X
      2.7Engages in evidence-based practice and uses best practicesXXX
      2.7ARecognizes and uses major diabetes nutrition-related peer reviewed publications and continuing education opportunitiesXXX
      2.7BIntegrates evidence-based practice and research evidence in delivering quality care (eg, Academy
      Academy=Academy of Nutrition and Dietetics (www.eatrightpro.org).
      and EAL
      EAL=Academy of Nutrition and Dietetics Evidence Analysis Library (www.andeal.org).
      ; ADA Standards of Medical Care in Diabetes

      American Diabetes Association. Standards of medical care in diabetes-2018. https://professional.diabetes.org/content-page/standards-medical-care-diabetes. Accessed March 5, 2018.

      ; National Standards for DSMES
      • Beck J.
      • Greenwood D.A.
      • Blanton L.
      • et al.
      2017 National standards for diabetes self-management education and support.
      ; ADA, AADE
      AADE=American Association of Diabetes Educators (www.diabeteseducator.org).
      , Academy Joint Position Statement
      • Powers M.
      • Bardsley J.
      • Cypress M.
      • et al.
      Diabetes self-management education and support in type 2 diabetes: A joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics.
      ; and organization position papers)
      XXX
      2.7CParticipates in research activities and publication of results to advance evidence and best practicesXX
      2.7DIntegrates research findings and evidence into peer-reviewed publications and recommendations for practiceX
      2.8Participates in peer review of others as applicable to role and responsibilitiesXXX
      2.8AEngages in peer review activities consistent with setting and patient/client population (eg, peer evaluation, peer supervision, clinical chart review, and performance evaluations)XXX
      2.9Mentors and/or precepts othersXXX
      2.9AParticipates in mentoring entry-level and competent level RDNs in diabetes care, and serves as a preceptor for dietetic students/interns; seeks guidance as neededXXX
      2.9BDevelops and directs mentoring or practicum opportunities for RDNs in diabetes practice to support achieving proficient level practice and/or specialist certificationXX
      2.9CPrecepts and mentors RDNs and non-nutrition professionals (eg, medical students/residents, advanced practice nurses, pharmacists, or behavioral health staff)X
      2.10Pursues opportunities (education, training, credentials, or certifications) to advance practice in accordance with laws and regulations and requirements of practice settingXXX
      2.10AObtains and maintains specialty certification in diabetes (eg, CDE or BC-ADM)XX
      2.10BDevelops programs, tools, and resources in support of assisting RDNs to obtain specialty certification in diabetes care and education (eg, CDE or certified diabetes technology clinician)XX
      2.10CDevelops programs, tools, and resources in support of assisting RDNs to obtain advanced practice certification in diabetes care, education, and management (eg, BC-ADM)X
      Examples of Outcomes for Standard 2: Competence and Accountability
      • Practice reflects:
        • Code(s) of ethics (eg, Academy/CDR, other national organizations, and/or employer code of ethics)
        • Scope of Practice, Standards of Practice, and Standards of Professional Performance
        • Evidence-based practice and best practices (eg, EAL, ADA Standards of Medical Care in Diabetes)
        • Commission on Dietetic Registration Essential Practice Competencies and Performance Indicators
      • Practice incorporates successful strategies for interactions with individuals/groups from diverse cultures and backgrounds
      • Competence is demonstrated and documented
      • Services provided are safe and customer-centered
      • Self-evaluations are conducted regularly to reflect commitment to lifelong learning and professional development and engagement
      • Professional development needs are identified and pursued
      • Directed learning is demonstrated
      • Relevant opportunities (education, training, credentials, and certifications) are pursued to advance practice
      • Commission on Dietetic Registration recertification requirements are met
      Standard 3: Provision of Services

      The registered dietitian nutritionist (RDN) provides safe, quality service based on customer expectations and needs, and the mission, vision, principles, and values of the organization/business.

      Rationale:

