connectionsdbcms.s3.amazonaws.com/media/files/1d196076-3137... · dining standards and the long...

Chair Update . . . . . . . . . . . . . . . . . . . . . . . . . .3

The Journey Worth Taking; a CultureChange Experience . . . . . . . . . . . . . . . . . . . . . . .6

NCP Corner . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

How to navigate the challenges andoptimize your experience as a preceptor . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Registered Dietitian Safety in Home Care . . . . . . . . . . . . . . . . . . . . . . . . .13

Hospice Corner - Geriatric Failure to Thrive . . . . . . . . . . . . . . . . . . . . . .15

Raise Your Voices! . . . . . . . . . . . . . . . . . . . . .16

50 Years with ADA! . . . . . . . . . . . . . . . . . . . .16

DHCC 2011 Award Recipients . . . . . . . . .17

National Pressure Ulcer Advisory Panel Update . . . . . . . . . . . . . . . . . . . . . . . . .18

2011 ADA Leadership Institute . . . . . . . .19

LET’S KEEP IN TOUCH . . . . . . . . . . . . . . . . .20

Call For Authors . . . . . . . . . . . . . . . . . . . . . .21

Printing and Mailing Courtesy of Abbott Nutrition, Columbus, OH

The New Dining Practice StandardsImpacting Long-term Care by Linda Roberts, MS, RD and Linda Handy MS, RD

Pioneer Network, an organization whose mission is to advocate and facilitate deepsystem change and transformation in our culture of aging by identifying andpromoting transformations in practice, services, public policy, and research. Theirvision is a culture of aging that is life affirming, satisfying, humane, and meaningful.Part of that vision is an in-depth change in systems requiring changes ingovernmental policy and regulation; changes in the individual's and society'sattitudes toward aging and elders; changes in elders' attitudes towards themselvesand their aging; and changes in the attitudes and behavior of caregivers towardthose for whom they care. (pioneernetwork.net)

Pioneer Network in partnership with the Centers for Medicare & Medicaid Services(CMS) have been partnering in the culture change of long-term care facilities.Culture change is a transformation anchored in values and beliefs that returncontrol to the elders and those who work closest with them. Culture change cantransform a facility into a home; a resident into a person; and a schedule into achoice.

In 2008 CMS and Pioneer Network partnered in “Creating Home in the NursingHome I: A National Symposium on Culture Change and the EnvironmentalRequirements.” (http://pioneernetwork.net/Events/CreatingHomeI/) Thesymposium featured national experts exploring the physical environment of thenursing home. The symposium was heralded as a success within the long-termcare community and a second symposium was soon in the works, “Creating Homein the Nursing Home II: A National Symposium on the Food and DiningRequirements.” This symposium was to bring together a diverse group ofprofessionals exploring current dining practices and relaying evidence basedpractices supporting culture change in dining. The symposium was snowed outleaving over 1200 potential participants hungry for information. Refusing to besilenced by Mother Nature, Pioneer Network and CMS elected to offer thesymposium on-line. (http://pioneernetwork.net/Events/CreatingHomeOnline/) Theinformation remains available on-line today.

An Industry of Regulations CMS regulations drive all systems within the long-term care facility; therefore anychanges within the industry must start with regulation or interpretive guidance.Karen Schoeneman, Deputy Director of CMS Long-term Care Division (has since

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This Symboldenotes thatCPEU credit

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stepped down) was a founding member of PioneerNetwork. Her vision for person-centered care hassignificantly impacted the interpretive guidance we followtoday. Her vision and intimate knowledge of theregulations lead to the New Dining Practice Standards,published September 2011 (http://pioneernetwork.net/Providers/DiningPracticeStandards/. It was her idea todevelop a set of dining standards that were agreed uponby a majority of professional organizations representingclinical practitioners. Through a grant from the Hulda B &Maurice L Rothschild Foundation the Pioneer Networkconvened a meeting of stakeholders to review, amend, andagree upon a set of dining standards that would embracecurrent thinking and evidence based practices of personcentered care. It was a brilliant move to secure theagreement of dining standards from a representativegroup of professional organizations. Why? There are anumber of CMS regulations that specifically referenceprofessional standards into which falls the New DiningPractice Standards.)

A. F281 Professional Standards. The facility must provideservices that meet professional standards of quality –services that meet accepted standards of clinicalpractice published by a professional organization suchorganizations as American Dietetic Association,American Medical Directors Association, and so forth.

B. F492 Compliance With Federal, State, and Local Lawsand Professional Standards. The facility must operateand provide services in compliance with all applicableFederal, State, and local laws, regulations, and codes,and with accepted professional standards and principlesthat apply to professionals providing services in such afacility.

