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Academy of Nutrition and Dietetics: Revised 2018 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Mental Health and Addictions

      Abstract

      In 2016, there were 44.7 million adults affected by mental illness, and 20.1 million people aged 12 years or older affected by substance use disorder. More than 8.2 million Americans are afflicted with co-occurring disorders or dual diagnosis, such as both a mental illness and an addiction. Registered dietitian nutritionists (RDNs) have an important role in the treatment of this population, as optimizing nutrition status improves cognitive and emotional functioning. The Behavioral Health Nutrition Dietetic Practice Group, with guidance from the Academy of Nutrition and Dietetics Quality Management Committee, has developed Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for RDNs in Mental Health and Addictions for three levels of practice: competent, proficient, and expert. The SOP uses the Nutrition Care Process and clinical workflow elements for care of individuals with mental illness and/or addictions. 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. 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, or specializing in, mental health and addictions and practicing in other mental health and addictions-related areas, including research. The SOP and SOPP are intended to be used by RDNs for self-evaluation to assure 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.
      The Behavioral Health Nutrition Dietetic Practice Group (BHN 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 in Behavioral Health Care originally published in 2006.
      • Emerson M.
      • Kerr P.
      • Del Carmen Soler M.
      • et al.
      American Dietetic Association: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Generalists, Specialists, and Advanced) in Behavioral Health Care.
      The revised documents, Academy of Nutrition and Dietetics: Revised 2018 Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Mental Health and Addictions, focus on two areas within behavioral health–mental health and addictions, and replace the 2006 Standards. Since the 2006 Behavioral Health Care Standards were published, two additional areas within behavioral health care have been published, the SOP and SOPP for Registered Dietitians in Intellectual and Developmental Disabilities
      • Cushing P.
      • Spear D.
      • Novak P.
      • et al.
      Academy of Nutrition and Dietetics: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent, Proficient, and Expert) in Intellectual and Developmental Disabilities.
      and the SOP and SOPP for Registered Dietitians in Disordered Eating and Eating Disorders.
      • Tholking M.M.
      • Mellowspring A.C.
      • Eberle S.G.
      • et al.
      American Dietetic Association: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent, Proficient, and Expert) in Disordered Eating and Eating Disorders (DE and ED).
      The 2018 SOP and SOPP for Registered Dietitian Nutritionists in Mental Health and Addictions build on the Academy of Nutrition and Dietetics: 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.
      The Academy of Nutrition and Dietetics/Commission on Dietetic Registration’s (CDR) Code of Ethics, revised in 2018,

      Academy of Nutrition and Dietetics (Academy)/Commission on Dietetic Registration (CDR) Code of Ethics for the Nutrition and Dietetics Profession Academy website. https://www.eatrightpro.org/practice/code-of-ethics/what-is-the-code-of-ethics. Accessed May 23, 2018.

      along with the Academy of Nutrition and Dietetics: 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 Revised 2017 Scope of Practice for the RDN,
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Registered Dietitian Nutritionist.
      guide the practice and performance of RDNs in all settings.
      Approved July 2018 by the Quality Management Committee of the Academy of Nutrition and Dietetics (Academy) and the Executive Committee of the Behavioral Health Nutrition Dietetic Practice Group of the Academy. Scheduled review date: December 2024. Questions regarding the Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists in Mental Health and Addictions 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].
      Scope of practice in nutrition and dietetics is composed of statutory and individual components, includes the code(s) of ethics (eg, Academy/CDR, other national organizations, and/or employer code of ethics), and encompasses the range of roles, activities, practice guidelines, and regulations within which RDNs perform. 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 Nutritionist.
      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.
      The RDN’s individual scope of practice is determined by education, training, credentialing, experience, and demonstrating and documenting competence to practice. Individual scope of practice in nutrition and dietetics has flexible boundaries to capture the breadth of the individual’s professional practice. Professional advancement beyond the core education and supervised practice to qualify for the RDN credential provides RDNs practice opportunities, such as expanded roles within an organization based on training and certifications, if required; or additional credentials (eg, focus area CDR specialist certification, if applicable; Certified Nutrition Support Clinician [CNSC], Certified Case Manager [CCM], or Certified Professional in Healthcare Quality [CPHQ]). The Scope of Practice Decision Tool, 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 (www.eatrightpro.org/scope). The tool is designed to assist 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.
      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 the term RDN to refer to both registered dietitians and registered dietitian nutritionists.
      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 July 16, 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 July 16, 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 if 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 27106-27157). http://www.gpo.gov/fdsys/pkg/FR-2014-05-12/pdf/2014-10687.pdf. Accessed July 16, 2018.

      The actual privileges granted will be based on the 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. Medicare and Medicaid Programs; reform of requirements for long-term care facilities. 42 CFR Parts 405, 431, 447, 482, 483, 485, 488, and 489. 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 July 16, 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, which 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 (https://www.eatrightpro.org/practice/quality-management/national-quality-accreditation-and-regulations/centers-for-medicare-and-medicaid-services). Review the state’s long-term care regulations to identify potential barriers to implementation; and identify considerations for developing the facility’s processes 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 contains the revised regulatory language (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 July 16, 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 professional 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 (NCP) 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 mental health and addictions 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 mental health and addictions nutrition and dietetics services. 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 Mental Health and Addictions were developed with input and consensus of content experts representing diverse practice and geographic perspectives. The SOP and SOPP for RDNs in Mental Health and Addictions were reviewed and approved by the Executive Committee of the BHN 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) (refer to 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 Mental Health and Addictions. In Academy focus areas, the three levels of practice are represented as competent, proficient, and expert.
      Figure 3Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (RDNs) (Competent, Proficient, and Expert) in Mental Health and Addictions
      Standards of Practice are authoritative statements that describe practice demonstrated through nutrition assessment, nutrition diagnosis (problem identification)nutrition intervention (planning, implementation), outcomes monitoring and evaluation (four separate standards), and the responsibilities for which registered dietitian nutritionists (RDNs) are accountable. The Standards of Practice (SOP) for RDNs in Mental Health and Addictions 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. Standards of Professional Performance (SOPP) for RDNs in Mental Health and Addictions 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 Utilization 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 in 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’s 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 as 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 mental health and addictions care and 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 ages 13 years and older. The 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 mental health and addictions (see figure below). In addition, the core indicators have been expanded to reflect the unique competence expectations for the RDN providing mental health and addictions related care and/or services.

      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 list. www.eatrightpro.org/scope. Accessed July 16, 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 list. www.eatrightpro.org/scope. Accessed July 16, 2018.

      A general practice RDN can include responsibilities across several areas of practice, including, but not limited to: community, clinical, consultation and business, research, education, and food and nutrition management. An RDN new to mental health and addictions nutrition and dietetics practice may utilize resources (eg, Recorded Webinar: Nutrition-Focused Physical Examinations in Behavioral Health Treatment Environments; Recorded Webinar: Linking Mental Health to Nutrients and Nutritional Status; located at www.bhndpg.org/store/) and seek out more experienced practitioners to add depth and breadth to his or her knowledge, skills, and responsibilities in mental health and addictions nutrition and dietetics. Competent RDNs need to build knowledge regarding the types of mental illness and addictions, and the characteristics and behavior of individuals experiencing these conditions. RDNs competent to practice in this focus area need to understand the side effects of prescribed medications or illicit drug use and potential impact on nutritional needs, the nutrients that may cause or influence an altered mental state if deficient or in excess, and the dietary habits and medications that may lead to deficiencies or excess of nutrients.

      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 the 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 list. www.eatrightpro.org/scope. Accessed July 16, 2018.

      Proficient practitioners in mental health and addictions have 1) gained additional knowledge in the care and management of individuals with mental illness and/or an addiction; 2) work experience in delivering medical nutrition therapy, counseling and education to this population with complex needs; and 3) may have obtained additional credentials or focused skill development in counseling.

      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 list. www.eatrightpro.org/scope. Accessed July 16, 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. Experts identify needs and plan educational resources or events for mental health and addictions professionals regarding the bidirectional influence of nutrition and mental status. Experts also make RDNs and nutrition and dietetics technicians, registered (NDTRs) aware of developments in the field and their applicability in the workplace, as well as develop resources, records, and data systems to contribute knowledge to the facility or to the broader field. Expert practitioners may have obtained certifications or credentials, such as the National Certified Addiction Counselor (www.naadac.org/certification) and the National Certified Counselor (www.nbcc.org/Certification/NCC).
      These Standards, along with the Academy/CDR Code of Ethics,

      Academy of Nutrition and Dietetics (Academy)/Commission on Dietetic Registration (CDR) Code of Ethics for the Nutrition and Dietetics Profession Academy website. https://www.eatrightpro.org/practice/code-of-ethics/what-is-the-code-of-ethics. Accessed May 23, 2018.

      answer the questions: Why is an RDN uniquely qualified to provide mental health and addictions nutrition and dietetics services? What knowledge, skills, and competencies does an RDN need to demonstrate for the provision of safe, effective, and quality mental health and addictions care and service at the competent, proficient, and expert levels?

      Overview

      The Academy’s Behavioral Health Nutrition Dietetic Practice Group encompasses four key areas of nutrition practice: addictions, mental health, intellectual and developmental disabilities, and disordered eating and eating disorders. These SOP and SOPP focus specifically on mental health and addictions (see Figure 4 for definitions). Mental illness includes a wide range of psychiatric diagnoses, including anxiety disorder, bipolar disorder, dementia, depression, obsessive-compulsive disorder, schizophrenia, as well as other disorders listed in the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders.
      American Psychiatric Association
      Diagnostic and Statistical Manual of Mental Disorders.
      In 2016, mental illness of any type affected 44.7 million adults aged 18 and older in the past year.

      Reports and Detailed Tables from the 2016 National Survey on Drug Use and Health (NSDUH). Substance Abuse and Mental Health Services Administration website. https://www.samhsa.gov/samhsa-data-outcomes-quality/major-data-collections/reports-detailed-tables-2016-NSDUH. Accessed July 16, 2018.

      Addiction is characterized by behaviors that include one or more of the following: impaired control over illicit or prescribed drugs and/or alcohol use, compulsive use and/or continued use despite harm and cravings.
      Addictions may also refer to behaviors such as disordered eating or gambling. Substance use disorder (alcohol or illicit drugs) was reported in 2016 to affect 20.1 million people aged 12 years or older in the past year.

      Reports and Detailed Tables from the 2016 National Survey on Drug Use and Health (NSDUH). Substance Abuse and Mental Health Services Administration website. https://www.samhsa.gov/samhsa-data-outcomes-quality/major-data-collections/reports-detailed-tables-2016-NSDUH. Accessed July 16, 2018.

      In addition, more than 8.2 million Americans are afflicted with co-occurring disorders or dual diagnoses, such as both a mental illness and an addiction.

      Reports and Detailed Tables from the 2016 National Survey on Drug Use and Health (NSDUH). Substance Abuse and Mental Health Services Administration website. https://www.samhsa.gov/samhsa-data-outcomes-quality/major-data-collections/reports-detailed-tables-2016-NSDUH. Accessed July 16, 2018.

      Druss BG, Walker ER. Mental disorders and medical comorbidity. Research Synthesis Report #21 February 2011. Robert Woods Johnson Foundation website. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2011/rwjf69438/subassets/rwjf69438_1. Published February 2011. Accessed July 16, 2018.

      Figure thumbnail gr1
      Figure 4Mental health and addictions definitions.

      Substance Use Disorders. Substance Abuse and Mental Health Services Administration website. https://www.samhsa.gov/disorders/substance-use. Accessed July 16, 2018.

      RDNs, with their unique skill set, have an important role to play in the treatment of this population. Optimizing nutritional status improves cognitive and emotional functioning for individuals with mental illness and/or addictions.
      • Schneider M.
      • Levant B.
      • Reichel M.
      • et al.
      Lipids in psychiatric disorders and preventive medicine.
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      • Sarris J.
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      on behalf of The International Society for Nutritional Psychiatry Research
      Nutritional medicine as mainstream in psychiatry.
      • Sarris J.
      • Logan A.C.
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      • et al.
      International Society for Nutritional Psychiatry Research consensus position statement: Nutritional medicine in modern psychiatry.
      • Jeynes K.D.
      • Leigh Gibson E.
      The importance of nutrition in aiding recovery from substance use disorders: A review.
      • Grant L.P.
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      • Sachan D.S.
      Nutrition education is positively associated with substance abuse treatment program outcomes.
      RDNs may be employees or consultants to organizations and programs serving the mental health or addictions populations. These include psychiatric hospitals, mental health or behavioral health units in acute care or long-term care settings, outpatient programs of hospitals, university student health centers, rehabilitation/recovery treatment centers, community health centers/clinics, and transitional community after care settings, as well as private practice.
      In organizations with nutrition services, RDNs serve as core members of the interprofessional team that plans and coordinates the overall treatment approach for patients/clients to support management of mental illness and/or recovery from alcohol and/or drug abuse.
      • Ross L.J.
      • Wilson M.
      • Banks M.
      • Rezannah F.
      • Daglish M.
      Prevalence of malnutrition and nutritional risk factors in patients undergoing alcohol and drug treatment.
      • Cowan J.A.
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      Diet and body composition outcomes of an environmental and educational intervention among men in treatment for substance addiction.
      • Barbadoro P.
      • Ponzio E.
      • Pertosa E.
      • et al.
      The effects of educational intervention on nutritional behaviour in alcohol-dependent patients.