      Quality programs and services are designed, executed, and promoted based on an RDN’s knowledge, skills, experience, judgment, and competence in addressing the needs and expectations of the organization/business and its customers.
      Indicators for Standard 3: Provision of Services
      Bold Font Indicators are Academy Core RDN Standards of Professional Performance IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      3.1Contributes to or leads in development and maintenance of programs/services that address needs of the customer or target population(s)XXX
      3.1AAligns program/service development with the mission, vision, principles, values, and service expectations and outputs of the organization/businessXXX
      3.1A1Participates in operational planning of diabetes nutrition-related programs and servicesXXX
      3.1A2Participates in strategic and operational planning for the acquisition and utilization of internal and external resources for the organization; and, for collaboration with local and regional programs that support and optimize provision of diabetes services (eg, networks and volunteer organizations)XX
      3.1A3Develops and manages DSMES and diabetes prevention programs in compliance with evidence-based guidelines and national standards (eg, ADA and AADE)XX
      3.1A4Seeks executive and/or medical staff commitment to new services that will meet organizational goals for diabetes careX
      3.1BUses the needs, expectations, and desired outcomes of customers/populations (eg, patients/clients, families, community, decision makers, administrators, and client organization[s]) in program/service developmentXXX
      3.1B1Conducts ongoing needs assessment of the diabetes environment to identify opportunities to deliver additional diabetes education, screening, and prevention services (eg, DSMES and prevention programs)XX
      3.1CMakes decisions and recommendations that reflect stewardship of time, talent, finances, and environmentXXX
      3.1C1Advocates for staffing which supports patient/client population, census, program services/goalsXX
      3.1DProposes programs and services that are customer-centered, culturally appropriate, and minimize disparitiesXXX
      3.1D1Adapts practices to minimize or eliminate health disparities associated with culture, race, gender, socioeconomic status, age, and other factorsXXX
      3.1EUses an evaluation plan for examining the program effectivenessXXX
      3.2Promotes public access and referral to credentialed nutrition and dietetics practitioners for quality food and nutrition programs and servicesXXX
      3.2AContributes to or designs referral systems that promote access to qualified, credentialed nutrition and dietetics practitionersXXX
      3.2A1Participates in or designs processes to receive or make referrals to other providers that address the needs of patient/client population (eg, pharmacist, mental/behavioral health professional, social worker, ophthalmologist, or podiatrist)XX
      3.2A2Directs and manages referral processes and systemsX
      3.2BRefers customers to appropriate providers when requested services or identified needs exceed the RDN’s individual scope of practiceXXX
      3.2B1Builds relationships with health care practitioners for collaboration and to assist with referrals when patient/client need(s) is outside RDN’s scope of practice (eg, mental/behavioral health professional, exercise physiologist, podiatrist, pharmacist, ophthalmologist, or dentist)XXX
      3.2B2Establishes and maintains networks to support the overall care of the patients/clients with diabetesXX
      3.2B3Uses facility electronic health record and population health tools to identify patients/clients with diabetes or at risk of diabetes for referral for MNT and/or DSMES according to organization policyXX
      3.2B4Supports referral resources with curriculum and training regarding the complex needs of patients/clients with diabetesX
      3.2CMonitors effectiveness of referral systems and modifies as needed to achieve desirable outcomesXXX
      3.2C1Tracks data to evaluate the effectiveness of nutrition and diabetes referral process and systemsXX
      3.2C2Audits, evaluates, and revises nutrition and diabetes referral processes for efficiency and effectivenessX
      3.3Contributes to or designs customer-centered servicesXXX
      3.3AAssesses needs, beliefs/values, goals, resources of the customer, and social determinants of healthXXX
      3.3A1Applies goal setting and behavior change strategies and techniques (eg, stages of change, TTM
      TTM=transtheoretical model (www.prochange.com/transtheoretical-model-of-behavior-change).
      , or motivational interviewing technique) in gathering information to reflect in design of customer-centered services
      XXX
      3.3BUses knowledge of the customer’s/target population’s health conditions, cultural beliefs, and business objectives/services to guide design and delivery of customer-centered servicesXXX
      3.3B1Adapts practice and participates in design and maintenance of program/services to meet the needs of culturally-diverse (race, ethnicity, age) populationsXXX
      3.3B2Pursues and uses resources to positively influence health-related decision making within patients’/clients’ specific ethnic/cultural communityXX
      3.3B3Develops, manages, and updates processes to identify, track, and monitor use of patient/client/population resources within the specific ethnic/cultural community, and collaborates as appropriateX
      3.3CCommunicates principles of disease prevention and behavioral change appropriate to the customer or target populationXXX
      3.3C1Recognizes patient/client/population cultural beliefs regarding chronic disease such as diabetes in relationship to healthXXX
      3.3C2Advises on and uses systems or tools for communicating disease prevention and behavioral change with specific populationsXX
      3.3C3Develops systems or tools to communicate disease prevention and behavioral change with specific populationsX
      3.3DCollaborates with the customers to set priorities, establish goals, and create customer-centered action plans to achieve desirable outcomesXXX
      3.3D1Collaborates with patients/clients/caregivers, health care providers, and other support resources to create person-centered action plans that reflect the patients’/clients’ needs, wishes, desired outcomes, and program/service objectivesXXX
      3.3EInvolves customers in decision making (eg designing MNT and DSMES program/services, and networking)XXX
      3.4Executes programs/services in an organized, collaborative, cost effective, and customer-centered mannerXXX
      3.4ACollaborates and coordinates with peers, colleagues, stakeholders, and within interprofessional teamsXXX
      3.4A1Collaborates, as part of an interprofessional team, with organization and community programming, resources, services, and referrals as neededXXX
      3.4A2Facilitates and fosters active communication, learning partnerships, and collaboration within an interprofessional diabetes team and with other providers as neededXX
      3.4A3Serves in consultant role for medical nutrition management of diabetes and comorbiditiesXX
      3.4A4Directs efforts to improve collaboration between patients/clients and other health care providersX
      3.4BUses and participates in, or leads in the selection, design, execution, and evaluation of customer programs and services