C. F501 Medical Director. The medical director isresponsible for implementation of resident care policiesand coordination of medical care. The Medical Directorcollaborates with facility leadership, staff, andconsultants to develop, implement, and evaluateresident care policies and procedures that reflect currentstandards of practice. (https://www.cms.gov/manuals/downloads/som107ap_pp_guidelines_ltcf.pdf )

These professional standards, approved by 12 professionalorganizations (text box), now have the full weight of CMSthrough interpretive guidance. In other words the long-

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term care community hasto sit up and take notice.In fact Alice Bonner PhD,Director Division ofNursing Homes, spoke toNew York’s Leading Age.In her presentation shestated, “CMS participatedin the Food and DiningClinical Task Force.Surveyor training is beingdeveloped on the newclinical practicestandards. Surveyors willbe evaluating the facility’sefforts to establish thenew standards.” Now thatwe know CMS is seriousabout these standardslet’s take a look.

The New Dining Practice StandardsThe documentrecommends ten newstandards in diningsupported by referencedcitations from ADA,AMDA, and CMS. • Individualized Nutrition Approaches/Diet Liberalization• Individualized Diabetic/Calorie Controlled Diet• Individualized Low Sodium Diet• Individualized Cardiac Diet• Individualized Altered Consistency Diet• Individualized Tube Feeding• Individualized Real Food First• Individualized Honoring Choices• Shifting Traditional Professional Control to Individualized

Support of Self Directed Living• New Negative Outcome

ADA’s position paper, Individualized Nutrition Approachesfor Older Adults in Health Care Communities (1) wasreferenced throughout the dining standards. It wasparticularly gratifying to see the word individualized in thestandards, mirroring the title of our position paper. It iseven more gratifying reading excerpts from our position

Professional Organizations American Association for Long Term Care Nursing (AALTCN) American Association of Nurse Assessment Coordination (AANAC) American Dietetic Association (ADA) American Medical Directors Association (AMDA) American Occupational Therapy Association (AOTA) American Society of Consultant Pharmacists (ASCP) American Speech-Language-Hearing Association (ASHA) Dietary Managers Association (DMA) Gerontological Advanced Practice Nurses Association (GAPNA) Hartford Institute for Geriatric Nursing (HIGN) National Association of Nursing Administration in Long-term Care

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I love this time of year! In Texas, it has finally cooled off some andfinally we have had rain. It is football time, family and friends seeeach other more and we can share time with each other. Mysister community in Bastrop, Texas, was the victim of one of theworst forest fires in the US in many years; over 1600 homes weredestroyed. It was truly a humbling experience to see friends,neighbors and strangers come together to care for each otherand provide basic needs. It is often hard to be thankful at timessuch as these. In the early summer, DHCC gave to the Red Crossto help the victims of the tornados that swept through the US.In Bastrop, skilled nursing facilities, schools and other foodservice organizations fed and cared for many extra people. Takethe time to be thankful for your family, friends, community andprofessional peer relationships.

FNCE in San Diego seems like it was just the other day but it hasbeen three months since we were there. It was so great torenew friendships and network with new peers. As we moveforward, DHCC continues to work to provide you the memberswith the tools that you need to make you more successful andyour jobs easier.

We received a grant from Abbott that will allow us to archive thePreFNCE workshop on our Web site for those of you who wereunable to come to San Diego. The six hour workshop will bedivided into three online webinar formatted workshops that willallow you to see and hear our speakers and receive continuingeducation for the information. A post test will be provided andonce this is taken you will receive a certificate of completion.Watch for these three sessions on our Web site beginning inJanuary. There will be a nominal fee for participation in this newtype of education tool. I will be eager to hear your commentsafter you participate.

Your DHCC Executive Committee (EC) continues to work eachmonth in conference calls and individual projects that move usthrough our program of work. Our new Web site is functioningwell. Our latest updated publication, Pocket Resource forManagement is available for purchase and we have made bothof our pocket resources- Management and NutritionAssessment available in a downloadable electronic format.Members of DHCC worked on the completion of the NewDining Standards and the Long Term Care NCP Toolkit. I wantto thank Linda Roberts, MS, RD, LDN, Linda Handy, MS, RD, andCarol Elliott, RD, LD/N, for taking the time to help completethese tasks.

We have scheduled eleven DHCC webinars beginning inJanuary. Check on www.dhccdpg.org for the titles, topics and

times for these learning tools. These will be available for yourreview January 1, 2012.

Several members of DHCC attended the American Health CareAssociation (AHCA) annual convention in Las Vegas inSeptember. We manned a booth at this convention along withPepin Tuma, from ADA Policy Initiatives and Advocacy staff tocontinue to support the need of the Registered Dietitian inskilled nursing facilities. It was an educational experience for usas well as the AHCA attendees and pointed out to us that weneed to continue to work with this organization to reinforce ourpresence and need in the long term care industry.