      Wiss DA, Schellenberger M, Prelip ML. Registered dietitian nutritionists in substance use disorder treatment centers [published online October 25, 2017]. J Acad Nutr Diet. https://doi.org/10.1016/j.jand.2017.08.113.

      • Kniskern M.
      Food for Recovery: Resolving malnutrition and disordered eating patterns in addiction and substance abuse populations. Behavioral Health Nutrition Dietetic Practice Group.
      • Verdin K.A.
      The role of nutrition intervention for improving health and outcomes in patients with alcohol use disorders: A literature review. Behavioral Health Nutrition Dietetic Practice Group.
      The interprofessional team may include RDNs, psychiatrists, psychologists, social workers, nurses, nurse practitioners, physician assistants, pharmacists, mental health technicians, substance abuse counselors, therapists (eg, occupational, physical, vocational, and recreational), and foodservice representatives. The RDN has a role in helping achieve treatment goals and supporting a healthy lifestyle and recovery. As interprofessional care is core to the treatment of individuals with mental health and addictions, an RDN must recognize the boundaries of nutrition counseling vs psychotherapy and when referral to another team member is necessary.
      • Setnick J.
      Nutrition counseling boundaries: Connecting with patients without practicing psychotherapy. Behavioral Health Nutrition Dietetic Practice Group.
      Individuals with a mental illness and/or an addiction may have comorbidities (eg, malnutrition,
      • Ross L.J.
      • Wilson M.
      • Banks M.
      • Rezannah F.
      • Daglish M.
      Prevalence of malnutrition and nutritional risk factors in patients undergoing alcohol and drug treatment.
      cardiovascular disease, swallowing disability due to a stroke, or Wernicke’s encephalopathy due to alcoholism) that need to be addressed. Nutrition screening on admission to the hospital/program, followed by a nutrition assessment by the RDN, identifies comorbidities impacted by nutrition, nutrition risk factors (eg, unplanned weight loss, food insecurity, disordered eating or an eating disorder, and/or nutrition knowledge deficits), and individual preferences to consider in support of a healthy lifestyle and prevention of relapse. The nutrition plan may require the RDN to modify the standard menus for creating a person-centered, individualized meal plan (eg, carbohydrate control for diabetes, reduced sodium), order or recommend medical food and/or dietary supplements, or food texture or liquid modifications for dentition and/or a swallowing disability.
      In mental health or addictions treatment settings that provide foodservice for the patient/client population, visitors, and staff, an RDN may serve as the department director or manager. Standard foodservice systems operations are used (eg, food purchasing, preparation, and service; food safety; and sanitation) with patients/clients receiving tray or cafeteria service, and separate cafeteria or coffee shop service available for visitors and staff. Patient/client service is tailored to the characteristics and needs of the population, as the foodservice environment must accommodate the various stages of recovery. In a mental health or addictions inpatient facility that treats individuals in recovery, a patient/client may require a period of detoxification, quiet time, or other needs, such as a more isolated meal service, as their illness may prevent them from eating in a cafeteria setting. The menus and snacks offered need to support the medical needs of the population as well as offer regular meals and snacks with healthful food selections.

      Wiss DA, Schellenberger M, Prelip ML. Registered dietitian nutritionists in substance use disorder treatment centers [published online October 25, 2017]. J Acad Nutr Diet. https://doi.org/10.1016/j.jand.2017.08.113.

      • Kniskern M.
      Food for Recovery: Resolving malnutrition and disordered eating patterns in addiction and substance abuse populations. Behavioral Health Nutrition Dietetic Practice Group.
      • Cowan J.A.
      • Devine C.M.
      Process evaluation of an environmental and educational nutrition intervention in residential drug-treatment facilities.
      These include complex carbohydrates, foods rich in n-3 fatty acids, fruits and vegetables, products with limited added sugar, and non-caffeinated beverages.

      Wiss DA, Schellenberger M, Prelip ML. Registered dietitian nutritionists in substance use disorder treatment centers [published online October 25, 2017]. J Acad Nutr Diet. https://doi.org/10.1016/j.jand.2017.08.113.

      • Kniskern M.
      Food for Recovery: Resolving malnutrition and disordered eating patterns in addiction and substance abuse populations. Behavioral Health Nutrition Dietetic Practice Group.
      • Cowan J.A.
      • Devine C.M.
      Process evaluation of an environmental and educational nutrition intervention in residential drug-treatment facilities.
      Sweets and caffeine may be foods of choice to curb cravings for individuals in recovery that contribute to undesired weight gain, sleep disturbances, depression, and relapse.

      Wiss DA, Schellenberger M, Prelip ML. Registered dietitian nutritionists in substance use disorder treatment centers [published online October 25, 2017]. J Acad Nutr Diet. https://doi.org/10.1016/j.jand.2017.08.113.

      • Kniskern M.
      Food for Recovery: Resolving malnutrition and disordered eating patterns in addiction and substance abuse populations. Behavioral Health Nutrition Dietetic Practice Group.
      • Cowan J.A.
      • Devine C.M.
      Process evaluation of an environmental and educational nutrition intervention in residential drug-treatment facilities.
      A staff or consultant RDN providing nutrition services needs to collaborate with the foodservice manager on the food offerings and accommodating special dietary needs of patients/clients.
      For transitions of care planning, discharge needs are identified to support recovery. Individuals are referred to a community mental health clinic/provider for continued care and are connected to needed resources in the community, such as meal programs, food pantries, and support groups. Examples of empowering the individual to have healthful food and beverage choices in the community include referral to other providers for support and education, teaching the individual or advocates about basic nutrition or special diet guidelines,
      • Grant L.P.
      • Haughton B.
      • Sachan D.S.
      Nutrition education is positively associated with substance abuse treatment program outcomes.
      • Kniskern M.
      Food for Recovery: Resolving malnutrition and disordered eating patterns in addiction and substance abuse populations. Behavioral Health Nutrition Dietetic Practice Group.
      • Verdin K.A.
      The role of nutrition intervention for improving health and outcomes in patients with alcohol use disorders: A literature review. Behavioral Health Nutrition Dietetic Practice Group.
      conducting basic cooking classes with a focus on nutrition, and assisting the individual with how to shop and budget for nutritious foods.
      • Jones A.D.
      Food insecurity and mental health status: A global analysis of 149 countries.
      Further resources for RDNs working in mental health and addictions areas may be found on the BHN DPG website. BHN has resources for practitioners in mental health and addictions, such as live and recorded webinars for a variety of settings, publications, links to organizations, and other resources that can be found at: www.bhndpg.org/about/membership-benefits/resources-2/.

      Academy Revised 2018 SOP and SOPP for RDNs (Competent, Proficient, and Expert) in Mental Health and Addictions

      An RDN can use the Academy Revised 2018 SOP and SOPP for RDNs (Competent, Proficient, and Expert) in Mental Health and Addictions (see Figures 1 and 2, available at www.jandonline.org, and Figure 3) to:
      • identify the competencies needed to provide mental health and addictions nutrition and dietetics care and services;
      • self-evaluate whether he or she has the appropriate knowledge, skills, experience, and judgment to provide safe, effective, and quality mental health and addictions nutrition and dietetics care and service 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 mental health and addictions nutrition and dietetics practice;
      • provide a foundation for public and professional accountability in mental health and addictions nutrition and dietetics care and services;
      • support efforts for strategic planning, performance improvement, outcomes reporting, and assist management in the planning and communicating of mental health and addictions nutrition and dietetics services and resources;
      • enhance professional identity and skill in communicating the nature of mental health and addictions nutrition and dietetics care and services;
      • guide the development of mental health and addictions nutrition and dietetics-related education and continuing education programs, job descriptions, practice guidelines, protocols, clinical models, competence evaluation tools, and career pathways; and
      • assist educators and preceptors in teaching students and interns the knowledge, skills, and competencies needed to work in mental health and addictions 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 mental health and addictions is learning the principles that underpin this focus area and is developing knowledge, skills, judgment, and gaining experience for safe and effective mental health and addictions 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, the RDN new to the focus areas of mental health and addictions must accept the challenge of becoming familiar with the body of knowledge and available resources to support and ensure quality mental health and addictions-related nutrition and dietetics practice.
      At the proficient level, an RDN has developed a more in-depth understanding of mental health and addictions nutrition and dietetics practice, and is better equipped to adapt and apply evidence-based guidelines and best practices than at the competent level. This RDN is able to modify practice according to unique situations. For example, RDNs may make substitutions for a patient with paranoia towards some foods, or integrate reported symptoms related to alcohol intake, a history of bariatric surgery, and postpartum depression. The RDN at the proficient level has the option of acquiring a specialist credential(s). Examples of certifications are the Licensed Mental Health Counselor, Mental Health Counselor (described by the American Counseling Association and Association for Creativity in Counseling at www.counseling.org/knowledge-center/clearinghouses), the National Certified Addiction Counselor, Level I (NCAC I) and Level II (NCAC II), and others described by The Association for Addiction Professionals.
      At the expert level, the RDN thinks critically, reflecting breadth of knowledge and experience, and demonstrates a more intuitive understanding of mental health and addictions nutrition and dietetics care and service, displays a range of highly developed clinical and technical skills, and formulates judgments acquired through a combination of education, experience, and critical thinking. Essentially, practice at the expert level requires the application of composite nutrition and dietetics knowledge, with practitioners drawing not only on their practice experience, but also on the experience of the mental health and addictions RDNs in various disciplines and practice settings. Expert RDNs, with their extensive experience and ability to see the significance and meaning of mental health and addictions nutrition and dietetics within a contextual whole, are fluid and flexible, and have considerable autonomy in practice. They not only develop and implement mental health and addictions nutrition and dietetics services, they also manage, drive, and direct care for individuals and/or groups; conduct and collaborate in research and advocacy; accept organization leadership roles; engage in scholarly work; guide interprofessional teams; and lead the advancement of mental health and addictions nutrition and dietetics practice.
      Indicators for the SOP and SOPP for RDNs in Mental Health and Addictions are measurable action statements that illustrate how each standard can be applied in practice (Figure 1 SOP and Figure 2 SOPP, available at www.jandonline.org). Within the SOP and SOPP for RDNs in Mental Health and Addictions, 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. A competent RDN in mental health and addictions could be an RDN starting practice after registration or an experienced RDN who has recently assumed responsibility to provide mental health and addictions nutrition care for patients/clients. This could include patients/clients with poor nutrition related to reduced food intake secondary to alcohol or recreational drug use, or individuals with excessive intake of some nutrients related to use of numerous dietary supplements.
      An “X” in the proficient column indicates that an RDN who performs at this level has a more in-depth understanding of mental health and addictions nutrition and dietetics and has the ability to modify or guide nutrition therapy to meet the needs of patients/clients in various situations (eg, history of bariatric surgery, trauma).
      An “X” in the expert column indicates that the RDN who performs at this level possesses a comprehensive understanding of mental health and addictions nutrition and dietetics and a highly developed range of skills and judgments acquired through a combination of experience and education. 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 mental health and addictions 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 Mental Health and Addictions 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 Mental Health and Addictions 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. This self-appraisal also enables mental health and addictions RDNs 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, the 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 the 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 during 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 mental health and addictions as learning opportunities and to promote consistency in practice and performance and continuous quality improvement. See Figure 5 for role examples of how RDNs in different roles, at different levels of practice, may use the SOP and SOPP in Mental Health and Addictions.
      Figure 5Role Examples of Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitian Nutritionists (RDNs) (Competent, Proficient, and Expert) in Mental Health and Addiction.
      RoleExamples of use of SOP and SOPP documents by RDNs in different practice roles
      For each role, the RDN updates the professional development plan to include applicable essential practice competencies for mental health and/or addictions nutrition care and services to support needed knowledge and skills, such as effective counseling techniques, pharmacology for common drugs of abuse, and potential nutrition-related impact(s).
      Clinical practitioner, psychiatric hospital or acute care psychiatric unitAn RDN working in a psychiatric hospital reports seeing more patients/clients with a psychiatric disorder complicated by drug and/or alcohol addictions. The RDN reviews available resources to guide nutrition services and medical nutrition therapy for these individuals. The RDN refers to the Revised 2018 Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for RDNs in Mental Health and Addictions to evaluate current knowledge, skills, experience, and competence for identifying areas to strengthen. The RDN consults with a colleague working with individuals with addictions in a community mental health center for information and recommendations for continuing education options.
      Clinical practitioner,