      (eg, nutrition screening system, medical and retail foodservice, electronic health records, interprofessional programs, community education, and grant management)
      XXX
      3.4B1Incorporates standards for nutrition and diabetes nutrition care based on evidence-based guidelines and recommendations in design of programs and services; seeks assistance as neededXXX
      3.4B2Identifies and uses population-specific nutrition and diabetes screening toolsXXX
      3.4B3Implements and manages diabetes nutrition and diabetes education and community prevention programs consistent with national standards for DSMES (ie, ADA Education Recognition Program and/or AADE Diabetes Education Accreditation Program), and diabetes prevention programs (eg, CDC DPP
      CDC DPP=Centers for Disease Control and Prevention-Diabetes Prevention Program (www.cdc.gov/diabetes/prevention/index.html).
      ) in compliance with CMS and state Medicaid regulations
      XX
      3.4B4Guides the development, implementation, and evaluation of diabetes care, programs, screening initiatives, and services (eg, MNT, DSMES, CDC DPP) inclusive of those at risk of diabetes, suboptimal and optimal control using electronic health record/population health toolsX
      3.4CUses and develops or contributes to selection, design and maintenance of policies, procedures (eg, discharge planning/ transitions of care), protocols, standards of care, technology resources (eg, HIPAA-compliant telehealth platforms), and training materials that reflect evidence-based practice (eg, EAL, ADA, and AADE) in accordance with applicable laws and regulationsXXX
      3.4C1Participates in the development and updating of policies, procedures, and evidence-based practice tools for diabetes nutrition-related services for populations served by practice setting(s) (eg, pediatric and/or adult type 1 diabetes and type 2 diabetes, prediabetes, and gestational diabetes)XXX
      3.4C2Develops and/or maintains diabetes nutrition programs, protocols, and policies based on research and evidence-based guidelines, best practices, trends, and national and international guidelines for practice settingXX
      3.4C3Leads interprofessional process of monitoring, evaluating, revising, and implementing protocols, guidelines, and diabetes practice tools/process as neededX
      3.4C4Leads the development of policies for data analysis according to program or organization diabetes practice needsX
      3.4DUses and participates in or develops processes for order writing and other nutrition-related privileges, in collaboration with the medical staff
      Medical staff: Medical staff is composed of doctors of medicine or osteopathy and, may in accordance with state law, including scope of practice laws, include other categories of physicians, and nonphysician practitioners who are determined to be eligible for appointment by the governing body.6
      or medical director (eg, post-acute care settings, dialysis center, public health, community, and free-standing clinic settings), consistent with state practice acts, federal and state regulations, organization policies, and medical staff rules, regulations, and bylaws
      XXX
      3.4D1Uses and participates in or leads development of processes for privileges or other facility-specific processes related to (but not limited to) implementing physician/non-physician practitioner
      Non-physician practitioner: A non-physician practitioner may include a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse-midwife, clinical social worker, clinical psychologist, anesthesiologist’s assistant, registered dietitian, or nutrition professional. Disciplines considered for privileging by a facility’s governing body and medical staff must be in accordance with state law.6,7 The term privileging is not referenced in the Centers for Medicare and Medicaid Services Long-Term Care Regulations. With publication of the Final Rule revising the Conditions of Participation for Long-Term Care facilities effective November 2016, postacute care settings, such as skilled and long-term care facilities, may now allow a resident’s attending physician the option of delegating order writing for therapeutic diets, nutrition supplements, or other nutrition-related services to the qualified dietitian or clinically qualified nutrition professional, if consistent with state law, and organization policies.9,10
      -driven delegated orders or protocols, initiating or modifying orders for therapeutic diets, medical foods/nutrition supplements, dietary supplements, enteral and parenteral nutrition, laboratory tests, medications, and adjustments to fluid therapies or electrolyte replacements
      XXX
      3.4D1iContributes to the development of privilege options for RDNs with CDE and/or BC-ADM advanced practice credentials (eg, training and management of patients/clients using CSII
      CSII=continuous sustained insulin infusion (ie, insulin pump).
      and CGM; adjusting medication order per provider or organization-approved protocol based on evaluation of SMBG
      SMBG=self-monitoring blood glucose.
      , CSII, and/or CGM data reports)
      XX
      3.4D1iiParticipates and/or leads in the development of provider or organization-approved pharmacotherapy protocols (eg, to initiate/titrate medications for management of diabetes, basic cardiovascular disease preventive medical regimen, and associated lab orders)X
      3.4D1iiiNegotiates and/or establishes nutrition privileges at a systems level for new advances in practiceX
      3.4D2Uses and participates in or leads development of processes for privileging for provision of nutrition-related services, including (but not limited to) initiating and performing bedside swallow screenings, inserting and monitoring nasoenteric feeding tubes, providing home enteral nutrition or infusion management services (eg, ordering formula and supplies), and indirect calorimetry measurementsXXX
      3.4D2iRecommends adjustments to diabetes nutrition plan consistent with medication plans, and/or referral to diabetes team or credentialed diabetes practitioner based on nutrition assessment, SMBG data reports, medical data, and/or patient/client/caregiver information/ request; seeks assistance as neededXXX
      3.4D2iiEnsures adjustments to CSII and CGM device settings are based on nutrition assessment, medical data, device data reports, and/or patient/client/caregiver information and according to provider or organization-approved protocolsXX
      3.4D2iiiCollaborates in the development of physician-driven protocols for managing individuals using CGM and/or CSII devices for use by credentialed practitioners with diabetes management privilegesX
      3.4EComplies with established billing regulations, organization policies, grant funder guidelines, if applicable to role and setting, and adheres to ethical and transparent financial management and billing practicesXXX
      3.4E1Develops tools to monitor ethical billing practice and adherence to billing regulationsXX
      3.4FCommunicates with interprofessional team and referring party consistent with HIPAA rules for use and disclosure of customer’s personal health informationXXX
      3.4F1Develops process and tools to monitor adherence to HIPAA rules and/or address breaches in personal health information protection and use of electronic medical recordXX
      3.5Uses professional, technical, and support personnel appropriately in delivery of customer-centered care or services in accordance with laws, regulations, and organization policies and proceduresXXX