One of many topics that we heard reports on in San Diego was areport from ADA’s Sharon McCauley, MS, MBA, RD, LDN, FADA,on the CMS initiative called QAPI. This initiative, QualityAssurance and Performance Improvement (QAPI), hopes toexpand the scope of the current survey process to improveoutcomes, correct deficiencies and put practices in place tomonitor skilled nursing facilities to improve performance. Newregulations will be established by CMS relating to qualityassurance and performance improvement. An expert panel hasbeen established and a grant awarded to the University ofMinnesota and Stratis Health Resource Group to begin thisprocess. Watch for more information about this in the nextnewsletter.

A task force has been established by the EC to study and definethe worth of the Registered Dietitian to the Long Term CareIndustry. Several members of this committee have begundefining how this process will work. We are eager to report onthe progress of this group as they move forward.

In early February, the EC will begin the process of strategicplanning for the next three years. When we began this processbefore, we asked for input from our membership on what yourneeds were. We will again seek this information. Please look fora survey in early January asking you to identify your concerns,needs and priorities.

We received news of the death of Betty Johnson, one of theearliest chairs of CD-HCF. Many kind thoughts and memorieswere shared by members of her enthusiasm and love of ourorganization and her profession. We sent her familycondolences from the membership of DHCC.

The Executive Committee of DHCC wishes you a wonderfulholiday season. Our hope is that you are able to spend timewith family and friends and enjoy many holiday traditions.

Chair Updateby Cynthia Piland, MS, RD, CSG, LD

CONNECTIONS FALL 2011


paper used to support the basic concepts of the NewDining Standards.

The New Dining Standards remind us that residents havethe right to choose the type and amount of food servedbased on preference and informed choice. Residentselection may not always agree with practitioner, butwhich of us always makes the ‘right’ choice? “Wheneducating residents keep in mind these are geriatricpatients and the goal of care is to avoid consequences,”states Jacki Lloyd, MD, Education Coordinator GeriatricsDepartment Florida State University College of Medicine. Itis not okay to prescribe a restrictive diet that will result innegative outcomes secondary to the resident’s refusal toeat.

Practitioners are encouraged to give residents the ‘right tofolly’, exhibit poor judgment in choice. Key word is choice.CMS regulation F151, ADA Code of Ethics (2)), andAmerican Dietetic Association Revised 2008 Standards ofPractice for Registered Dietitians in Nutrition Care;Standards of Professional Performance for RegisteredDietitians; Standards of Practice for Dietetic Technicians,Registered, in Nutrition Care; Standards of ProfessionalPerformance for Dietetic Technicians, Registered (3) in theextended care setting support the individual’s right tochoose, even if that choice is contradictory to evidencebased practices. Furthermore a resident’s choice cannot becategorized as non-compliant. The term non-compliant isgoing to become a red flag to surveyors signaling a lack ofresident informed choice.

Teaching the resident about food selection that supportsoverall health is a vital role of the Registered Dietitian (RD).An important teaching tool will be the select menu ormenu with alternates. This menu must offer usual andcustomary foods to the region and a selection of healthfulfoods so the resident has a true choice. For example, aTexan will probably never give up chicken fried steak withgravy, but may welcome a healthful alternative onoccasion.

The interdisciplinary team (IDT), including the physician,plays a vital role in educating the resident and family of therisk/benefit of their choices. The New Standards supportinformed choice not only with therapeutic diets but alsofood/fluid consistency and tube feeding. Each resident has

the right to decide which is more important, quantity orquality of life. A regular diet with thin liquids may lead toaspiration pneumonia and untimely death, but somewould argue enjoyment derived from savoring food/fluidsfar outweighs the risk. Who amongst us really wants todeprive the individual with end stage dementia the simplejoy and comfort of a familiar food or beverage? ADA’sposition paper on end-of-life (4) states tube feeding doesnot prolong survival, improve function, prevent aspirationpneumonia, reduce the risk of pressure ulcers, or providepalliation for the individual with advanced dementia.(eatright.org)

When residents eat food they enjoy there is a decreasedneed for supplements. Too often the oral nutritionalsupplement is the first line of treatment for poor appetiteor weight loss. The RD must evaluate assessment data andidentify the root cause of the problem beforerecommending interventions. (5) Oral supplement may bethe best choice in some cases, but not all. Keep in mindfood quality may be the root cause and only throughimproved food service will resident outcomes improve.

Offering real food first, in the right size portion, has beenassociated with weight stabilization or weight gain. Realfood first may inspire recipe enhancement; use currentrecipes as a foundation and add flavor enhancements forincreased acceptance. Trained chefs have become moreprevalent in long-term care facilities by offeringknowledge in recipe development and food preparation.Quantity food production may take a backseat to a la cartemenus offering resident point of service choice. RDs andChefs truly working together may be the solution to real,flavorful food first.