      post-acute/long-term care
      An RDN consultant for a long-term care facility notices an increase in the number of new residents with a psychiatric disorder. The RDN refers to the SOP and SOPP in Mental Health and Addictions to enhance knowledge and skills for guiding assessment and plan of care decision making for these individuals. The RDN reviews the resources identified in the SOP and SOPP article and figures to identify areas for continuing education. The RDN consults with an RDN colleague who provides care for individuals with mental illnesses for appropriate diet orders and type of adjustments that may be needed for menus and dining options to support a resident’s nutritional needs.
      Clinical nutrition managerA clinical nutrition manager (CNM) who oversees RDNs in a large psychiatric hospital considers the SOP and SOPP for Mental Health and Addictions for developing job descriptions, work assignments, assisting staff in evaluating competence and additional knowledge and/or skills needs in mental health and addictions nutrition care and services. The CNM recognizes the SOP and SOPP along with other applicable focus area SOP and SOPP (eg, diabetes care) as important tools for staff to use in assessing their own competence, identifying personal performance plans, and guiding quality improvement data monitoring and evaluation to optimize patient/client outcomes.
      Food and nutrition services managerA new food and nutrition services manager in an addictions treatment facility uses the resources identified in the SOP and SOPP in Mental Health and Addictions and other relevant focus area SOP and/or SOPP to identify practice expectations when working with individuals with addictions. The RDN learns further information to assist with design/redesign of foodservice systems and menu and snack offerings in support of meeting the nutritional needs of the client population.
      Community-based support program practitionerAn RDN working in a community-based flexible support program provides consultations for participants with mental illnesses and other medical diagnoses who present with nutrition-related problems. The RDN reviews the SOP and SOPP for RDNs in Mental Health and Addictions and other relevant focus area SOP SOPP periodically to evaluate knowledge, skills and competence level for providing care to program participants. The SOP and SOPP are used as a resource for developing approaches in nutrition care, and guiding quality improvement projects to maximize participant and program outcomes.
      Telehealth practitionerAn RDN working in telehealth whose nutrition consultations include individuals with mental illness considers the SOP and SOPP in Mental Health and Addictions when determining expertise needed. The RDN identifies knowledge areas and resources to support care for individuals with mental illness, for communications with referring practitioner, and to strengthen professional counseling and education skills. The RDN reviews all relevant state laws and regulations, the Academy of Nutrition and Dietetics telehealth resources, and organizational policies and procedures regarding the practice of telehealth, noting differences for providing patient/client services to those not residing within the same state as the RDN.
      University Health Center practitionerAn RDN in a university student health center who provides counseling for nutrition and healthy lifestyle notes an increasing number of students being referred for poor nutrition because of alcohol and/or substance abuse. The RDN reviews the SOP and SOPP in Mental Health and Addictions for resources to guide nutrition assessments and develop interventions/plans of care. Review of indicators showed areas for increased knowledge, skills, and experience that were needed. The RDN consults with the interprofessional team on medical and nutrition management plans, and for recommendations on continuing education options.
      Private practice practitionerAn RDN working in a private practice setting whose nutrition consultations include individuals with mental illness and/or addictions considers the SOP and SOPP in Mental Health and Addictions when determining knowledge, skills and expertise needed. The RDN collaborates with the referring provider and, with client’s permission, other health care professionals guiding client’s treatment plan to incorporate addressing nutrition needs. The RDN uses the SOP and SOPP to identify resources for personal development and to support care for clients with mental illness and/or addictions.
      a For each role, the RDN updates the professional development plan to include applicable essential practice competencies for mental health and/or addictions nutrition care and services to support needed knowledge and skills, such as effective counseling techniques, pharmacology for common drugs of abuse, and potential nutrition-related impact(s).
      In some instances, components of the SOP and SOPP for RDNs in Mental Health and Addictions 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. The 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 refined with each review of these Standards as expert-level RDNs systematically record and document their experiences, often through use of exemplars. Exemplary actions of individual mental health and addictions RDNs in practice settings and professional activities that enhance patient/client/population care and/or services, can be used to illustrate outstanding practice models.

      Future Directions

      Emerging evidence-based research regarding neurotransmitters, the microbiome, the gut–brain axis, and psychobiotics will offer diagnostic and treatment options that support nutrition as a core component. These options may lead to effective treatments and improved quality of life for individuals with mental health disorders and addictions.
      • Marx W.
      • Moseley G.
      • Berk M.
      • Jacka F.
      Nutritional psychiatry: The present state of the evidence.
      • Sarris J.
      • Logan A.C.
      • Akbaraly T.N.
      • et al.
      on behalf of The International Society for Nutritional Psychiatry Research
      Nutritional medicine as mainstream in psychiatry.

      Wiss DA, Schellenberger M, Prelip ML. Registered dietitian nutritionists in substance use disorder treatment centers [published online October 25, 2017]. J Acad Nutr Diet. https://doi.org/10.1016/j.jand.2017.08.113.

      • Jacka F.N.
      Nutritional psychiatry: Where to next?.
      While acute and psychiatric hospitals, and long-term care settings have regulations that address food and nutrition services and the role for RDNs, no such regulations or standards on nutrition exist currently for substance abuse treatment settings. RDNs need to advocate for consistent availability of nutrition services and insurance coverage to benefit the health status of individuals in substance abuse treatment for improved outcomes.

      Wiss DA, Schellenberger M, Prelip ML. Registered dietitian nutritionists in substance use disorder treatment centers [published online October 25, 2017]. J Acad Nutr Diet. https://doi.org/10.1016/j.jand.2017.08.113.

      • Ruscigno M.
      Nutrition therapy in substance use disorders.
      In addition, RDNs have a critical skill set to use in private practice with individuals with mental illness or addictions. RDNs need to gain the necessary knowledge and skills when dealing with complex issues. Increased recognition of the importance of nutrition in mental health and addictions treatment will offer RDNs in community and private practice settings opportunities to contribute their expertise in this growing practice area. RDNs who work with clients over longer periods of time addressing mental health and addictions are able to develop supportive sustained collaborative relationships and achieve positive outcomes.
      • Harper C.
      • Maher J.
      Investigating philosophies underpinning dietetic private practice.
      The SOP and SOPP for RDNs in Mental Health and Addictions are innovative and dynamic documents. Future revisions will reflect changes and advances in practice, changes to dietetics education standards, regulatory changes, and outcomes of practice audits. Continued clarity and differentiation of the three practice levels in support of safe, effective, and quality practice in mental health and addictions 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. The SOP and SOPP for RDNs in Mental Health and Addictions are complementary documents and are key resources for RDNs at all knowledge and performance levels. These standards can and should be used by mental health and addictions RDNs to consistently improve and appropriately demonstrate competency 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 mental health and addictions nutrition and dietetics 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 mental health and addictions nutrition 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 BHN Dietetic Practice Group, 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 the 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

      Special acknowledgement and thanks to the Behavioral Health Nutrition Dietetic Practice Group’s Executive Committee. The authors also extend thanks to all who were instrumental in the process for the revisions of the article. Finally, the authors thank Academy 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 SOP and SOPPs.

      Author Contributions

      Each author contributed to editing the components of the article (eg, article text and figures) and reviewed all drafts of the manuscript. K. Russell authored first draft of Figures 1 and 2, T. Anderson Girard authored first draft of role examples and article, R. Leyse-Wallace contributed literature search, and reviewed, with input, all interim submissions. All authors read, reviewed, and submitted perspective on all segments of the revision. T. Anderson Girard, K. Russell, and R. Leyse-Wallace collected the data. T. Anderson Girard and K. Russell wrote the first draft with contributions from R. Leyse-Wallace. All authors reviewed and commented on subsequent drafts of the manuscript.

      Supplementary Materials

      Figure 1Standards of Practice for Registered Dietitian Nutritionists (RDNs) in Mental Health and Addictions. Note: The terms patient, client, customer, individual, person, participant, group, or population are used interchangeably with the actual term used in a given situation, depending on the setting and the population receiving care or services.
      Standards of Practice for Registered Dietitian Nutritionists in Mental Health and Addictions

      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 in order 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 (HIPAA)-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 medical and nutritional historyXXX
      1.1A1Reviews information from nutrition screening for application to nutrition assessmentXXX
      1.1A2Reviews existing individualized service plans or plans of care addressing patient’s/client’s nutritional concerns and any progress made toward achieving established goals, and assesses patient’s/client’s level of understanding of nutrition concernsXXX
      1.1BEvaluates reports and evidence of: gastrointestinal discomfort, pain, difficulty chewing, and/or swallowingXXX
      1.1CEvaluates medical and family history for mental health disorders, addictions, and comorbiditiesXXX
      1.1DEvaluates for medical and disease conditions common in:
      • a) addictions (eg, Wernicke-Korsakoff syndrome, esophageal varices, intermittent lactose intolerance, gastroesophageal reflux disease, peptic ulcer disease, hepatic cirrhosis/necrosis, withdrawal syndrome)
      • b) mental illnesses (eg, somatic complaints, chemical dependency, delirium, disordered eating/eating disorder (DE/ED), electrolyte imbalance, over/under hydration, pre-/post-bariatric surgery)
      • c) dual diagnosis (eg, Prader-Willi syndrome, head/neck injuries, phenylketonuria, and other inborn errors of metabolism)
      • d) comorbidities commonly found in mental health and addictions populations (eg, diabetes, metabolic syndrome, cardiovascular and respiratory disorders, hyperlipidemia, human immunodeficiency virus/acquired immunodeficiency syndrome, hepatitis C, tuberculosis, nicotine dependency, osteoporosis, irritable bowel syndrome)
      XX
      1.2Anthropometric assessment: Assesses anthropometric indicators (eg, height, weight, body mass index [BMI], waist circumference, arm circumference), comparison to reference data (eg, percentile ranks/z-scores), and individual patterns and historyXXX
      1.2AUses age-appropriate standard procedures and equipment for height, weight, calculation of BMI, waist circumference, amputation adjustmentsXXX
      1.2BEvaluates developmental history (eg, growth history, developmental milestones)XXX
      1.2CIdentifies and interprets trends in anthropometric indices taking into consideration cultural diversityXXX
      1.2DEvaluates abdominal girth in the presence of ascites, aerophagiaXX
      1.2EUses in-depth knowledge of body composition and nutritional physiologyX
      1.3Biochemical data, medical tests, and procedure assessment: Assesses laboratory profiles (eg, acid–base balance, renal function, endocrine function, inflammatory response, vitamin/mineral profile, and lipid profile), and medical tests and procedures (eg, gastrointestinal study and metabolic rate)XXX
      1.3AEvaluates consultation reports for nutrition implications (eg, psychological testing, dental consults, speech/occupational/physical therapy evaluations, physician consultative reports)XXX
      1.3A1Includes the World Health Organization Disability Assessment Schedule 2 (WHODAS 2.0)XX
      1.3BUses biochemical data to evaluate nutritional status in relation to mental illness and addictionsXXX
      1.3B1Comprehensive blood panelsXXX
      1.3B2Vitamin/mineral deficiency/toxicityXX
      1.3B3Heavy metal toxicityXX
      1.3B4Essential fatty acidsXX
      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
      1.4AConducts NFPE that includes, but is not limited to: evaluate for evidence of oral, perioral, and skin-related abnormalities; notes patient/client reports of alterations in taste, smell, and dentition/chewing ability; considers vital signs (blood pressure, temperature, and rate of respiration) as reported by othersXXX
      1.4BEvaluates body composition measures (eg, fat and muscle stores, anthropometrics)XXX
      1.4CEvaluates clinical signs of fluid imbalance (eg, edema, ascites, pulmonary congestion, skin turgor with dehydration, fatigue, muscle cramps, dark urine, rapid weight changes with fluid overload or loss, constipation)XXX
      1.4DEvaluates clinical signs of undernutrition (eg, dry, brittle, or thinning hair and nails, irritability, inability to concentrate)XXX
      1.4EEvaluates clinical signs of malnutrition (eg, hypothermia, bradycardia, lanugo, muscle wasting, tooth erosion, bony protrusions, parotid gland enlargement, gastrointestinal distress) in the context of mental illness and addictionsXX
      1.5Food and nutrition–related history assessment (ie, dietary assessment)–Evaluates the following components:
      1.5AFood and nutrient intake including the composition and adequacy, meal and snack patterns, and appropriateness related to food allergies and intolerancesXXX
      1.5A1Assesses food and beverage intake for macro- and micronutrient sufficiency or excessXXX
      1.5A2Assesses for variations in patterns of intake commonly found in mental health and addiction disorders or conditions (eg, polydipsia, self-restriction, binging, purging, abuse of appetite suppressants [diet pills, caffeine, nicotine], oral defensiveness, food/fluid avoidance due to paranoia, hallucinations, or delusions, excessive or inadequate intake related to mania or depression, post-traumatic stress disorder, anxiety)XX
      1.5A3Assesses for variations in timing of food and fluid intake common in mental health and addictions disorders or conditions (eg, persons with chemical dependency eating only once a day or not at all; persons with dementia who forget to eat or forget to stop eating; night-time eating contributing to sleep disturbances and obesity)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
      1.5B1Assesses influences on eating patterns (eg, budget, time, food preferences) and responsibilities related to meal planning, purchasing, and preparationXXX
      1.5B2Assesses social environment (eg, living situation and the influence of others on eating and food and beverage choices)XXX
      1.5B3Assesses lifestyle practices (eg, food episodes, structure, location, and timing of meals and snacks)XXX
      1.5B4Assesses level of support needed for self-directed food selection, attainment, preparation, and intake (eg, support of care providers, adaptive equipment, literacy tools)XX
      1.5CMedication and dietary supplement use, including prescription and over-the-counter medications, and integrative and functional medicine productsXXX
      1.5C1Evaluates potential interactions between nutrients/ nutritional status and prescribed medications, over-the-counter and illicit drugs, dietary supplements, including herbals, functional medicine products, bioactive substances, caffeineXXX
      1.5C2Evaluates drug/food and dietary supplement/food interactions (eg, St John’s wort, valerian root, kava kava, grapefruit juice); refer to database resources (eg, Natural Medicine Comprehensive Database: http://naturaldatabase.therapeuticresearch.com/home.aspx)XXX
      1.5C3Evaluates nutrition-related side effects of common mental health and addictions medications (eg, weight gain, fluid retention, dry mouth, excessive thirst, constipation, altered glucose and/or lipid metabolism, reduced calorie needs, gastrointestinal discomfort, anorexia, increased appetite)XX
      1.5C4Evaluates drug-food/nutrient interactions of common mental health and addictions medications (eg, monoamine oxidase inhibitors, Antabuse, lithium)XX
      1.5C5Evaluates use of illicit drugs and potential complications (eg, ascites, Wernicke-Korsakoff syndrome, oral-dental conditions, vitamin/mineral deficiencies)XX
      1.5C6Incorporates and applies in-depth knowledge of drug-food/nutrient and drug–dietary supplement interactions and associated pharmacokinetics and pharmacodynamicsX
      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 food preparation skills and knowledgeXXX
      1.5D2Assesses patient/client and/or family/caregiver reports of food cravings (eg, fats, simple carbohydrates)XXX
      1.5D3Listens for and notes eating beliefs and convictions (eg, food combinations, orthorexia, food is poisoned)XX
      1.5D4Documents patient/client reports of triggers for maladaptive behaviorsXX
      1.5D5Notes behavioral mediators (or antecedents) related to dietary intake (eg, attitudes, self-efficacy, knowledge, intentions, motivations, readiness and willingness to change, perceived social support, and feelings about living with a mental illness)XX
      1.5D6Notes readiness of patient/client to receive selected nutrition interventions, considering patient’s/client’s cognitive, emotional, developmental, and behavioral readiness to benefit from planned interventionsXX
      1.5EFood security defined as factors affecting access to a sufficient quantity of safe, healthful food and water, as well as food/nutrition-related suppliesXXX
      1.5E1Evaluates psychosocial, socioeconomic, functional, and behavioral factors related to food access, selection, preparation, and understanding of health conditionXXX
      1.5E2Notes observations of health care professionals and/or patient/client/family and social services reports:
      • living situation (eg, independent, semi-independent, group home)
      • barriers to adequate food access (eg, homelessness, transportation, finances, lack of or poor food preparation skills)
      XXX
      1.5E3Investigates non-apparent barriers or conflicts that would interfere with food access, selection, preparationXX
      1.5FPhysical activity, cognitive and physical ability to engage in developmentally appropriate nutrition-related tasks (eg, self-feeding and other activities of daily living), instrumental activities of daily living (eg, shopping, food preparation), and breastfeedingXXX
      1.5F1Evaluates nutrition-related tasks the patient/client is able to perform independently, with assistance, and is able to do, but is not doing routinelyXXX
      1.5F2Observes ability to complete activities of daily living (eg, self-feeding, grocery shopping, cooking)XXX
      1.5F3Notes observations and/or reports of excessive activity or non-activity (eg, pacing, wandering, excessive sleeping)XXX
      1.5F4Observes for presence of, or risks for, depression, cognitive decline, anxiety, delusionsXX
      1.5GOther factors affecting intake and nutrition and health status (eg, cultural, ethnic, religious, lifestyle influencers, psychosocial and social determinants of health)XXX
      1.5G1Considers risk of harm to self and possible interaction with nutrition careXXX
      1.5G2Evaluates impact of substance use disorder (eg, alcohol, tobacco, drugs) on ability to care for selfXXX
      1.5G3Notes significant recent stressors and any influence on food intake (eg, change of caregiver, loss of significant other)XXX
      1.5G4Uses validated assessment instruments to assess level of developmental function (eg, activities of daily living) and mental statusXX
      1.5G5Evaluates symptoms suggesting a negative health event (eg, delirium tremens, withdrawal, seizures, overdose or toxic use, dehydration)XX
      1.5G6Evaluates risk/history of DE/ED, and related factors (eg, medication adjustments, food intake, physical activity, weight history, food texture issues, psychiatric diagnosis)XX
      1.5G7Evaluates other behaviors or factors that may delay the patient’s/client’s progress toward nutritional independence (eg, history of trauma,