      3.5AAssigns activities, including direct care to patients/clients, consistent with qualifications, experience, and competence of professional, technical, and support personnelXXX
      3.5A1Assesses and determines capabilities/expertise of support staff in working with patients/clients with diabetes to determine tasks that may be delegatedXX
      3.5BSupervises professional, technical, and support personnelXXX
      3.5B1Trains professional, technical, and support personnel and evaluates their competenceXX
      3.6Designs and implements food delivery systems to meet the needs of customersXXX
      3.6ACollaborates in or leads design of food delivery systems to address health care needs and outcomes (including nutrition status), ecological sustainability, and to meet the culture and related needs and preferences of target populations (ie, health care patients/clients, employee groups, visitors to retail venues, schools, child and adult day care centers, community feeding sites, farm to institution initiatives, and local food banks)XXX
      3.6A1Collects data and provides feedback on current food delivery systems serving individuals with diabetes in health care and community settings (eg, inpatient and ambulatory care settings, long-term care settings, senior meal sites, and home delivery)XXX
      3.6A2Evaluates foodservice planning and delivery for individuals with diabetes to identify areas for improvement applicable to setting and roleXX
      3.6A3Consults on design, evaluation, and/or revision of food delivery systems and nutrition-related services (eg, for nonselect, selective, and/or room service menu systems) in health care and community settingsX
      3.6BParticipates in, consults/collaborates with, or leads the development of menus to address health, nutritional, and cultural needs of target population(s) consistent with federal, state, or funding source regulations or guidelinesXXX
      3.6B1Participates in development or provides consultation on menu system to meet needs of individuals with diabetes across the lifespanXX
      3.6B2Develops nutrition and diabetes-related guidelines reflecting national standards (eg, ADA Standards of Medical Care in Diabetes, EAL,) and applicable federal or state regulations (eg, menu-related regulations and food assistance programs) to guide foodservice program according population served by the settingX
      3.6CParticipates in, consults/collaborates with, or leads interprofessional process for determining medical foods/nutritional supplements, dietary supplements, enteral and parenteral nutrition formularies, and delivery systems for target population(s)XXX
      3.6C1Provides guidance regarding medical food/nutritional supplements, enteral and parenteral nutrition, in accordance with best practice for diabetes care (eg, ADA Standards for Medical Care in Diabetes and ASPEN
      ASPEN=American Society for Parenteral and Enteral Nutrition (www.nutritioncare.org).
      )
      XX
      3.6C2Designs or consults on organizational protocols to provide guidance for nutrition support best practices for individuals with diabetesX
      3.7Maintains records of services providedXXX
      3.7ADocuments according to organization policies, procedures, standards, and systems, including electronic health recordsXXX
      3.7A1Uses and/or participates in design/revision of electronic health recordsXX
      3.7BImplements data management systems to support interoperable data collection, maintenance, and utilizationXXX
      3.7B1Contributes to design of electronic health record system to capture data needed to document care and monitor outcomes for patients/clients with diabetesXX
      3.7B2Seeks opportunities to contribute expertise to national bioinformatics/medical informatics projects as applicable/requestedX
      3.7CUses data to document outcomes of services (ie, staff productivity, cost/benefit, budget compliance, outcomes, quality of services), and provide justification for maintenance or expansion of servicesXXX
      3.7C1Analyzes and uses data to communicate value of nutrition services in relation to patient/client and organization outcomes/goalsXX
      3.7DUses data to demonstrate program/service achievements and compliance with accreditation standards, laws, and regulationsXXX
      3.7D1Prepares and presents reports for organization and accrediting bodies, if applicable (eg, ADA Education Recognition Program or AADE Diabetes Education Accreditation Program)XX
      3.8Advocates for provision of quality food and nutrition services as part of public policyXXX
      3.8ACommunicates with policy makers regarding benefit/cost of quality food and nutrition servicesXXX
      3.8A1Advocates with state and federal legislative representatives regarding benefit of MNT/diabetes management and prevention services on health care costs (eg, responds to Academy Action Alerts and other calls to action)XXX
      3.8A2Initiates and coordinates advocacy activities/issues (eg, article development, presentations, and networking events)XX
      3.8A3Interacts and serves as a resource with legislators, payers, and policy makers to contribute and influence diabetes care and services (eg, providing testimony at legislative and regulatory hearings and meetings)XX
      3.8A4Develops and revises policy and statutes and contributes to development/review/comments on administrative rules and regulationsX
      3.8BAdvocates in support of food and nutrition programs and services for populations with special needs and chronic conditionsXXX
      3.8B1Participates in patient/client diabetes advocacy activities (eg, community diabetes screenings, local ADA and JDRF
      JDRF=Juvenile Diabetes Research Foundation (www.jrdf.org).
      events, NDEP
      NDEP=National Diabetes Education Program (www.cdc.gov/diabetes/ndep/index.html).
      )
      XXX
      3.8B2Assesses patient/client population for situations where diabetes advocacy is needed and participates in efforts to address issue(s) (eg, local, state, and national diabetes coalitions or collaborations)XX
      3.8CAdvocates for protection of the public through multiple avenues of engagement (eg, legislative action, establishing effective relationships with elected leaders and regulatory officials, participation in various Academy committees, workgroups, and task forces, Dietetic Practice Groups, Member Interest Groups, and State Affiliates)XXX
      Examples of Outcomes for Standard 3: Provision of Services
      • Program/service design and systems reflect organization/business mission, vision, principles, and values, and customer needs and expectations
      • Customers participate in establishing program/service goals and customer-focused action plans and/or nutrition interventions (eg, in-person or via telehealth)
      • Customer-centered needs and preferences are met
      • Customers are satisfied with services and products
      • Customers have access to food assistance
      • Customers have access to food, nutrition, and DSMES services
      • Foodservice system incorporates sustainability practices addressing energy and water use and waste management
      • Menus reflect the cultural, health, and/or nutritional needs of target population(s) and consideration of ecological sustainability
      • Evaluations reflect expected outcomes and established goals
      • Effective screening and referral services are established or implemented as designed
      • Professional, technical, and support personnel are supervised when providing nutrition care to individuals with diabetes
      • Ethical and transparent financial management and billing practices are used per role and setting
      Standard 4: Application of Research