Recommendations of the Food and Dining ClinicalStandards Task ForceThe final recommendations published in the New DiningPractice Standards include: • Diet is to be determined with the person and in accordance with his/her informed choices, goals, and preferences not exclusively by diagnosis.• Assess the condition of the person using quality of life markers such as satisfaction with food, mealtime service, level of control, and independence.• Assess and provide a resident’s preferred mealtime routine and unique mealtime needs. These may include:

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eating alone or with others; requiring assist with meal preparation, adaptive eating device, opening cartons, cutting food, adapted wheelchair placement; eating when hungry rather than at prescribed mealtimes or a person skipping breakfast may prefer an early lunch. Include quality of life markers such as satisfaction with food, meal service, level of independence and control.• Unless a medical condition warrants a restricted diet consider beginning with a regular diet and monitor tolerance.• Empower and honor the person first and the IDT second when creating effective solutions.• Support a self-directed, individualized plan of care.• Ensure the physician and consultant pharmacist are aware of resident food and dining preferences so medication issues can be addressed and coordinated (e.g., medication timing and impact on diet/food intake).• Monitor the person and his/her condition related to goals regarding nutritional status and their physical, mental and psychosocial well-being.• Although a person may not be able to make decisions about certain aspects of their life, it does not mean they cannot make choices in dining.• When a person makes a ‘risky’ decision the plan of care will be adjusted to honor informed choice and provide support to mitigate the risks.• Most professional code of ethics require the professional to support the person in making their own decisions; being an active, non-passive participant in their care.• All decisions default to the person.

Every resident has the right to make informed decisionsbased on individual preferences and goals. One size doesnot fit all. As health care providers it becomes our job toensure resident autonomy is supported by policy andpractice. For example does every resident in the facilitybeing treated with dialysis have a standardized renal dietorder? What happens if the resident has a low potassiumlevel? Does the RD intervene by educating the residentabout foods rich in potassium and then offering theresident a choice in food or is a potassium supplementgiven while the diet stays the same? Does every personwith diabetes have to be on a controlled carbohydrate dietplanned by the RD or can some residents make their ownfood selections while maintaining acceptable bloodglucose levels? Does every resident with dysphagia haveto eat mechanically altered foods and drink thickened

liquids? When does quality of life trump evidence-basedtreatments?

Examine your answers to these questions. If yourresponses were aligned with provider knows best thenconsider becoming a student of the New Dining Standards,CMS regulations and the ADA publications cited in thisarticle. As for the rest of you, one word best describes yourelder’s feelings - thankful.

References1. Dorner B, Friedrich EK, Posthauer ME; American Dietetic Association.

Position of the American Dietetic Association: individualized nutritionapproaches for older adults in health care communities. J Am Diet Assoc. 2010 Oct;110(10):1549-53. Erratum in: J Am Diet Assoc. 2010 Dec;110(12):1941.

2. American Dietetic Association. Code of Ethics. Available at http://www.eatright.org/Members/content.aspx?id=6442452672Accessed 13 December 2011.

3. American Dietetic Association. Standards of Practice and ProfessionalPerformance. Available at http://www.eatright.org/sop/ Accessed 13 December 2011.

4. Maillet JO, Potter RL, Heller L. Position of the American Dietetic Association: ethical and legal issues in nutrition, hydration, and feeding. J Am Diet Assoc. 2002 May;102(5):716-26.

5. American Dietetic Association. International Dietetics & Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process:: 3rd Edition (7/1/2010)

Linda Handy, MS, RD, is a retired RD specialty surveyor/trainer for the CADept. of Public Health who now provides CE presentations & ‘practical’CE self study manuals on survey compliance. She can be reached atwww.handydietaryconsulting.com

Linda Roberts, MS, RD, LDN, is President of Linda Roberts andAssociates. She can be reached at [email protected].

The Journey Worth Taking; a Culture Change Experienceby Coreyann Poly, PhD, MEd, RD, LDN

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Although elders enter into the extended care environmentfor many reasons, one similarity they all share is their in-ability to care for themselves at home. Leaving their homeenvironment to come and live in a nursing home is diffi-cult. However, as the transition from the traditional nursinghome to a more home-like environment continues, eldersbegin to feel more comfortable in their new home. Culturechange is becoming a familiar term in the extended careenvironment. It involves the difficult task of transformingthe nursing home setting from an institutional establish-ment with a top down approach to decision-making, to aresident centered approach with environments that aremore homelike and where the residents and staff are em-powered. Residents are given choices and are involved inthe decisions regarding their care.