      Trauma-Informed Approach and Trauma-Specific Interventions. https://www.samhsa.gov/nctic/trauma-interventions. Substance Abuse and Mental Health Services Administration web site. Updated April 27, 2018. Accessed July 16, 2018.

      refusal of food, motivation)
      XX
      1.5G8Notes involvement and/or preoccupation with religious/ cultural factors that may influence nutrition (eg, religious fasting, food avoidance)XX
      1.6Comparative standards: Uses reference data and standards to estimate nutrient needs and recommended body weight, BMI, 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
      1.7Physical activity habits and restrictions: Assesses physical activity, history of physical activity, and physical activity trainingXXX
      1.7AEvaluates reports of current level of physical activity relative to Physical Activity Guidelines for AmericansXXX
      1.7BEvaluates physical activity in context of current mental health and addictions treatment planXXX
      1.7CEvaluates physical activities patient/client enjoys, but is not doing routinelyXXX
      1.7DEvaluates for atypical physical activities (eg, non-ambulatory, athletes, compulsivity)XX
      1.8Collects data and reviews collected and/or documented data by the nutrition and dietetics technician, registered (NDTR), other health care practitioner(s), patient/client, or staff for factors that affect nutrition and health statusXXX
      1.8AObtains and integrates data from members of the interprofessional
      Interprofessional: The term interprofessional is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physician, nurses, dietitian nutritionists, physician assistants, pharmacists, psychologists, social workers, and occupational and physical therapists), depending on the needs of the patient/client. Interprofessional could also mean interdisciplinary or multidisciplinary.
      treatment team
      XXX
      1.9Uses collected data to identify possible problem areas for determining nutrition diagnosesXXX
      1.10Documents and communicates:XXX
      1.10ADate and time of assessmentXXX
      1.10BPertinent data (eg, medical, social, behavioral)XXX
      1.10CComparison to appropriate standardsXXX
      1.10DPatient/client/population perceptions, values and motivation related to presenting problemsXXX
      1.10EChanges in patient/client/population perceptions, values and motivation related to presenting problemsXXX
      1.10FReason for discharge/discontinuation or referral if appropriateXXX
      1.10F1Provides pertinent nutrition information to contribute to coordination of transitions of care (eg, post discharge follow-up, transfer to another care setting)XXX
      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 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.