      The registered dietitian nutritionist (RDN) applies, participates in, and/or generates research to enhance practice. Evidence-based practice incorporates the best available research/evidence and information in the delivery of nutrition and dietetics services.

      Rationale:

      Application, participation, and generation of research promote improved safety and quality of nutrition and dietetics practice and services.
      Indicators for Standard 4: Application of Research
      Bold Font Indicators are Academy Core RDN Standards of Professional Performance IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      4.1Reviews best available research/evidence and information for application to practiceXXX
      4.1AUnderstands basic research design and methodologyXXX
      4.1BReads primary peer-reviewed publications for diabetes self-management care and support; uses evidenced-based practice guidelines and algorithms and related resources (eg, EAL, ADA Standards of Medical Care in Diabetes) to guide clinical practiceXXX
      4.1CMentors RDNs and other health care professionals to develop skills in accessing and critically analyzing research for application to practiceXX
      4.1DIdentifies and addresses diabetes management-related questions and uses a systematic approach for applying research and evidence-based guidelines (eg, EAL); guides others in making informed decisions for diabetes careX
      4.1EFunctions as a primary or senior author of research, academic and/or organization position and practice papers, or other scholarly workX
      4.2Uses best available research/evidence and information as the foundation for evidence-based practiceXXX
      4.2AApplies evidence-based practice guidelines (eg, EAL, AHA
      AHA=American Heart Association (www.heart.org).
      , AACE
      AACE=American Association of Clinical Endocrinologist (www.aace.org).
      , and ADA) to provide consistent, safe, effective quality care for individuals with diabetes; consults with more experienced practitioner for guidance as needed
      XX
      4.2BCritically evaluates and applies available scientific literature in situations where evidence-based practice guidelines for diabetes are not established (eg, complex disease processes)X
      4.2CUses advanced training, available research, and emerging theories to manage complex cases (eg, uncontrolled type 1 diabetes and type 2 diabetes, multiple comorbidities, and complications) in target populationsX
      4.3Integrates best available research/evidence and information with best practices, clinical and managerial expertise, and customer valuesXXX
      4.3AManages the integration of evidence-based guidelines into policies, procedures, and protocols for diabetes self-management education and MNT practiceXX
      4.4Contributes to the development of new knowledge and research in nutrition and dieteticsXXX
      4.4AParticipates in efforts to extend research to practice through journal clubs, professional supervision, and the Academy’s DPBRN
      DPBRN=Dietetics Practice-Based Research Network (www.eatrightpro.org/resources/research/projects-tools-and-initiatives/dpbrn).
      XXX
      4.4BParticipates in practice-based research networks (ie, Academy’s DPBRN or EAL workgroup) and the development and/or implementation of practice-based researchXX
      4.4CIdentifies and initiates research relevant to diabetes practice; acts as principal or co-investigator as part of collaborative research or with health care teams examining nutrition and diabetes careX
      4.4DServes as advisor, preceptor, and/or committee member for graduate level researchX
      4.5Promotes application of research in practice through alliances or collaboration with food and nutrition and other professionals and organizationsXXX
      4.5AIdentifies research questions and facilitates or participates in studies related to diabetes careXXX
      4.5BCollaborates with interprofessional and/or interorganizational teams to perform and disseminate nutrition and diabetes researchXX
      4.5CLeads interprofessional and/or interorganizational research activities and integration of research data into publications and presentations related to diabetes careX
      Examples of Outcomes for Standard 4: Application of Research
      • Evidence-based practice, best practices, clinical and managerial expertise, and customer values are integrated in the delivery of nutrition and dietetics services
      • Customers receive appropriate services based on the effective application of best available research/evidence and information
      • Best available research/evidence and information is used as the foundation of evidence-based practice
      Standard 5: Communication and Application of Knowledge

      The registered dietitian nutritionist (RDN) effectively applies knowledge and expertise in communications.