This concept is only logical given the nature of long-termcare, but implementing a completely different approach tocaring for elders is a difficult feat. At Beaumont Rehabilita-tion and Skilled Nursing Centers, creating a caring environ-ment for residents was already a part of the strongfoundation of this family owned company, therefore mov-ing towards a Culture Change idealism was never a ques-tion. Owned and operated by the Salmon family,Beaumont began the process of Culture Change more thanfive years ago. Understanding that changing a culturetakes time, the initial roll-out, termed Home Within AHome, was more about educating staff to the concept ofculture change with the goal of getting the staff to beginto problem solve at the resident level. Employees from alldepartments attended conferences, Q & A forums, andneighborhood meetings. Employee focus groups help toput mission and value statements into words. Employeesbecame resident advocates and neighborhood leaders.

The next step was ensuring that staff members were con-sistently with the same residents in order to develop rela-tionships and trust between residents and staff. Eventuallyneighborhoods were established, and residents and staffmembers got together to determine the name of theirneighborhood. Each building underwent major renova-tions in their décor bringing in warm colors to the wallsand floors with matching furniture and draperies. Framedpictures accentuated the new environment by reflectingwonderful moments in life.

In January 2008, a decentralized dining program waslaunched. The process began nearly a year earlier, dis-cussing all aspects of the program with members of eachneighborhood. Dining meetings were held weekly, equip-ment needs were evaluated to determine what would bestmeet our needs; and guidelines were created to addressaspects of the new dining program. Mike Salmon, Directorof Operations for Dining Services states, “We designed ourown equipment, provided choice at service, and elimi-nated tray service in all our dining rooms. “ Dining roomsused seasonal center pieces, new china, and linens on thetables. Mike reports that the residents’ reaction was reallygreat. Residents felt they had more choice, better personalservice and hotter food. Mike reflects that the greatestcomment he heard was from a certified nursing assistantwho stated, “It’s more work than the tray service, but theresidents are so happy. I would never want them to have togo back to tray service.”

Many aspects contributed to the success of the decentral-ized dining service. One major contributor was communi-cation. Feedback and collaboration among those involvedin dining service was and remains essential to the successof this program. Another aspect was reducing the numberof therapeutic diet extensions outlined in a company-spe-cific diet manual. House diets with specific food elimina-tions ensured that specific diet and nutrition needs weremet without adding an extra therapeutic diet. Food safetywas ensured through education and training. In addition,multiple disciplines involved in dining became ServSafe®Certified. Training was also provided on subjects such asplate presentation, understanding diets and portion sizes.Policy and procedures, job descriptions and job flows wereall redone to ensure that staff had the tools and guidelinesneeded to safely provide decentralized dining service.

Communication and training remain ongoing. MikeSalmon reports that training is extremely important espe-cially given the cultural diversity and beliefs of the staffand residents. “Although staff knew what eggs are, theymay not know the difference between a boiled and friedegg; or that cranberry sauce goes with the turkey dinner,”replies Mike. Understanding residents’ cultural needs areequally important. The dining program stresses the impor-tance of the interaction between staff and residents duringmeal times to build

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relationships, trust and understanding between staff andresident.

Major benefits were found with residents’ satisfaction, sig-nificant decline in supplement use, and reduced platewaste. Resident satisfaction survey results showed an in-crease in satisfaction in food/meals across the company.Residents no longer complained about cold food or had towait for a meal change because the food was served rightin the dining room. Dining personnel who once put a glassof juice on a tray now were serving the whole meal. Al-though nervous at first, their job satisfaction went up asthey became part of the neighborhood, engaged directlywith the residents, getting to know their residents andother staff members of the neighborhood. Dining issuesare now being solved in the neighborhood instead of bymanagers.

Innovations in dining continued to move forward at withimplementation of a dementia -based dining program thatincludes colored china, dining times that meet the resi-dents’ schedule, and other dining room enhancements. Inaddition, a family style dining program was launchedwhere recreation staff sit down and enjoy the meal withresidents. Meal modeling not only improves consumption,it improves socialization and mood.

On one campus residents’ have an outdoor vegetable gar-den that once harvested is planned into the menu. Lastly,an enhanced room service program where residents whoprefer to eat in their rooms now receives a tray that looksmore like they are eating in a hotel room than in a nursinghome with linen, a flower vase and china.

Each dining service operation has remained deficiency-freesince the start of the culture change dining programs. Resi-dents participate in menu development. Food quality,safety and service remain top priorities. “The bottom line,”states Mike, “is that resident satisfaction is way up, but soare their expectations.” Dining services will continue toevolve to meet the resident needs.

Dining is just one of many culture changes that BeaumontRehabilitation and Skilled Nursing Centers have under-gone. Each campus defines and executes Home Within aHome programs based on their residents’ needs andwishes.