      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
      2.1AEvaluates and integrates complex assessment data consisting of physical, behavioral, psychosocial, and environmental nutrition assessment findings that impact nutritional status to identify nutrition diagnosis(es) and the etiology(ies)XXX
      2.1BEvaluates multiple factors that impact nutrition diagnosis(es) to identify the major cause(s) likely to respond to intervention(s)XX
      2.1CUses complex information related to food and nutrient intake and clinical complications in relationship to their management within the treatment environmentX
      2.2Prioritizes the nutrition problem(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
      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 Terms13 and the Centers for Medicare and Medicaid Services, Hospital Conditions of Participation8).
      perception of importance
      XXX
      2.2AUses evidence-based protocols and guidelines to prioritize nutrition diagnoses in order of urgencyXXX
      2.2BUses experience, critical thinking skills and judgment to determine nutrition diagnosis hierarchy for patients/clients with complex needsXX
      2.2CDetermines the nutrition diagnosis hierarchy for disease states and complications to incorporate into nutrition protocols and guidelines, and guides discussions with interprofessional teamX
      2.3Communicates the nutrition diagnosis(es) to patients/clients/advocates, community, family members or other health care professionals when possible and appropriateXXX
      2.3AUses the most appropriate communication method (eg, written, oral, low literacy) to share informationXXX
      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 statement(s)])XXX
      2.5Re-evaluates and revises nutrition diagnosis(es) when additional assessment data become availableXXX
      2.5AUses most current information that may impact nutrition diagnosis(es), revises if needed, and communicates change to interprofessional team, patient/client/family/caregiver as appropriate in a timely mannerXXX
      Examples of Outcomes for Standard 2: Nutrition Diagnosis
      • Nutrition diagnostic statements accurately describe the nutrition problem of the patient/client and/or community in a clear and concise way
      • 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 a 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 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
      3.1APrioritization may include consideration of:
      3.1A1Medical conditionsXXX
      3.1A2Urgency of the issue/evidence of abnormal nutrition (eg, history of unhealthy weight loss/gain, prolonged poor nutritional intake)XXX
      3.1A3Comorbid diseases or conditionsXXX
      3.1A4Actual or risk of acute complicationsXXX
      3.1A5Patient’s/client’s available resources and supportXXX
      3.1A6Patient’s/client’s ability and willingness to implement and adhere to nutrition care planXXX
      3.1A7Mental health and addictions disorders (eg, schizophrenia, bipolar disorder, depression, intellectual and developmental disabilities [IDD], DE/ED, substance use disorder)XX
      3.1A8Maladaptive behaviors (eg, hording, pica)XX
      3.1A9Challenges that impact nutrition status (eg, genetic disorders, sensory processing disorders, pica)XX
      3.2Bases intervention/plan of care on best available research/evidence and information, evidence-based guidelines, and best practicesXXX
      3.2AConsults nationally developed adult and pediatric evidence-based practice guidelines and position papers (eg, Academy of Nutrition and Dietetics [Academy] position and practice papers, Academy Evidence Analysis Library, and Adult and Pediatric Nutrition Care Manuals) for guidelines for control or improvement of the disease or conditions as defined and supported in the literatureXXX
      3.2A1Evaluates and applies the most appropriate practice guidelines for the patient’s/client’s diagnosis(es), nutritional needs, and other factors (eg Evidence Analysis Library, Nutrition Care Manual, Substance Abuse and Mental Health Services Administration, Association for Addiction Professionals)XXX
      3.2A2Tailors plan of care based on the individual’s needs and response to interventionXXX
      3.2A3Recognizes when it is appropriate and safe to deviate from established guidelinesXX
      3.2A4Contributes to or directs the development of intervention guidelinesX
      3.2BIncorporates scientific, clinical, and humanistic knowledge and skills in clinical decision making and practiceXX
      3.2CApplies knowledge, skills, and practice experiences in communications, information management, problem solving, and resource utilization to guide interventions and interactions with interprofessional teamX
      3.3Refers to policies and procedures, protocols, and program standardsXXX
      3.3AAdheres to federal, state, and local laws and regulations related to care of patients/clients with mental health and addictions disordersXXX
      3.3BAdheres to departmental/organizational program policies, procedures, guidelines, and protocolsXXX
      3.4Collaborates with patient/client/advocate/population, caregivers, interprofessional team, and other health care professionalsXXX
      3.4AServes as an integral member of the interprofessional teamXXX
      3.4A1Recognizes specific knowledge and skills of other providers, and collaborates to provide comprehensive careXX
      3.4A2Teaches clinical practice skills and rationales for nutrition interventions to students, colleagues, and interprofessional team membersX
      3.4BConsiders individual and family/caregiver knowledge, self-management skills, behavior/habits, and willingness to implement nutrition interventions to achieve goalsXXX
      3.4CCollaborates with the patient/client, including family, caregiver, interprofessional team, and other health care practitioners as needed in all aspects of nutrition care and patient/client-centered interventions and planningXXX
      3.4DRefers patient/client to appropriate health care provider for problems outside scope of practiceXXX
      3.5Works with patient/client/population, advocate, and caregivers to identify goals, preferences, discharge/transitions of care needs, plan of care, and expected outcomesXXX
      3.5AEncourages patient/client to play an active role in goal setting for behavior changeXXX
      3.5BDevelops expected outcomes in observable and measurable terms that are clear, concise, patient-/client-centered, and tailored to what is reasonable for the patient’s/client’s circumstances, and specific in relation to treatments and outcomes; seeks assistance as neededXXX
      3.5CIdentifies potential barriers to successful implementation of plan (eg, patient compliance, food availability and preparation issues, social support, readiness to change)XX
      3.5DDevelops and implements strategies to address lapses in commitment or behaviors, and identifies recovery strategiesXX
      3.5EAnticipates how nutrition intervention may minimize treatment-related side effects, treatment delays, and the need for increased level of care (eg, hospital admission)X
      3.6Develops the nutrition prescription and establishes measurable patient-/client-focused goals to be accomplishedXXX
      3.6AEngages the patient/client in establishing nutrition prescription and plans for execution of interventionsXXX
      3.6A1Considers behavioral and environmental influences on nutritional intakeXX
      3.6A2Considers impacts of nutrition and appetite on behavior and readiness to learnXX
      3.6BTailors nutrition prescription by taking into consideration factors affecting nutrition status (eg, health risks associated with overweight and obesity, addictions, mental health, comorbidities, such as disordered eating, intellectual and developmental disabilities, and living situation)XXX
      3.6B1Reviews pharmacotherapy plan to evaluate for potential impact on nutrition prescriptionXX
      3.6B2Uses critical thinking and synthesis skills to guide decision making in complicated, unpredictable, and dynamic situationsXX
      3.6B3Considers emerging/alternative treatment strategies that are supported by scientific evidence (evidence-based research, guidelines, and information)X
      3.6CAddictions–Includes consideration of the following when developing the nutrition prescription:
      3.6C1Types of maladaptive substance useXXX
      3.6C2Contraindications for alcohol consumption (eg, medication interaction, commitment to abstinence, history of substance use disorder, peri-conception, pregnant, or lactating, children and adolescents, specific medical conditions)XXX
      3.6C3Nutrition in the prevention of developmental disabilities (eg, maternal nutrition, abstaining from alcohol and drugs, pica)XXX
      3.6C4Effects of chemical dependency on physical health (eg, ascites, osteoporosis, peptic ulcer disease, esophageal reflux disease; cancers of the mouth, esophagus, stomach, bowel; heart disease, pancreatitis, altered glucose regulation, liver cirrhosis/necrosis, dyslipidemia, lactose intolerance, malnutrition)XXX
      3.6C5Stage of detoxification or recovery from substance use disorderXX
      3.6C6Effects of substance use disorder on mental and brain health (eg, altered mood, encephalopathy, neuropathy, dementia)XX
      3.6C7Nutrition for recovery and relapse preventionXX
      3.6C8Appropriate use of vitamin, mineral, and other nutritional supplements (eg, thiamin and digestive enzymes) in recoveryXX
      3.6C9Use of addictive substances acting as appetite suppressants (eg, caffeine, nicotine, and other addictive stimulants)XX
      3.6C10Necessity for, as well as the psychological and health effects of, nutrition interventionXX
      3.6C11Community/prevention programs specific to substance use disorder that provide nutrition-related supportXX
      3.6DMental Health–Includes consideration of the following when developing the nutrition prescription:
      3.6D1Nutrient imbalances associated with changes in mental functioning (eg, vitamin B-12 deficiency in depression, thiamin deficiency in dementia, lithium-electrolyte imbalance)XX
      3.6D2Altered energy requirements associated with changes in activity patterns, sleep patterns, medicationsXX
      3.6D3Altered hydration status (eg, polydipsia/water intoxication, dehydration, medication toxicity)XX
      3.6D4Influence of mood and thought disorders in food selection and meal structuringXX
      3.6D5Loss of appetite and poor self-care as symptoms of mental illness (vegetative or negative symptoms)XX
      3.6D6Personality disorders (eg, borderline, antisocial, avoidant, narcissistic, passive-aggressive, and dependent personality features) that may impact nutritionXX
      3.6EComorbidities and/or dual diagnosis(es) of DE/ED, IDD–Includes consideration of the following when developing the nutrition prescription:
      3.6E1Physiological consequences of eating disorders (eg, dental erosion, osteoporosis, esophageal erosion/tears/bleeding, delayed growth and sexual development, hair loss, muscle atrophy, dermatitis, mental confusion, reduced hormone production, bradycardia, cardiac arrest, dehydration, hypotension, weakness, hypothermia, death)XXX
      3.6E2Need for alternative feeding methods or dining setting, rehabilitation evaluation/treatmentXXX
      3.6E3Prevention of, or need to address potential for, refeeding syndromeXXX
      3.6E4Impairments of oral structure and functionXX
      3.6E5Oral hygiene and overcoming oral defensivenessXX
      3.6E6Food and fluid textures to optimize safety and acceptanceXX
      3.6E7Realistic weight goals considering the impact of any skeletal abnormalities, psychiatric medications, actual or potential for physical activity, behaviors unique to the patient/clientXX
      3.6E8Psychological consequences of disordered eating (eg, depression, substance use disorder, self-harm)XX
      3.6E9Patient/client distortions in body image and food portionsXX
      3.6E10Environmental/cultural/media literacy factors influencing disordered eatingXX
      3.6FConsiders impact of living situation information on addressing nutrition needs and design of nutrition prescriptionXXX
      3.6F1Healthful content of food choices, frequency, and schedule of mealsXXX
      3.6F2Daily routines that interfere with nutritional intakeXXX
      3.6F3Access to food and nutrition services (eg, access to grocery store, funds to purchase, living situation where meals can be prepared)XXX
      3.6F4Access to mental health and/or addictions services in the continuum of care (eg, transportation, community support clubhouse programs, mental health outreach programs)XX
      3.6F5Policies/regulations that influence access to food and nutrition servicesXX
      3.7Defines time and frequency of care including intensity, duration, and follow-upXXX
      3.7AIdentifies time and frequency of care based on individual needs, established goals and outcomes, and expected response to intervention(s)XXX
      3.7BConsiders severity of nutritional issues, and/or pending medical and/or behavioral/psychiatric interventions that are influenced by or may influence nutrition statusXX
      3.8CDevelops guidelines for timing of intervention(s) and follow-up based on organization guidelines, research, and best practicesX