      Rationale:

      The RDN works with others to achieve common goals by effectively sharing and applying unique knowledge, skills, and expertise in food, nutrition, dietetics, and management services.
      Indicators for Standard 5: Communication and Application of Knowledge
      Bold Font Indicators are Academy Core RDN Standards of Professional Performance IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      5.1Communicates and applies current knowledge and information based on evidenceXXX
      5.1ADemonstrates critical thinking and problem-solving skills when communicating with othersXXX
      5.1A1Demonstrates ability to review and apply evidence-based guidelines when communicating and disseminating informationXX
      5.1A2Demonstrates ability to convey complex concepts to other health care practitioners, patients/clients, and the public when communicating and disseminating informationX
      5.1BIdentifies and reviews relevant diabetes-related nutrition and education publications, resources, and public health trends (eg, prevalence, prevention, and treatment) and applies to practiceXXX
      5.1CEvaluates and translates public health trends, epidemiologic reports, regulatory, accreditation, reimbursement programs, and standards specific to diabetes prevention, care, and education (eg, CMS, The Joint Commission, NCQA, and ADA) and applies to practiceXX
      5.1DConsults as an expert on complex diabetes service issues with other health care professionals, organizations, and communityX
      5.2Selects appropriate information and most effective communication method or format that considers customer-centered care and needs of the individual/group/populationXXX
      5.2AUses communication methods (ie, oral, print, one-on-one, group, visual, electronic, and social media) targeted to various audiencesXXX
      5.2BUses information technology to communicate, disseminate, manage knowledge, and support decision makingXXX
      5.2B1Identifies and uses web-based/electronic diabetes tools/resources (eg, lifestyle apps) and electronic health records within the worksite as appropriateXXX
      5.2B2Develops and updates web-based/electronic diabetes nutrition tools/resources (eg, lifestyle apps)XX
      5.2B3Leads technology/informatics advancement in diabetes managementX
      5.2B4Contributes diabetes and nutrition-related expertise to national informatics projects (eg, national databases)X
      5.2CParticipates in, uses, and/or leads electronic professional networking groups to stay current in diabetes nutrition practice (eg, Academy’s Diabetes Care and Education Dietetic Practice Group listserv or My AADE Network)XXX
      5.3Integrates knowledge of food and nutrition with knowledge of health, culture, social sciences, communication, informatics, sustainability, and managementXXX
      5.3AIntegrates current and emerging scientific knowledge of diabetes care and nutrition when considering an individual’s health status, behavior barriers, communication skills; seeks collaborative guidance as neededXX
      5.3BLeads the integration of scientific knowledge and experience in diabetes management into practice for complex problems or in new research methodologiesX
      5.4Shares current, evidence-based knowledge, and information with various audiencesXXX
      5.4AGuides customers, families, students, and interns in the application of knowledge and skillsXXX
      5.4A1Contributes to educational and professional development of RDNs, students, and health care professionals in other fields, through formal and informal teaching activities, preceptorship, and mentorshipXX
      5.4A2Builds and maintains collaboration between researchers, faculty, and/or decision makers to facilitate effective knowledge transfer for health professionals’ education programs (eg, fellowships)X
      5.4BAssists individuals and groups to identify and secure appropriate and available educational and other resources and servicesXXX
      5.4B1Recommends current, evidence-based diabetes management educational resources (eg, Academy, US Department of Agriculture Choose My Plate at www.choosemyplate.gov, NHLBI
      NHLBI=National Heart, Lung, and Blood Institute (www.nhlbi.nih.gov).
      , Diabetes Care and Education Dietetic Practice Group website at www.DCE.org)
      XXX
      5.4B2Provides programs/services that deliver cost-effective care and education with improved metabolic outcomes (eg, diabetes prevention, reduction of diabetes complications, and improved quality of life)XXX
      5.4B3Establishes systematic process and provides guidance to consumers regarding participation in diabetes-related clinical research studiesXX
      5.4B4Directs and manages systematic processes to identify, track, and monitor use of patient/client resourcesX
      5.4CUses professional writing and verbal skills in all types of communicationsXXX
      5.4C1Sharpens written and oral communication skills to address communication needs of various audiencesXXX
      5.4DReflects knowledge of population characteristics in communication methodsXXX
      5.4D1Reflects knowledge of population characteristics in communication methods used with patient/client population (eg, literacy and numeracy levels, need for translation of written materials and/or a translator, and communication skills)XXX
      5.5Establishes credibility and contributes as a food and nutrition resource within the interprofessional health care and management teams, organization, and communityXXX
      5.5ACommunicates with providers and other allied health care professionals (eg, nurses, pharmacists, diabetes educators, physical therapists, social workers, and psychologists) to promote the use of evidence-based guidelines and the EAL to integrate food and nutrition with diabetes care and managementXXX
      5.5BParticipates in interprofessional collaborations at a systems level promoting the use of evidence-based guidelines integrating food and nutrition and RDNs in diabetes care and management to state, regional, and national professional organizationsXX
      5.5CLeads interprofessional collaborations at an organization or systems levelX
      5.6Communicates performance improvement and research results through publications and presentationsXXX
      5.6APresents information on evidence-based diabetes guidelines and research at the local level (eg, community groups and colleagues)XXX
      5.6A1Presents evidence-based diabetes management research and information at professional meetings and conferences (eg, local, regional, national, and international)XX
      5.6BServes in leadership role for local and national organizations, publications (ie, editor or editorial advisory board) and program planning committeesXX
      5.6CDirects collation of research data into publications (eg, systematic reviews and position papers) and presentationsX
      5.6DCommunicates information about evolving roles of advanced level practitioner (eg, initiating/titrating medications based on provider-approved protocols)X
      5.7Seeks opportunities to participate in and assume leadership roles with local, state, and national professional and community-based organizations (eg, government-appointed advisory boards, community coalitions, schools, foundations, or nonprofit organizations serving the food insecure) providing food and nutrition expertiseXXX
      5.7AFunctions as diabetes nutrition resource as an active member of local/state organizations, coalitions and industry task forces, committees, or advisory boardsXXX
      5.7BServes as subject matter expert on regional and national diabetes organizations/coalitions/task forces/advisory boards for health professionals and industryXX
      5.7CProactively seeks opportunities to integrate diabetes practices and programs at local, regional, national, and international levelXX
      5.7DPursues leadership development opportunities to be identified as a recognized expert in diabetes careXX
      5.7ELeads development, testing, implementation, review, and revision of innovative approaches to complex diabetes practice issuesX
      5.7FProactively seeks opportunities for leadership positions to be identified as an expert on diabetes nutrition-related issues and educational needs of consumers and health care professionals (eg, consultant to business, industry, national diabetes organizations, and/or media spokesperson)X
      Examples of Outcomes for Standard 5: Communication and Application of Knowledge
      • Expertise in food, nutrition, dietetics, and management is demonstrated and shared
      • Interoperable information technology is used to support practice
      • Effective and efficient communications occur through appropriate and professional use of e-mail, texting, and social media tools
      • Individuals, groups, and stakeholders:
        • Receive current and appropriate information and customer-centered service
        • Demonstrate understanding of information and behavioral strategies received
        • Know how to obtain additional guidance from the RDN or other RDN-recommended resources
      • Leadership is demonstrated through active professional and community involvement
      Standard 6: Utilization and Management of Resources