Other programs that were developed started out from agood idea staff members had that answered a need for theresidents that live there. The Annual Poker Tournament andthe Intergenerational Activity Program are two such pro-grams. The annual poker tournament that takes place eachyear that originally started by a conversation between amale resident and the Director of Environmental Services.The resident was complaining that he was bored and theactivities were more for the ladies. Soon the conversationcentered around poker leading to a weekly poker game.That poker game soon expanded into a full poker tourna-ment with both long-term care residents and assisted liv-ing residents breaking an invisible barrier that had beenestablished long ago. The final matches come down to abig game where all neighborhoods, staff members andfamily members are invited to see who will win the PokerChampionship trophy. Each final player enters the winnerstable by being introduced over a microphone with a bit oftheir personal history and the methods they used to getthem to this final match. A cake decorated with pokerchips sits next to the trophy. Although this started becausethere were not enough male-focused activities, male andfemale alike have become fierce competitors. It is an eventwhere everyone cheers and it cheers everyone.

Intergenerational activities take place on all campuses. Forexample, children from the SALMON Centers for Early Edu-cation join the residents of Beaumont in activities such asplaying games, singing songs and just sharing time to-gether. Intergenerational programming and informal inter-actions promote a unique understanding among the twoage groups. During Halloween, children and elders alikedress up to celebrate the holiday forming a big parade thatculminates with a trick-or-treating finale. No matter whatthe event, smiles can be found among both generations asthey share the excitement and joy of these special mo-ments.

The efforts of culture change are ongoing. It has neverbeen a simple process and many things remain to be doneor improved upon. Since Beaumont first started this diffi-cult journey there has never been a time when staffthought it wasn’t worth the effort. Matt Salmon, Chief Op-erating Officer, reflects, “Once we understood what culturechange was about, it made sense for us as a natural pro-gression from the attitude my grandmother established so

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many years ago. We studied, learned and set out to im-prove the lives of our elders.” Culture change embodies thecore values of caring for elders in an extended care envi-ronment including providing quality, individualized care,and allowing residents to be make their own choices, re-specting their wishes, and involving them in decision mak-

ing process. Elders have the right to be actively involved,feel honored and respected, and be as happy and healthyas possible.

Coreyann Poly, PhD, MEd, RD, LD/N, is the Clinical Nutrition Coordinatorfor Salmon Health and Retirement and CEO of Dietitians of New Eng-land. She can be reached at [email protected].

Welcome to the newest feature of the Dietetics in HealthCare Communities (DHCC) Connections newsletter. “NCPCorner” was added in an effort to assist DHCC members inbecoming experts in the application of the Nutrition CareProcess (NCP). Each newsletter will cover various topics re-lated to the NCP. As an original member (2005-present) ofthe Peer Network for Nutrition Diagnosis (PNND) nowknown as the Peer Network for Nutrition Care Process(PNNCP), I will start the information dialog with a discus-sion on NCP, the nutrition diagnosis and writing a PESstatement (Problem (P), Etiology (E) and Sign/Symptoms(S) statement).

The ten year (2003-2013) phase in period for the AmericanDietetic Association’s (ADA) Nutrition Care Process andModel (NCPM) will soon be upon us. Some registered dieti-tians (RDs) have enthusiastically learned and applied theNCP and Standardized Language to their practice. Someare still learning, while others are not sure if they evenwant to learn this concept. This learning scenario repre-sents the theoretical model/stages of change. NCP is not adocumentation process. It is a critical thinking process thatis designed to be applied to all areas of dietetic practice.However, the application of the NCP to the documentationof medical nutrition therapy (MNT) has received the mostattention from ADA members. All members are on thesame phase in time line. Granted, the newest membershave an advantage because this is the method they weretaught. The seasoned and well-seasoned members need toadapt and learn this critical thinking method and apply itto their practice. For dietitians to be reimbursed for theirservices, evidenced based outcomes to demonstrate howthe care received from the RD successfully impacts the

health and nutrition status of the resident are needed. RDsbelieve they positively impact the outcomes of care butthere has been little documented evidence to back this up.The standardized language provides terms that can beused effectively to collect outcomes data. Without this evi-dence, receiving reimbursement for services has been diffi-cult to obtain. Diabetes and renal care are reimbursedbecause there is documented evidence that the care pro-vided by the RD positively affects the outcomes of the nu-trition care.

Food and nutrition professionals are well trained in collect-ing assessment data, determining the intervention(s) toutilize and the specific areas to monitor and evaluate dur-ing the reassessment. However, diagnosing the nutritionalproblem is a new concept. The nutrition diagnosis is thelink between the assessment data and the intervention(s).Becoming a diagnostician takes critical thinking skills. Thisincludes the ability to determine the root cause of theproblem, to select the best intervention(s) to resolve theproblem and to identify the areas to monitor and evaluateupon reassessment.