      3.8Uses standardized terminology for describing interventionsXXX
      3.9Identifies resources and referrals neededXXX
      3.9AIdentifies:
      • tools to assist patient/client with self-management of nutrition status
      • resources to support patient/client/family/caregiver with behavior change goals (eg, support groups, health care services, meal programs, community outreach programs)
      XXX
      3.9BIdentifies and facilitates referrals as needed for physical assistance (eg, adaptive equipment, speech therapy, occupational therapy, physical therapy, dental services, home care)XXX
      3.9CIdentifies and facilitates referrals as needed for:
      • behavioral services (eg, psychotherapist, pastoral counseling, community-based support groups including 12-step groups, The National Alliance on Mental Illness)
      • educational adjuncts (eg, Cooperative Extension nutrition program, community education programs)
      • financial resources (eg, state or federal food assistance programs [eg, SNAP {Supplemental Nutrition Assistance Program} or WIC {Special Supplemental Nutrition Assistance Program for Women, Infants, and Children}], community meal programs, food pantries)
      XXX
      Implements the Nutrition Intervention/Plan of Care:
      3.10Collaborates with colleagues, interprofessional team, and other health care professionalsXXX
      3.10ACollaborates with physician and interprofessional team to use approved protocols or similar documents consistent with facility/program policesXXX
      3.10BCollaborates for guidance or assistance or refers to other members of the interprofessional team when need is outside scope of practice of RDN (eg, psychiatrist, psychologist, social worker, occupational therapist, speech therapist, RDN with expertise in DE/ED)XXX
      3.10CFacilitates and fosters active communication, learning, partnerships, and collaboration with the interprofessional teamXX
      3.10DLeads or directs the interprofessional team and others as appropriateX
      3.11Communicates and coordinates the nutrition intervention/plan of careXXX
      3.11AReviews nutrition goals, interventions, and referrals/resources necessary to meet goals in nutrition plan of care and communicates with patient/client, caregivers, interprofessional team, other health care or community settings)XXX
      3.11BCollaborates with the interprofessional team and other agencies to coordinate nutrition care after discharge (eg, caregivers, family)XXX
      3.11CEnsures communication of nutrition plan of care and transfer of nutrition-related data between care settings as neededXXX
      3.11DCoordinates care for the patient/client with multiple diagnoses or repeat admissions with other members of the interprofessional team (eg, physician, psychiatrist, psychologist, social worker, behavioral therapist)XX
      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 qualified nutrition professional. Disciplines considered for privileging by a facility’s governing body and medical staff must be in accordance with state law.8,9 The term privileging is not referenced in the Centers for Medicare and Medicaid Services long-term care (LTC) regulations. With publication of the Final Rule revising the Conditions of Participation for LTC 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, nutrition supplements, or other nutrition-related services to the qualified dietitian or clinically qualified nutrition professional, if consistent with state law, and organization policies.11,12
      -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 diet, nutrition-related 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
      3.12A3Initiates and performs nutrition-related services (eg, bedside swallow screenings, inserting and monitoring nasoenteric feeding tubes, and indirect calorimetry measurements, or other permitted services)XXX
      3.12BIndividualizes nutrition and mental health- and addictions-related interventions to the setting and patient/clientXXX
      3.12CUses a variety of educational and behavioral approaches, tools, and materials as appropriateXXX
      3.12DIntegrates proficient-level experience and clinical judgment skills to guide and tailor interventions (eg, selects from a range of possibilities with additional consideration of the patient/client learning style, readiness, and willingness to change)
      • adapts general nutrition educational tools to individualized learning style and method of communication
      • incorporates stages of behavior change as a guide to assess the patient’s/client’s readiness to learn and adjusts counseling style accordingly
      • uses appropriate behavior change theories (eg, motivational interviewing, behavior modification, modeling) to facilitate self-management/self-care strategies
      • encourages greater independence in food choices and empowers the patient/client to take control of their health as they move toward a less structured environment
      • uses critical thinking and synthesis skills for combining multiple intervention approaches as appropriate
      XX
      3.12EExercises advanced diagnostic reasoning and judgment (eg, reflecting the holistic focus of mental health and addictions as complex disorders)X
      3.12FDraws on experiential knowledge and current body of expert knowledge about the patient/client population to individualize the strategy/plan of care for complex interventions in complicated, unpredictable, and dynamic situationsX
      3.13Assigns activities to NDTR and other professional, technical, and support personnel in accordance with qualifications, organizational policies/ protocols, and applicable laws and regulationsXXX
      3.13ASupervises professional, technical, and support personnelXXX
      3.13A1Provides support personnel with information and guidance to complete assigned activitiesXXX
      3.14Continues data collectionXXX
      3.14AUses measurable, standardized indicators based on goals and outcomes and documents using prescribed/standardized format for recording dataXXX
      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 intervention/plan 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
      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 assure 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
      4.1A1Verifies patient’s/client’s understanding of nutrition intervention by having the patient/client/family/caregiver verbalize and/or demonstrate understandingXXX
      4.1BDetermines whether the nutrition intervention/plan of care is being implemented as prescribedXXX
      4.1B1Investigates barriers to implementation of nutrition interventionXXX
      4.1B2Evaluates nutrition intervention in the face of complex clinical situationsXX
      4.2Measures outcomes:XXX
      4.2ASelects the standardized nutrition care measurable outcome indicator(s)XXX
      4.2A1Uses indicators that are S.M.A.R.T. (specific, measurable, attainable, realistic, and timely)XXX
      4.2BIdentifies positive or negative outcomes, including impact on potential needs for discharge/transitions of careXXX
      4.2CChecks intended effects and potential adverse effects of pharmacological and nonpharmacological treatment (eg, change in weight and glycemic control associated with antipsychotic medication)XXX
      4.3Evaluates outcomes:XXX
      4.3ACompares monitoring data with nutrition prescription and established goals or reference standardXXX
      4.3A1Monitors and analyzes clinical data to improve patient/client outcomes; seeks assistance as neededXXX
      4.3A2Reviews and understands data based on experience, clinical judgment, and/or identifies criteria to which the indicator(s) is comparedXX
      4.3A3Compares and analyzes the data for each problem area to nutrition prescription/goal using experience and clinical judgment skills, and incorporates additional consideration of progress with mental health and addictions treatment plan, the patient’s/client’s learning style, readiness, and willingness to changeXX
      4.3A4Analyzes data considering the complexity of problems and correlates one problem to another (eg, using expert clinical judgment skills reflecting on the holistic focus of mental health and addictions as complex disorders)X
      4.3A5Conducts comprehensive data analysis to identify trends in collaboration with interprofessional teamX
      4.3A6Benchmarks data sets from program participants to national, state, and local public health data sets (eg, Healthy People 2010 Leading Health Indicators, Health Plan Employer Data and Information Set, National Quality Forum Behavioral Health Measures, Hospital-Based Inpatient Psychiatric Services Core Measures)X
      4.3BEvaluates impact of the sum of all interventions on overall patient/client/population health outcomes and goalsXXX
      4.3B1Evaluates positive and negative outcomes in context of overall treatment plan, including impact on potential needs for discharge/transitions of careXXX
      4.3CEvaluates progress or reasons for lack of progress related to problems and interventionsXXX
      4.3C1Uses most appropriate measures for evaluation of goal attainment (eg, changes in food intake, anthropometrics, or biochemical data)XXX
      4.3C2Identifies patient/client factors that facilitate or impede progress (eg, emotional, social, cognitive, behavioral, environmental, motivators, and incentives to change and/or consequences to change)XXX
      4.3C3Uses multiple resources to assess progress (eg, laboratory and other clinical data, self-monitoring tools, changes in body weight/composition) relative to effectiveness of planXXX
      4.3C4Identifies changes to patient’s/client’s cognitive, physical, environmental status and implications of subsequent changes to medical treatment that could interfere with the nutrition plan of careXX
      4.3C5Identifies problems beyond scope of nutrition care that are interfering with the interventions to review with interprofessional teamX
      4.3DEvaluates evidence that the nutrition intervention/plan of care is maintaining or influencing a desirable change in the patient/client/population behavior or statusXXX
      4.3D1Accesses appropriate sources for evidence of problems or adherence (eg, food choices, food logs, laboratory results, objective data, NFPE)XXX
      4.3D2Uses direct observation, interviews, and/or other factors specific to the patient/client (eg, social, cognitive, environmental) that can explain lack of response or could influence response to nutrition interventionXXX
      4.3D3Consults with the interprofessional team and other health care practitionersXXX
      4.3ESupports conclusions with evidenceXXX
      4.3E1Demonstrates that prescribed nutrition intervention is successful/unsuccessful through documentation of clinical, cognitive, and psychosocial indicatorsXXX
      4.3E2Uses current evidence-based literature to support conclusionsXX
      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 upon outcomes data, trends, best practices, and comparative standardsXXX
      4.4A1Modifies intervention(s) as appropriate to address individual patient/client needs and preferences or priorities; seeks assistance as neededXXX
      4.4A2Arranges for additional resources, or more intensive resources, to fulfill the nutrition prescription and achieve treatment goals in collaboration with interprofessional team as neededXX
      4.4A3Tailors tools and methods to ensure desired outcomes that reflect the patient’s/client’s social, physical, and environmental factorsXX
      4.4A4Uses experience and expertise to identify additional resources and/or avenues of therapy to enhance effectiveness or follow through of interventionX
      4.5Documents:XXX
      4.5ADate and timeXXX
      4.5BIndicators measured, results, and the method for obtaining measurementXXX
      4.5CCriteria to which the 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 the nutrition diagnosis and the 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
      a Interprofessional: The term interprofessional is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physician, nurses, dietitian nutritionists, physician assistants, pharmacists, psychologists, social workers, and occupational and physical therapists), depending on the needs of the patient/client. Interprofessional could also mean interdisciplinary or multidisciplinary.
      b 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 July 16, 2018.

      ).
      c 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 qualified 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 July 16, 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 July 16, 2018.

      The term privileging is not referenced in the Centers for Medicare and Medicaid Services long-term care (LTC) regulations. With publication of the Final Rule revising the Conditions of Participation for LTC 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, 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. Medicare and Medicaid Programs; reform of requirements for long-term care facilities. 42 CFR Parts 405, 431, 447, 482, 483, 485, 488, and 489. 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 July 16, 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 July 16, 2018.