      The registered dietitian nutritionist (RDN) uses resources effectively and efficiently.

      Rationale:

      The RDN demonstrates leadership through strategic management of time, finances, facilities, supplies, technology, natural and human resources.
      Indicators for Standard 6: Utilization and Management of Resources
      Bold Font Indicators are Academy Core RDN Standards of Professional Performance IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      6.1Uses a systematic approach to manage resources and improve outcomesXXX
      6.1ARecognizes and uses existing resources (eg, educational/training tools and materials and staff time) as needed in the provision of diabetes nutrition servicesXXX
      6.1BManages effective delivery of diabetes nutrition programs and services (eg, business and marketing plan, staffing, budget and billing processes, program administration, education programs, materials development, and supplies)XX
      6.1CEvaluates and monitors current diabetes practices at the systems level considering business best practices, expected revenue, and formulates revisions based on dataX
      6.1DDirects or manages design and delivery of diabetes nutrition services in various settingsX
      6.2Evaluates management of resources with the use of standardized performance measures and benchmarking as applicableXXX
      6.2AUses the Standards of Excellence Metric Tool to self-assess quality in leadership, organization, practice, and outcomes for an organization (www.eatrightpro.org/excellencetool)XXX
      6.2BLeads and participates in data collection regarding the population served, services provided, and outcomes (eg, demographic characteristics, staffing benchmarking, and reimbursement/revenue)XX
      6.2CEvaluates the provision of diabetes care, including staff to patient/client ratio, reimbursement/revenue data, and customer satisfaction survey resultsX
      6.3Evaluates safety, effectiveness, efficiency, productivity, sustainability practices, and value while planning and delivering services and productsXXX
      6.3ADemonstrates understanding of and complies with The Joint Commission standards (www.jointcommission.org), the National Standards for DSMES and the ADA Standards of Medical Care in Diabetes, and those of other accreditation bodiesXXX
      6.3BParticipates in evaluation, selection, and implementation (when applicable) of new products, equipment, and services to ensure safe, optimal, and cost-effective delivery of diabetes nutrition care and servicesXXX
      6.3CManages evaluation of products, equipment, and services (eg, blood glucose meters and medical food/nutrition supplements)XX
      6.3DEvaluates at the systems level, safety, effectiveness, and budget; and planning and delivery of DSMES and nutrition care, services, and productsX
      6.4Participates in QAPI
      QAPI=quality assurance and performance improvement.
      and documents outcomes and best practices relative to resource management
      XXX
      6.4AParticipates actively in QAPI, including collecting, documenting, and analyzing relevant data to ensure continued assessment of resource use (eg, personnel, services, fiscal, materials, and supplies)XXX
      6.4BRecognizes best practices in similar diabetes settings and collaborates with interprofessional team for applicationXXX
      6.4CProactively and systematically recognizes needs; anticipates outcomes and consequences of various approaches; and modifies resource management and/or delivery of services for improvement in achieving desired outcomesXX
      6.5Measures and tracks trends regarding internal and external customer outcomes (eg, satisfaction and key performance indicators)XXX
      6.5AGathers and assesses data regarding patient/client satisfaction related to diabetes care, education, and related services; seeks assistance as needXXX
      6.5BAnalyzes data related to program services and customer satisfaction; communicates results and recommendations for change(s)XX
      6.5CImplements, monitors, and evaluates changes based on data collection and analysisX
      Examples of Outcomes for Standard 6: Utilization and Management of Resources
      • Resources are effectively and efficiently managed
      • Documentation of resource use is consistent with operational and sustainability goals
      • Data are used to promote, improve, and validate services, organization practices, and public policy
      • Desired outcomes are achieved, documented, and disseminated
      • Identifies and tracks key performance indicators in alignment with organization mission, vision, principles, and values
      a HIPAA=Health Insurance Portability and Accountability Act.
      b CDE=Certified Diabetes Educator (www.ncbde.org).
      c BC-ADM=Board Certified-Advanced Diabetes Management (www.diabeteseducator.org).
      d CGM=continuous glucose monitoring.
      e Interprofessional: Interprofessional is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physicians, nurses, dietitian nutritionists, pharmacists, diabetes educators, psychologists, social workers, and occupational and physical therapists), depending on the needs of the customer. Interprofessional could also mean interdisciplinary or multidisciplinary.
      f CMS=Centers for Medicare and Medicaid Services (www.cms.gov).
      g NCQA=National Committee for Quality Assurance.
      h HEDIS=Healthcare Effectiveness Data and Information Set.
      i PROMIS: The Patient-Reported Outcomes Measurement Information System (PROMIS) (https://commonfund.nih.gov/promis/index) is a reliable, precise measure of patient-reported health status for physical, mental, and social well-being. It is a web-based resource and is publicly available.
      j MNT=medical nutrition therapy (www.eatrightpro.org/scope > Definition of terms).
      k DSMES=diabetes self-management education and support (https://professional.diabetes.org/content-page/standards-medical-care-diabetes).
      l Academy=Academy of Nutrition and Dietetics (www.eatrightpro.org).
      m EAL=Academy of Nutrition and Dietetics Evidence Analysis Library (www.andeal.org).
      n AADE=American Association of Diabetes Educators (www.diabeteseducator.org).
      p CDC DPP=Centers for Disease Control and Prevention-Diabetes Prevention Program (www.cdc.gov/diabetes/prevention/index.html).
      q Medical staff: Medical staff is composed of doctors of medicine or osteopathy and, may in accordance with state law, including scope of practice laws, include other categories of physicians, and nonphysician practitioners who are determined to be eligible for appointment by the governing body.