The International Dietetic Nutrition Terminology (IDNT)Manual, Third Edition, contains the current standardizedlanguage and definitions of the terms needed to formulatePES statements. These are terms related to the practice ofnutrition/dietetics and problems that can be resolved bythe RD. Diagnosing a nutrition problem and writing a PESstatement can be approached by three different methods: 1) the problem can be intuitively determined; 2) the Nutrition Assessment Matrix may be used as a

reference; and

NCP Corner by Carol H. Elliott, RD, LD/N

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NCP Corner continued from page 8

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3) working backwards, knowing the signs and symptoms will allow the etiology to be determined and then the problem or diagnosis can be identified. Knowing the intervention(s) and outcome(s) desired will indicate the problem(s) or (diagnoses) to be resolved.

The “P” (Problem) part of the PES statement is expressedusing the standard language terminology. This is usuallyterms from the intake domain. The “E” (Etiology) part of thePES statement can be written from standard languageterms, usually terms from the clinical or behavioral do-mains or it can be free text. The etiology is the root causeand drives the intervention(s). The “S” (Signs/Symptoms)part of the PES statement can be written using standardlanguage, usually terms from the clinical domain or it canbe free text. This information is gleaned from the assess-ment and demonstrates support of the nutrition diagnosis.The indicators for monitoring and the criteria for evaluat-ing progress during the reassessment of the nutrition diag-nosis tie back to the “S” section of the PES statement. ThePES statement(s) are the problem(s) used in the residentcare plan.

Writing the etiology has been difficult for some members.ADA has designed an Etiology Matrix to assist in the deci-sion making for this component of the PES statement. ThePES statement sections are connected by the words “re-lated to” and “as evidenced by”. This connects the selectedterms and data into a complete statement. Problem (P)______________ related to Etiology (E) ________________as evidenced by Signs/Symptoms (S) ________________.The PES statement needs to be simple and clearly written.The statement is usually 25 words or less. That includes thewords “related to” and the “as evidenced by”. The interven-tion(s) are selected to improve the etiology (root cause)and may also address signs/symptoms of the problem. Re-solving the etiology will cause the problem to go away.Resolution of the nutrition diagnosis demonstrates the ef-fectiveness of the RD’s intervention(s) and care. The moni-toring indictors and the evaluation criteria tie back to thesigns/symptoms. These are also the areas to be reviewedand evaluated when the resident is seen for follow up careby the RD.

After determining the root cause, choose an etiology thatthe RD can address. The goal is to demonstrate the successof the RD’s intervention(s) and that the problem resolves. If

a medical diagnosis is selected for the etiology the RD can-not address/correct this condition. Thus, the problem willnot go away. This PES statement will be included in everyfollow up note written because the RD will only addressthe signs/symptoms and not resolve the problem. How-ever, with this being said the situation may occur and thatthe PES statement will be ongoing and remain in allprogress notes. Therefore, ask why? 5 times and determinean etiology that can be addressed by the RD. This will showRD success in care. Using the medical diagnosis and bring-ing the PES statement forward in all progress notes may re-sult in the perception that the RD interventions are notsuccessful even though the signs/symptoms are improv-ing. Reference page 40 in the IDNT, Third Edition for theevaluation questions to be used when determining the nu-trition diagnosis and etiology.

Examples of PES statements:

(P) Inadequate oral intake related to (E) dislike of low fat/cholesterol/no added salt diet as evidenced by (S) refusingmeals,3% weight loss in one week.

(P) Excessive oral intake related to (E) personal snacks/extraserving requests during meals as evidenced by (S) weightgain(6% in 30 days)/BMI greater than 30.

(P) Inconsistent carbohydrate intake related to (E) ad libdaily snacking: self purchased/brought in items as evi-denced by (S) lack of willingness to modify carbohydratetiming.

The reassessment begins with the PES statement(s) fromthe initial assessment/previous reassessment. This estab-lishes the nutrition diagnosis (es) to be evaluated for thisreview. Next collect the evaluation data to support the out-come(s) of the previously selected intervention(s). Did theproblem(s) improve? Did the problem(s) resolve? Is theproblem(s) continuing? Do the intervention(s) need to beadjusted? Does a new problem exist? All these questionsneed to be answered to complete the reassessment. Ifthere is a new problem, the process starts all over again. Ifthe initial problem continues, there will be two PES state-ments to be evaluated during the next reassessment.

The most difficult decision for the RD is to state that “thereis no nutrition problem”. As the assessment data is re-


NCP Corner continued from page 9

viewed and analyzed, it may be determined that there isno problem. In this case, document that “there is no nutri-tion diagnosis/problem at this time”. This does not meanthat the resident does not have concerns. It means thatafter reviewing and analyzing the data the RD has deter-mined that all of the necessary interventions are in placeand there are no nutrition interventions to add/adjust forthe care of the resident. There is not always going to be anutrition diagnosis and the RD needs to be comfortablewith this conclusion. As a consultant your expertise hasbeen requested in the evaluation of the resident, then if anintervention is needed then write the PES statement(s), in-terventions, monitoring indicators and the evaluation cri-teria. However, if there is no recommendation, state thatthere is no nutrition diagnosis/problem. This does notmean that the resident does not need care or that the resi-dent will not be followed. It means that when the residentwas assessed on this specific day there was no problem toaddress and the plan of care meets the resident’s needs.This may not be the case when the resident is reassessed. Achange in condition may occur at a later date.