      Figure 2Standards of Professional Performance for Registered Dietitian Nutritionists (RDNs) in Mental Health and Addictions. Note: The term customer is used in this evaluation resource as a universal term. Customer could also mean client/patient/customer, family, participant, consumer, student, or any individual, group, or organization to which the RDN provides service.
      Standards of Professional Performance for Registered Dietitian Nutritionists in Mental Health and Addictions

      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 Indicators
      The “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 practiceXXX
      1.1AComplies with state licensure laws and regulations, including telehealth (http://www.telehealthresourcecenter.org/toolbox-module/licensure-and-scope-practice) and continuing education requirementsXXX
      1.2Performs within individual and statutory scope of practice and applicable laws and regulationsXXX
      1.2AAdheres to the practice boundaries related to nutrition vs mental health/psychotherapy or addictions counseling unless qualified through additional credentials (eg, National Certified Counselor, National Certified Addiction Counselor) and state-specific regulationsXXX
      1.3Adheres to sound business and ethical billing practices applicable to the role and settingXXX
      1.3AComplies with appropriate billing codes for payer and type of nutrition visit applicable to settingXXX
      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) to improve the quality of services provided and to enhance customer-centered servicesXXX
      1.4AUses nationally standardized and consensus-based behavioral health performance measures (eg, American Psychiatric Association Mental Health Performance Measures, SAMHSA
      SAMHSA=Substance Abuse and Mental Health Services Administration (www.samhsa.gov).
      National Behavioral Health Quality Framework) in design and evaluation of nutrition care and services; seeks assistance if needed
      XXX
      1.4BLeads efforts to maximize mental health and addictions nutrition services using national quality and safety dataXX
      1.4CLeads organization’s/program’s interprofessional team review and application of national consensus-based standards and measures in performance monitoring processX
      1.5Uses a systematic performance improvement model that is based on practice knowledge, evidence, research, and science for delivery of the highest quality servicesXXX
      1.5AUses the organization/department performance improvement process to measure performance against desired outcomesXXX
      1.5BLeads the development of performance improvement criteria to monitor effectiveness of servicesXX
      1.5CCollaborates with the interprofessional
      Interprofessional: The term interprofessional is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physicians, nurses, dietitian nutritionists, physician assistants, pharmacists, psychologists, social workers, and occupational and physical therapists), depending on the needs of the customer. Interprofessional could also mean interdisciplinary or multidisciplinary.
      team to create and evaluate systems, processes, and programs that support the organization’s/program’s and mental health and addictions and nutrition-related objectives
      X
      1.5DDirects the development and management of systems, processes, and programs in mental health and/or addictions nutrition-related care for continuous quality assurance and performance improvementX
      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
      1.6A1Participates in and coordinates interprofessional efforts to evaluate and improve mental health and/or addictions patient/client population outcomesXX
      1.6A2Leads interprofessional efforts to promote and measure quality of mental health and addictions nutrition care and servicesX
      1.6BDefines expected outcomesXXX
      1.6B1Identifies evidence-based nutrition-specific care and service outcomes and related processes to measureXX
      1.6B2Determines the desired nutrition-specific outcomes for the patient/client population through direct evaluation, benchmarking, and evaluation of environmental trendsX
      1.6CUses indicators that are specific, measurable, attainable, realistic, and timely (S.M.A.R.T.)XXX
      1.6DMeasures quality of services in terms of structure, process, and outcomesXXX
      1.6D1Participates in organization and local, state, and national quality improvement initiativesXXX
      1.6D2Develops and/or uses systematic processes to collect and organize dataXXX
      1.6D3Uses defined outcomes and related processes to measure as part of the outcomes management programXXX
      1.6D4Uses aggregated data to evaluate current performance measurement process against expected outcomes observed to determine if changes are requiredXX
      1.6D5Leads the development of clinical, operational, and financial measures related to mental health and addictions nutrition-related care and servicesX
      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
      1.6E1Ensures that screening for nutrition risk is a component of assessment using evidence-based screening tools for the setting and/or populationXXX
      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. PROMIS is a web-based resource and is publicly available.
      )
      XXX
      1.6F1Documents and reports outcomes to appropriate individuals and groups; seeks assistance if neededXXX
      1.6F2Evaluates patient/client and service outcomes using identified metrics to reinforce current practices or implement changes in practice(s)XX
      1.6F3Synthesizes and shares effectiveness outcomes on programs and services with the mental health and addictions communitiesX
      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
      1.6HCollaborates with RDN colleagues in local/regional mental health/addictions treatment programs to collect data for documenting and reporting outcomes of nutrition interventionsXX
      1.6ILeads local, state, and national quality initiative efforts to support mental health and addictions nutrition and related servicesX
      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 nutrition care delivery; seeks assistance as neededXXX
      1.7A1Collaborates with pharmacist to contribute to the awareness of potential drug–food/nutrient and drug–dietary supplement (eg, vitamin mineral, herbal) interactions; and to educate patients/clients/families and interprofessional teamXXX
      1.7A2Refers patients/clients to appropriate services when error/hazard is outside of the RDN’s scope of practiceXXX
      1.7BCollaborates with the interprofessional team to identify, address, and prevent errors in the delivery of mental health and addictions nutrition services (eg, food allergy/intolerance vs food aversion)XXX
      1.7B1Develops safety alert systems to monitor key indicators of mental health and addictions patients’/clients’ medical conditionsXX
      1.7CMaintains awareness of problematic product names and error prevention recommendations provided by ISMP
      ISMP=The Institute for Safe Medication Practices (www.ismp.org).
      (www.ismp.org), FDA
      FDA=Food and Drug Administration (www.fda.gov).
      (www.fda.gov), and USP
      USP=US Pharmacopeia Convention (www.usp.org).
      (www.usp.org)
      XX
      1.7DRecognizes possible drug–nutrient interactions and potential interactions between prescribed treatments and integrative and functional medicine therapiesXX
      1.7EDevelops best practices to identify, address, and prevent errors and hazards in the delivery of mental health and addictions food and nutrition servicesX
      1.8Compares actual performance to performance goals (ie, Gap Analysis, SWOT Analysis [Strengths, 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 individual performance to established goals and expected outcomesXXX
      1.8CCompares departmental/organizational performance to established goals and outcomes; and to national programs and standardsXX
      1.8DLeads in benchmarking of mental health and addictions nutrition care based on health and population-based indicators (eg, https://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi-topics/Mental-Health)X
      1.9Evaluates interventions and workflow process(es) and identifies service and delivery improvementsXXX
      1.9AUses evaluation data and/or collaborates with interprofessional team to identify organizational/departmental improvementsXX
      1.9BLeads 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
      1.10AAdjusts services and programs based on data and review of current evidence-based information (eg, practice guidelines and quality improvement data for mental health and addictions) in collaboration with interprofessional teamXXX
      1.10BLeads the evaluation and revision of nutrition systems, processes, and programs to ensure mental health and/or addictions evidence-based practices and organizational policies and procedures are followedX
      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 systems specific to program(s)/service(s) are established and updated as needed; are 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/Commission on Dietetics Registration (CDR), other national organizations, health care professional 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(s) SOP and/or SOPP into practice (www.eatrightpro.org/sop)XXX
      2.2BUses SOP and SOPP for RDNs in Mental Health and Addictions to:
      • assess performance at the appropriate level of practice
      • develop and implement a professional development plan to improve the quality of practice and performance and to advance practice
      XXX
      2.2CDevelops corporate/organizational policies, guidelines, human resource materials (eg, job descriptions, career ladders, care and service activities for each performance level) using the SOP and SOPP for RDNs in Mental Health and AddictionsXX
      2.3Demonstrates and documents competence in practice and delivery of customer-centered service(s)XXX
      2.3AManages change effectively, demonstrating knowledge of the change processXXX
      2.3BDemonstrates attributes, such as assertiveness, enhanced listening, and conflict resolution skillsXX
      2.3CDocuments examples of expanded professional responsibility reflective of a proficient or expert practice roleXX
      2.4Assumes accountability and responsibility for actions and behaviorsXXX
      2.4AIdentifies, acknowledges, and corrects errorsXXX
      2.4BKnows and complies with policies, procedures, and other organizational standards applicable to role and responsibilitiesXXX
      2.4CDevelops and implements policies and procedures that ensure staff accountability and responsibilityXX
      2.5Conducts self-evaluation at regular intervalsXXX
      2.5AIdentifies needs for professional developmentXXX
      2.5A1Evaluates role and responsibilities at the organizational and/or systems level to identify areas for continuing education to strengthen knowledge/skills or qualifications for new rolesXX
      2.5BEvaluates current level of practice to:
      • identify needs for professional development based on self-evaluation considering evidence-based guidelines, best practices, and research in mental health and/or addictions
      • assure quality of current practice, and advance level of practice to achieve career goals
      XXX
      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
      2.7Engages in evidence-based practice and uses best practicesXXX
      2.7AIntegrates evidence-based practice and research evidence in delivering quality care using SAMHSA, NIMH,
      NIMH=National Institute of Mental Health (www.nimh.nih.gov).
      NIAAA,
      NIAAA=National Institute on Alcohol Abuse and Alcoholism (www.niaaa.nih.gov).
      Academy
      Academy=Academy of Nutrition and Dietetics (www.eatright.org).
      resources, Academy EAL,
      EAL=Academy of Nutrition and Dietetics Evidence Analysis Library (www.andeal.org).
      position papers, and best practices
      XXX
      2.7BDevelops skill in accessing and critically analyzing researchXXX
      2.7CAdvocates for the advancement of evidence-based knowledge for the profession (eg, research, presentations, publications)XXX
      2.7DParticipates in research activities and publication of results to advance evidence and best practices in mental health and addictions nutrition practiceXX
      2.7EServes as an author of mental health and/or addictions-related evidence-based publicationsXX
      2.7FContributes expertise and critical thinking skills as a reviewer of original research and/or evidence-based guidelines relevant to mental health and addictions nutrition practiceX
      2.7GUses and guides others in applying planned change principles to integrate research into practiceX
      2.8Participates in peer review of others as applicable to role and responsibilitiesXXX
      2.8AEngages in peer review activities consistent with setting, responsibilities, and patient/client population (eg, peer evaluation, peer supervision, clinical chart review, performance evaluations)XXX
      2.8BConducts scholarly review of professional articles, chapters, books, programs, and guidelinesXX
      2.8CLeads/serves on editorial board for review of professional articles, chapters, and booksX
      2.9Mentors and/or precepts othersXXX
      2.9AParticipates in mentoring students and interns and serves as a preceptor for dietetic interns/students; seeks guidance as neededXXX
      2.9BDevelops mentor/mentee programs for nutrition and dietetics practitioners and health professionals of other disciplinesXX
      2.9CMentors competent- and proficient-level RDNs and non-nutrition professionals (eg, medical students/residents, advanced practice nurses, pharmacists)X
      2.10Pursues opportunities (education, training, credentials, certifications) to advance practice in accordance with laws and regulations and requirements of practice settingXXX
      2.10AServes on committees with the Academy and dietetics practice groups to develop programs, tools, and resources in support of assisting the RDN to obtain relevant certifications/credentialsXX
      2.10BLeads efforts to develop or advance education, training, and credential opportunities in mental health and/or addictionsX
      Examples of Outcomes for Standard 2: Competence and Accountability
      • Practice reflects
        • Code(s) of ethics (eg, Academy/CDR, or 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
        • CDR 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, certifications) are pursued to advance practice
      • CDR 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 the 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 Indicators
      The “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 strategic planning for the acquisition and utilization of internal and external resources for mental health and addictions nutrition programs (ie, program planning, staffing, marketing, budgeting, billing, if applicable)XX
      3.1A2Develops and manages nutrition programs tailored to the needs of the organization and the patient/client populationsXX
      3.1A3Designs, provides justification, promotes, and seeks executive commitment to new services that will meet organization and department/program goals for mental health and addictions nutrition servicesX
      3.1A4Contributes to and leads business and strategic planning with interprofessional team to identify programs and services that address the needs of the patient/client population served by the organizationX
      3.1BUses the needs, expectations, and desired outcomes of the customers/populations (eg, patients/clients, families, community, decision makers, administrators, client organization[s]) in program/service developmentXXX
      3.1B1Adheres to the practice boundaries related to nutrition vs mental health/psychotherapy or addictions counseling; seeks assistance if neededXXX
      3.1B2Develops mental health and addictions-specific community/prevention nutrition-related programs (eg, education, treatment, or service) incorporating behavior change theory, self-concept, lifestyle functions, and systematic evaluation of learningXX
      3.1B3Develops, evaluates, and ensures programs/services meet/address the customer characteristics, health status, and nutrition needs of mental health and/or addictions populationXX
      3.1B4Collaborates with local and regional programs that support and optimize provision of mental health and addictions nutrition services (eg, NAMI,
      NAMI=National Alliance on Mental Illness (www.nami.org/Learn-More/Mental-Health-By-the-Numbers).
      NIMH)
      XX
      3.1CMakes decisions and recommendations that reflect stewardship of time, talent, finances, and environmentXXX
      3.1C1Advocates for staffing that supports the customer population care and education needs, census/case load, goals, and programs and servicesXX
      3.1DProposes programs and services that are customer-centered, culturally appropriate, and minimize disparitiesXXX
      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
      3.2A1Receives referrals for services from and makes referrals to other nutrition or health care professionals to address identified customer needsXXX
      3.2A2Participates in or designs process to receive or make referrals to other providers that address the needs of the customer population (eg, social worker, pharmacist, case manager)XX
      3.2A3Designs, directs, and coordinates referral process 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 other health care practitioners to facilitate collaboration and making referrals that meet customer needsXXX
      3.2B2Establishes and maintains networks to support the overall care and recovery of customers transitioning to home or another care or community settingXX
      3.2B3Supports referral resources with curriculum and training regarding the types of complex nutrition needs of customers with mental illness and addictionsX
      3.2CMonitors effectiveness of referral systems and modifies as needed to achieve desirable outcomesXXX
      3.2C1Tracks data to evaluate efficiency and effectiveness of the nutrition referral processesXXX
      3.2C2Collaborates with the interprofessional team and other health care providers to review data and update the nutrition referral process and tools when neededXX
      3.2C3Manages and/or leads the review and revision process for nutrition referrals and tools in collaboration with the interprofessional team and others as neededX
      3.3Contributes to or designs customer-centered servicesXXX
      3.3AAssesses needs, beliefs/values, goals, resources of the customer, and social determinants of healthXXX
      3.3A1Recognizes the influences that culture, health literacy, and socioeconomic status have on health/illness experiences and the customer population’s use of and access to health care servicesXXX
      3.3A2Participates in or conducts needs assessment in collaboration with interprofessional team and community stakeholders to identify needs of the customer population and services that are availableXX
      3.3A3Incorporates behavior change strategies and counseling theories in program/service designXX
      3.3A4Leads in utilizing, evaluating, and communicating the effectiveness of different theoretical frameworks for interventions (eg, health belief model, social cognitive theory/social learning theory, stages of change [ie, transtheoretical theory])X
      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 to meet the needs of an ethnically and culturally diverse population (eg, using translators, conducting culturally appropriate assessments, selecting appropriate levels of intensity of cultural interventions, adapting education/counseling approaches and materials, adapting content to teaching modality)XXX
      3.3B2Identifies and connects customers and support networks with established resources and services within the specific ethnic/cultural communityXXX
      3.3B3Participates in or plans, develops, and implements systems of care and services reflecting needs of the population (health conditions, ethnic/cultural characteristics)XX
      3.3B4Pursues and collaborates with additional resources to positively influence health-related decision making within the customer’s specific ethnic/cultural communityXX
      3.3CCommunicates principles of disease prevention and behavioral change appropriate to the customer or target populationXXX
      3.3C1Identifies and considers customer-specific characteristics that influence delivery of mental health and addictions nutrition education and careXXX
      3.3C2Designs tools to communicate disease prevention and behavioral change principlesXX
      3.3DCollaborates with the customers to set priorities, establish goals, and create customer-centered action plans to achieve desirable outcomesXXX
      3.3D1Designs mental health and addictions nutrition plans of care systems according to customers’ care needs and priorities, desired outcomes with consideration of and input from other health care practitioners/caregiversXXX
      3.3D2Confirms that mental health and addictions nutrition plans of care are reflective of evidence-based approachesXXX
      3.3D3Incorporates systems to support customers in stages of readiness to change by establishing realistic goalsXXX
      3.3D4Participates in or initiates development of guidelines and tools to guide customers and/or their support networks (eg, family, caregivers) in health-related shared decision making and goal setting for maximizing outcomesXX
      3.3EInvolves customers in decision makingXXX
      3.3E1Uses appropriate tools, such as deep listening, motivational interviewing, and cognitive behavioral therapy to involve customers in directing their mental health and addictions nutrition careXX
      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
      3.4A1Serves as a consultant for issues related to nutrition for mental health and addictionsXX
      3.4A2Directs efforts to improve collaboration between customers and other 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
      3.4B1Plans and implements mental health and addictions nutrition programs and services that reflect evidence-based guidelines and best practicesXX
      3.4B2Uses or develops nutrition screening guidelines, programs, and recommendations relevant to the patient/client populationXX
      3.4B3Implements and manages organization and/or community-based nutrition programs for mental health and addictions populations consistent with recognized practice guidelinesXX
      3.4B4Reviews and applies community/prevention program indicators and national, state, and local public health and population-based indicators (eg, Healthy People 2020 Leading Health Indicators, HEDIS,
      HEDIS=Healthcare Effectiveness Data and Information Set (www.ncqa.org/hedis-quality-measurement).
      Behavioral Health Quality Improvement measure sets) to benchmark against organization/program outcomes for positive impact on program planning and development
      X
      3.4B5Leads team on program/service review, identifying changes, and process revisions as neededX
      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
      HIPAA=Health Insurance Portability Accountability Act (www.hhs.gov/ocr/hipaa).
      -compliant telehealth platforms), and training materials that reflect evidence-based practice in accordance with applicable laws and regulations
      XXX
      3.4C1Collaborates with interprofessional team to inform and seek input on the design and evaluation of nutrition policies, procedures, and services for meeting needs of customer population (eg, screening for nutrition risk, discharge/transitions of care process, process for team reporting observations on patient/client response to nutrition care or educational needs)XX
      3.4C2Leads department and interprofessional process of developing, monitoring, evaluating, and improving the protocols, guidelines, and practice toolsX
      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 can, in accordance with state law, including scope of practice laws, include other categories of physicians, and non-physician practitioners who are determined to be eligible for appointment by the governing body.8
      or medical director (eg, post-acute care settings, dialysis center, public health, community, 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, qualified dietitian, or qualified nutrition professional. Disciplines considered for privileging by a facility’s governing body and medical staff must be in accordance with state law.8,9 The term privileging is not referenced in the Centers for Medicare and Medicaid Services long-term care (LTC) regulations. With publication of the Final Rule revising the Conditions of Participation for LTC 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, nutrition supplements or other nutrition-related services to the qualified dietitian or clinically qualified nutrition professional, if consistent with state law, and organization policies.11,12
      -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
      3.4D1iAdheres to setting-specific medical director protocol or medical staff bylaws, rules, and regulations that address ordering privileges or delegated orders for diet order writingXXX
      3.4D1iiContributes to organization/medical staff process for identifying RDN privileges to support mental health and addictions care and services (eg, diet orders, medical food/nutritional supplements, vitamin and mineral supplements)XX
      3.4D1iiiNegotiates and/or establishes nutrition privileges at organization/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
      3.4D3Establishes collaborative practice with other health care providers at organization or systems level (eg, participate in treatment team meetings, and/or a disease management program, case management)XX
      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 adherence to billing regulations and ethical billing practicesXX
      3.4FCommunicates with the interprofessional team and referring party consistent with the HIPAA rules for use and disclosure of customer’s personal health information (PHI)XXX
      3.4F1Develops process and tools to monitor adherence to HIPAA rules and/or address breaches in the protection of PHIXX
      3.5Uses professional, technical, and support personnel appropriately in the 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 the qualifications, experience, and competence of professional, technical, and support personnelXXX
      3.5A1Determines capabilities/expertise of support staff in working with customer population to determine tasks that may be delegatedXX
      3.5BSupervises professional, technical, and support personnelXXX
      3.5B1Trains professional, technical, and support personnel and evaluates their competence/skillsXX
      3.6Designs and implements food delivery systems to meet the needs of customersXXX
      3.6ACollaborates in or leads the 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, local food banks)XXX
      3.6A1Participates in foodservice planning and delivery for health care and community settings that provide mental health and addictions servicesXXX
      3.6A2Develops mental health and addictions nutrition-related guidelines for foodservice system planning and deliveryXX
      3.6A3Evaluates effectiveness of foodservice planning and delivery for patients/clients with mental illness and addictions to identify areas for improvementXX
      3.6A4Serves as consultant to organizational leadership in determining services to be providedX
      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 the development of master menus and snack options with modifications to address health and nutrition needs of mental health and addictions populations served by the setting