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State operations manual. Appendix A-survey protocol, regulations and interpretive guidelines for hospitals (Rev. 176, 12-29-17); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf. Accessed March 5, 2018.

      r Non-physician practitioner: A non-physician practitioner may include a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse-midwife, clinical social worker, clinical psychologist, anesthesiologist’s assistant, registered dietitian, or nutrition professional. Disciplines considered for privileging by a facility’s governing body and medical staff must be in accordance with state law.

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State operations manual. Appendix A-survey protocol, regulations and interpretive guidelines for hospitals (Rev. 176, 12-29-17); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf. Accessed March 5, 2018.

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State operations manual. Appendix W-survey protocol, regulations and interpretive guidelines for critical access hospitals (CAHs) and swing-beds in CAHs (Rev. 165, 12-16-16); §485.635(a)(3)(vii) Dietary Services; §458.635 (d)(3) Verbal Orders. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_w_cah.pdf. Accessed March 5, 2018.

      The term privileging is not referenced in the Centers for Medicare and Medicaid Services Long-Term Care Regulations. With publication of the Final Rule revising the Conditions of Participation for Long-Term Care facilities effective November 2016, postacute care settings, such as skilled and long-term care facilities, may now allow a resident’s attending physician the option of delegating order writing for therapeutic diets, nutrition supplements, or other nutrition-related services to the qualified dietitian or clinically qualified nutrition professional, if consistent with state law, and organization policies.

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. 42 CFR parts 405, 431, 447, 482, 483, 485, 488, and 489 Medicare and Medicaid programs; reform of requirements for long-term care facilities. Final rule (FR DOC#2016; pp 68688-68872) – Federal Register October 4, 2016; 81(192):68688-68872; §483.30(f)(2) physician services (pp 65-66), §483.60 food and nutrition services (pp 89-94), §483.60 food and nutrition services (pp 177-178). https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities. Accessed March 5, 2018.

      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State operations manual-appendix PP-guidance to surveyors for long-term care facilities. (Rev. 173, 11-22-17); §483.30 physician services, §483.60 food and nutrition services. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf. Accessed March 5, 2018.

      s CSII=continuous sustained insulin infusion (ie, insulin pump).
      t SMBG=self-monitoring blood glucose.
      u ASPEN=American Society for Parenteral and Enteral Nutrition (www.nutritioncare.org).
      v JDRF=Juvenile Diabetes Research Foundation (www.jrdf.org).
      w NDEP=National Diabetes Education Program (www.cdc.gov/diabetes/ndep/index.html).
      x AHA=American Heart Association (www.heart.org).
      y AACE=American Association of Clinical Endocrinologist (www.aace.org).
      z DPBRN=Dietetics Practice-Based Research Network (www.eatrightpro.org/resources/research/projects-tools-and-initiatives/dpbrn).
      aa NHLBI=National Heart, Lung, and Blood Institute (www.nhlbi.nih.gov).
      bb QAPI=quality assurance and performance improvement.

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      Biography

      P. Davidson is an assistant professor, Nutrition Department, West Chester University of Pennsylvania, West Chester.
      T. Ross is coordinator, Healthy Living with Diabetes, Lexington-Fayette County Health Department, Lexington, KY.
      C. Castor is an assistant professor, Nutritional Sciences Department, Howard University, Washington, DC.