      Wiss DA, Schellenberger M, Prelip ML. Registered dietitian nutritionists in substance use disorder treatment centers [published online October 25, 2017]. J Acad Nutr Diet. https://doi.org/10.1016/j.jand.2017.08.113.

      • Kniskern M.
      Food for Recovery: Resolving malnutrition and disordered eating patterns in addiction and substance abuse populations. Behavioral Health Nutrition Dietetic Practice Group.
      XXX
      3.6B2Directs the development of menus, recipes, and foodservice operations consistent with role and settingXX
      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
      3.6C1Designs structured best practice programs to fund and provide enteral/parenteral nutrition supportX
      3.7Maintains records of services providedXXX
      3.7ADocuments according to organization policies, procedures, standards, and systems, including electronic health recordsXXX
      3.7BImplements data management systems to support interoperable data collection, maintenance, and utilizationXXX
      3.7B1Contributes to the design of the electronic health record system for capturing data needed in documenting nutrition care and monitoring outcomesXX
      3.7B2Advocates for and participates in the development of clinical, operational, and financial databases upon which mental health and addictions nutrition care-sensitive outcomes can be derived, reported, and used for improvementX
      3.7B3Seeks opportunities to contribute expertise to national mental health or addictions-related bioinformatics 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 customer population and organization outcomes/goalsXX
      3.7DUses data to demonstrate program/service achievements and compliance with accreditation standards, laws, and regulationsXXX
      3.7D1Collects data and documents outcomes and compares against targets and evidence-based/best practices, standards, laws, and regulationsXXX
      3.7D2Determines impact of data to the organizations and providers specific to mental health and addictions care settings; participates in development of sustainable plan of complianceXX
      3.7D3Prepares and presents analysis of nutrition care service and outcomes data for organization and accrediting bodiesX
      3.8Advocates for provision of quality food and nutrition services as part of public policyXXX
      3.8ACommunicates with policy makers regarding the benefit–cost of quality food and nutrition servicesXXX
      3.8A1Advocates with state and national congressional representatives regarding benefit of mental health and addictions nutrition care services on health care costs (eg, responds to Academy Action Alerts and other calls to action via Action Center, letters, emails, and/or phone calls)XXX
      3.8A2Interacts and serves as a resource with legislators, payers, and policy makers to contribute and influence mental health and addictions care and services (eg, providing testimony at legislative and regulatory hearings and meetings)XX
      3.8BAdvocates in support of food and nutrition programs and services for populations with special needs and chronic conditionsXXX
      3.8B1Participates in patient/client advocacy activitiesXXX
      3.8B2Advocates for policies that reduce discrimination based on disability related to mental illness and addictionsXXX
      3.8B3Leads advocacy activities (eg, authors article(s), delivers presentations on topics, networks)XX
      3.8B4Leads the development of public policy related to mental health and addictions nutrition services at the regional or national levelX
      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, 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 and nutrition 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 customers
      • 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 Indicators
      The “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 major peer-reviewed publications in mental health and addictions and nutrition; uses evidence-based guidelines, practice guidelines, and related resourcesXXX
      4.1CDemonstrates understanding of current research, trends, and epidemiologic surveys in mental health and addictions nutrition, and related areas and applies to professional practice as appropriateXXX
      4.1DIdentifies key clinical and management questions and uses systematic methods to apply research and evidence-based guidelines to answer questions and inform decisionsXX
      4.1EPromotes the use of evidence-based tools/resources (eg, Academy EAL, practice guidelines) as a basis for stimulating awareness and integration of current evidence into practiceXX
      4.2Uses best available research/evidence and information as the foundation for evidence-based practiceXXX
      4.2ADemonstrates adherence to evidence-based practice guidelines (eg, SAMHSA, NIMH, NIAAA, Academy EAL, Academy) to provide safe, effective quality care for individuals with mental illness and addictions; seeks guidance as neededXXX
      4.2BDemonstrates adherence to evidence-based practice to reduce variation in practice patterns (eg, considers the best available research on nutrition-related prevention of relapses/exacerbations in mental health and addictions nutrition care)XX
      4.2CAnalyzes and applies the available scientific literature in situations where evidence-based practice guidelines for mental health and addictions nutrition care are not establishedXX
      4.2DUses advanced training, available research, and emerging theories to manage complex cases in mental health and addictions nutrition care (eg, dialectical behavioral therapy, cognitive behavioral therapy, motivational interviewing)X
      4.3Integrates best available research/evidence and information with best practices, clinical and managerial expertise, and customer valuesXXX
      4.3ADevelops familiarity with and accesses commonly used sources of evidence in identifying applicable courses of action for patient/client care and services (eg, NQF
      NQF=National Quality Forum’s National Quality Partners Serious Mental Illness Action Team resources (http://www.qualityforum.org/NQP_Serious_Mental_Illness.aspx).
      mental illness resources, SAMHSA)
      XXX
      4.4Contributes to the development of new knowledge and research in nutrition and dieteticsXXX
      4.4AParticipates in efforts to extend research into practice through journal clubs, professional supervision, and the Academy’s Research workgroupsXXX
      4.4BParticipates in practice-based research networks (eg, Academy Research workgroups) and the development and/or implementation of practice-based researchXX
      4.4CDevelops Academy EAL questions in mental health and addictions nutrition careXX
      4.4DAuthors original research papers and book chapters to advance evidence and best practicesX
      4.4EIdentifies and initiates research relevant to mental health and addictions as the principal or co-investigator in collaborative research or interprofessional teams that examine relationships related to nutrition and mental health and addictions care and outcomesX
      4.4FServes as advisor, preceptor, and/or committee member for graduate level researchX
      4.4GProvides analysis of evidence-based guidelines, best practices, and practice experience to generate new knowledge in mental health and addictions nutrition care and servicesX
      4.5Promotes application of research in practice through alliances or collaboration with food and nutrition and other professionals and organizationsXXX
      4.5AIdentifies research issues/questions and participates in studies related to mental health and addictions care servicesXXX
      4.5BCollaborates with interprofessional and/or interorganizational teams to perform and disseminate nutrition research related to mental health and addictionsXX
      4.5CLeads interprofessional and/or interorganizational collaborative research activitiesX
      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 Indicators
      The “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 flexibility and innovation to effectively communicate and apply complex ideasXX
      5.1A3Demonstrates the ability to convey complex concepts to other health care practitioners, patients/clients, and the public when communicating and disseminating informationX
      5.1BIdentifies and uses relevant mental health/addictions nutrition care and education publications in practiceXXX
      5.1CInterprets regulatory, accreditation, and reimbursement programs and standards for organizations and providers that are specific to mental health and addictions care and education (eg, CMS,
      CMS=Centers for Medicare and Medicaid Services (www.cms.gov). CMS regulations (www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107Appendicestoc.pdf).
      TJC,
      TJC=The Joint Commission (www.jointcommission.org).
      CARF,
      CARF=Commission on Accreditation of Rehabilitation Facilities (www.carf.org).
      NCQA,
      NCQA=National Center for Quality Assurance (www.ncqa.org).
      HFAP,
      HFAP=Healthcare Facilities Accreditation Program (www.hfap.org).
      NIMH); seeks assistance if needed
      XXX
      5.1DEvaluates public health trends and epidemiological reports related to mental health and addictions prevalence, prevention, and treatment, as well as underlying etiologies and applies data in clinical practice, professional activities, and work settingsXX
      5.1EOversees the process of interpretation, distribution, and communication of evidence-based research in behavioral health and education initiatives to mental health and addictions nutrition practiceXX
      5.1FConsults as an expert on complex mental health and addictions nutrition issues with other health care professionals, organizations, and the communityX
      5.2Selects appropriate information and the most effective communication method or format that considers customer-centered care and the 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
      5.2A1Adapts communications with customers to consider health literacy, culture, preferred language, educational level, and hearing or vision disabilitiesXXX
      5.2BUses information technology to communicate, disseminate, manage knowledge, and support decision makingXXX
      5.2B1Identifies and uses web-based/electronic practice tools/resources and electronic health records within the worksite as appropriateXXX
      5.2B2Develops and updates web-based/electronic mental health and addictions nutrition and patient/client or professional education tools and resourcesXX
      5.2B3Leads the design and development of individual- and system-specific approaches that effectively convey nutrition information to diverse audiences addressing a variety of mental health and addictions nutrition-related conditionsX
      5.2B4Provides mental health and addictions nutrition expertise to national informatics projects (eg, national databases)X
      5.3Integrates knowledge of food and nutrition with knowledge of health, culture, social sciences, communication, informatics, sustainability, and managementXXX
      5.3AUses and applies current and emerging knowledge of mental health and addictions nutrition, when considering a customer’s health status, behavior barriers, communication skills, and interprofessional team involvement; seeks guidance as neededXXX
      5.3BParticipates in and/or leads the integration of scientific knowledge and experience in mental health and addictions nutrition into practice for complex problems or in new research methodologiesXX
      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 and/or coordinates the educational and professional development of RDNs and Nutrition and Dietetics Technicians, Registered, students/interns, and health care practitioners in other fields, through formal and informal teaching activities, preceptorships, and mentorshipXX
      5.4A2Develops formal, structured mentor and preceptorship programs in mental health and addictions nutrition care and educationX
      5.4BAssists individuals and groups to identify and secure appropriate and available educational and other resources and servicesXXX
      5.4B1Identifies and recommends current, evidence-based mental health and addictions nutrition educational resources (eg, Academy, Behavioral Health Nutrition Dietetic Practice Group [https://www.bhndpg.org], NIMH, US Department of Agriculture Choose My Plate)XXX
      5.4B2Establishes systematic process to identify, track, and update resources available to patients/clients and interprofessional teamXX
      5.4B3Leads individuals and groups in efforts to identify and secure appropriate and available resources and services (eg, outpatient, community)XX
      5.4CUses professional writing and verbal skills in all types of communicationsXXX
      5.4C1Demonstrates professional writing and oral communication skills with the ability to translate complex scientific and policy information to the publicXXX
      5.4DReflects knowledge of population characteristics in communication methodsXXX
      5.4D1Considers culture, literacy, and communication styles in dialogue, written communications, and educational activities for all audiences (eg, patients/clients, organization staff/leaders, community stakeholders)XX
      5.5Establishes credibility and contributes as a food and nutrition resource within the interprofessional health care and management team, organization, and communityXXX
      5.5APromotes the use of evidence-based guidelines and the Academy’s EAL with the interprofessional team and others to integrate food, nutrition, and lifestyle behaviors with mental health and addictions treatmentXXX
      5.5BConsults with physicians and other health care professionals (eg, psychologists, social workers, nurses, physical/occupational/ recreational therapists, addictions counselors)XXX
      5.5CParticipates in and leads interprofessional collaborations at the organization and systems levelXX
      5.5DContributes nutrition-related expertise and serves as lead collaborator for national projects and professional organizations (eg, Academy practice groups, NIMH, SAMHSA, NQF)X
      5.6Communicates performance improvement and research results through publications and presentationsXXX
      5.6APresents evidence-based mental health and addictions nutrition research and information to community groups and colleaguesXXX
      5.6BContributes to and advocates for the advancement of the body of knowledge for the profession (eg, research, presentations, publications, patient/client education)XX
      5.6CPresents evidence-based mental health and addictions nutrition research, guidelines, and information at professional meetings and conferences (eg, local, regional, national, international)XX
      5.6DServes in a leadership role for mental health and addictions nutrition–related scholarly work (eg, reviewer, editor, editorial advisory board) and in program planning and conferences (eg, local, regional, national, international)X
      5.6ETranslates research findings for incorporation into development of policies, procedures, and guidelines for nutrition in mental health and addictions at national and international levelsX
      5.6FDirects collation of research data into publications and presentations (eg, position papers, practice papers, meta-analyses, review articles)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 non-profit organizations serving the food insecure) providing food and nutrition expertiseXXX
      5.7AFunctions as mental health and addictions and nutrition resource as an active member of local/state/national organizationsXXX
      5.7BServes on local mental health and addictions nutrition and service planning committees/coalitions/task forces for health professionals, industry, and the communityXXX
      5.7CServes on regional and national mental health and addictions committees/task forces/advisory boards for health-related organizations, industry, and communityXX
      5.7DAdvocates for the advancement of mental health and addictions nutrition practice to stakeholders (eg, CMS, TJC, state licensure boards, the Academy’s Policy Initiative and Advocacy Office)XX
      5.7EIdentifies new opportunities for leadership and cross discipline dialogue to promote nutrition and dietetics in a broader contextXX
      5.7FProactively seeks opportunities (local, regional, and national, and international levels) to integrate practice expertise and programs with larger systems, such as SAMHSA; mental health-specific professional groups, such as Mental Health America, NAMI; and addictions-specific professional groups, such as the Association for Addiction Professionals, the International Association of Addictions and Offender Counselors, and the National Association of Addiction Treatment ProvidersX
      5.7GProactively seeks opportunities for leadership development and positions, and is identified as an expert related to mental health and addictions nutrition issuesX
      5.7HServes and advocates in leadership roles on committees and/or for publications (eg, editor, editorial board member, column editor)X
      5.7IFunctions in leadership roles and as a content expert for business, industry, and national organizationsX
      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 Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      6.1Uses a systematic approach to manage resources and improve outcomesXXX
      6.1AParticipates in operational planning of mental health and addictions nutrition programs and servicesXXX
      6.1BRecognizes and uses existing resources (eg, educational/training tools and materials, and staff time) as needed in the provision of mental health and addictions nutrition servicesXXX
      6.1CImplements administratively sound programs (eg, food quality and food safety, mental health and addictions nutrition care and services)XXX
      6.1DCollaborates with administrative, medical, and foodservice staffs, if applicable, in operational planning to secure resources and services for achieving desired outcomesXX
      6.1EDirects or manages the design and delivery of mental health and addictions 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
      6.2BCollects or contributes data and participates in analyzing customer population and outcomes data, program resource/service participation, and expense data to evaluate and adjust programs and servicesXXX
      6.2CMonitors, documents, and evaluates program and service resource usage against budget or other metrics (eg, staff hours, staff to patient/client ratio, referral requests, program participation rates, revenue/insurance reimbursement data, and supplies, training, technology, professional development, and food cost)XX
      6.2DDirects operational review reflecting evaluation of performance and benchmarking data to manage resources and modifications to design and delivery of mental health and addictions nutrition programs and servicesX
      6.3Evaluates safety, effectiveness, efficiency, productivity, sustainability practices, and value while planning and delivering services and productsXXX
      6.3AParticipates in evaluation and selection of equipment, tools, and new products (eg, nutritional supplements, dietary supplements, medical foods, food/meals, web-based programs, and monitoring systems) to assure safe, optimal, and cost-effective delivery of servicesXXX
      6.3BEvaluates safety, effectiveness, and value of programs and services in meeting the needs of the target populationsXX
      6.3CUses operational data to enhance program outcomesXX
      6.3DEvaluates safety, effectiveness, productivity, sustainability practices, and value of services at the system levelX
      6.4Participates in quality assurance and performance improvement (QAPI) and documents outcomes and best practices relative to resource managementXXX
      6.4ACollects QAPI data using designated tools and analyzes to improve outcomes and identify best practices in collaboration with others as neededXXX
      6.4BParticipates in QAPI activities to evaluate and report outcomes of delivery of services against goals and performance targets (eg, services provided [eg, number of assessments, hours for group classes], budgeted vs actual hours, actual vs budgeted revenue, actual vs projected patient/client volumes)XXX
      6.4CProactively and systematically recognizes needs, anticipates outcomes and consequences of various approaches, and modifies resources and/or service delivery to achieve targeted outcomesXX
      6.4DIntegrates quality measures and performance improvement processes into management of human and financial resources, and information technologyX
      6.5Measures and tracks trends regarding internal and external customer outcomes (eg, satisfaction, key performance indicators)XXX
      6.5AGathers and assesses data regarding customer satisfaction related to mental health and/or addictions care, education, and related services; seeks assistance as needXXX
      6.5BAnalyzes and communicates data and, where indicated, recommends or modifies programs and services to improve stakeholder (eg, patient/client, caregivers, employees, administration) satisfaction with mental health and addictions nutrition program and servicesXX
      6.5CImplements, monitors, and evaluates changes based on collected dataX
      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 the organization mission, vision, principles, and values
      a SAMHSA=Substance Abuse and Mental Health Services Administration (www.samhsa.gov).
      b Interprofessional: The term interprofessional is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physicians, nurses, dietitian nutritionists, physician assistants, pharmacists, psychologists, social workers, and occupational and physical therapists), depending on the needs of the customer. Interprofessional could also mean interdisciplinary or multidisciplinary.
      c 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. PROMIS is a web-based resource and is publicly available.
      d ISMP=The Institute for Safe Medication Practices (www.ismp.org).
      e FDA=Food and Drug Administration (www.fda.gov).
      f USP=US Pharmacopeia Convention (www.usp.org).
      g NIMH=National Institute of Mental Health (www.nimh.nih.gov).
      h NIAAA=National Institute on Alcohol Abuse and Alcoholism (www.niaaa.nih.gov).
      i Academy=Academy of Nutrition and Dietetics (www.eatright.org).
      j EAL=Academy of Nutrition and Dietetics Evidence Analysis Library (www.andeal.org).
      k NAMI=National Alliance on Mental Illness (www.nami.org/Learn-More/Mental-Health-By-the-Numbers).
      l HEDIS=Healthcare Effectiveness Data and Information Set (www.ncqa.org/hedis-quality-measurement).
      m HIPAA=Health Insurance Portability Accountability Act (www.hhs.gov/ocr/hipaa).
      n Medical staff: Medical staff is composed of doctors of medicine or osteopathy and can, in accordance with state law, including scope of practice laws, include other categories of physicians, and non-physician 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 July 16, 2018.

      o 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 qualified 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 July 16, 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 July 16, 2018.

      The term privileging is not referenced in the Centers for Medicare and Medicaid Services long-term care (LTC) regulations. With publication of the Final Rule revising the Conditions of Participation for LTC 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, 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. Medicare and Medicaid Programs; reform of requirements for long-term care facilities. 42 CFR Parts 405, 431, 447, 482, 483, 485, 488, and 489. 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 July 16, 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 July 16, 2018.

      p NQF=National Quality Forum’s National Quality Partners Serious Mental Illness Action Team resources (http://www.qualityforum.org/NQP_Serious_Mental_Illness.aspx).
      q CMS=Centers for Medicare and Medicaid Services (www.cms.gov). CMS regulations (www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107Appendicestoc.pdf).
      r TJC=The Joint Commission (www.jointcommission.org).
      s CARF=Commission on Accreditation of Rehabilitation Facilities (www.carf.org).
      t NCQA=National Center for Quality Assurance (www.ncqa.org).
      u HFAP=Healthcare Facilities Accreditation Program (www.hfap.org).

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      Biography

      T. Anderson Girard is a registered dietitian, Marquis Health Care Corporation at Blueberry Hill, Beverly, MA.
      K. Russell is director, Food and Nutrition Services, State of Michigan, Walter P Reuther Psychiatric Hospital, Westland.
      R. Leyse-Wallace is an author, retired clinical psychiatric dietitian, and adjunct faculty member, San Diego Mesa Community College, Alpine, CA.