Everyone wants a form for their documentation. There areseveral methods of documentation and one form may notfit all. If the preferred documentation method is a narrativenote, incorporate the standard language into the structureof the sentences. For the SOAP method, collect the data forthe “S” and “O” sections as usual. Then place the PES state-ment(s) in the “A” section. The “P” section includes the inter-ventions, monitoring indicators and the evaluation criteria.When using the PIE method, the “P” section is the PESstatement(s), the “I” section the interventions and the “E”section is the monitoring indicators and the evaluation cri-teria. The ADIME/ADI method fits easily into the NCP as thisis the order of the process. The preferred documentationmethod is the choice of the RD. The electronic healthrecord (E H R) brings another situation, as the format de-pends on the software programmers, however, it may beinfluenced by dialogue initiated by the RD. The RD mayprovide a one to two page form for data collection to theprogrammers. When the data entry form appears in thecomputerized format the information may be located dif-ferently than on the original form or there may be threedifferent sections to populate. The view of informationwithin an E H R is determined by the specific software pro-gram used, however, many programs provide options forthe final design.

At Elliott Consulting, Inc., the RDs have been using the NCPsince March 2006. We have received fantastic feedbackfrom nursing staff, medical directors, physicians, nursepractitioners, medical records and MDS coordinators, ad-ministrators and state and federal surveyors. In fact duringone inspection a surveyor was looking for me. Of course, Ithought “What happened?” Come to find out she wantedto express the gratefulness and enthusiasm of the wholeteam for the clear and informative documentation in theresident medical records. I was relieved that there was noproblem and that they were expressing positive feedbackon our NCP documentation for MNT.

I realize that everyone is internalizing this concept to theirown particular situation. However, I would like to point outthat the title of the IDNT manual starts with the word “In-ternational.” There are countries around the world lookinginto the use of this process. To date the Netherlands has re-quested the use of the nutrition diagnosis in their healthcare databases. Australia has initiated a research study toevaluate the face validity of the nutrition diagnosis. Israeland Canada are discussing the use of the NCP. Japan, SouthKorea, Hungry, Netherlands, Sweden and Canada (French)have agreements for translating the IDNT into their ownlanguages. There are more countries considering NCPtranslation. As you can see IDNT and NCP are larger thanyou and me; they are global.

Do you need assistance? Learning new concepts and howto apply them takes time. There is no better time to startthan the present. The Long-Term Care NCP Toolkit, updatedto match the IDNT Third Edition, is now available. The ADAwebsite also has many resources to assist in learning thisprocess at www.eatright.org. Sign in and go to the practicearea and click on NCP. The Nutrition Assessment Matrix andNutrition Etiology Matrix are also available on this website.These matrices along with the IDNT manual/pocket guideare designed to assist in the application of the NCP and thewriting of the PES statement(s).

As I mentioned in the beginning of this article, the “NCPCorner” will be a feature in each newsletter to assist DHCCmembers to become experts on NCP and its application.Do you have questions that you would like answered in thenewsletter? Do you have specific areas of the NCP that youwould like discussed in the newsletter? If so, please sendyour requests to [email protected].

Carol Elliott, RD, LD/N is President of Elliott Consulting. She can bereached at [email protected].



The Commission on Accreditation for Dietetics Education(CADE) requires dietetic interns to complete 1,200 hours ofsupervised practice from an approved and accredited Di-etetic Internship (DI) (American Dietetic Association, 2008).The 2008 standards for supervised practice experience re-flect an increase of 300 hours, from the 2002 standards of900 hours. The DI program director ensures all interns areprovided with supervised rotations that address a wide va-riety of topics and competencies, as well as, provide thefoundational knowledge necessary for the interns toemerge as entry-level dietitians (ADA, 2008). Distance pro-grams are an option for students that require students tofind their own preceptors, adding another challenge for DIprogram directors and students.

In 2008, CADE initiated several new requirements for all DIprograms including the implementation of the NutritionCare Process (NCP) in a variety of settings including acutecare, critical care, and long term care (ADA, 2008). Thesenew guidelines are requiring program directors to reachout to dietitians working in all health care communities in-cluding long term care facilities and home health agencies.However, program directors are having a difficult time find-ing registered dietitians (RD) in these areas to serve as pre-ceptors. Without willing preceptors, directors and internswill be unable to meet the competencies of working witholder adults and working in extended care facilities.

We all have been in the challenging position of being a di-etetic intern, and ideally all experiences were positive.However, it is more likely that we have also experienceddifficult preceptors during the internship. Serving as a di-etetic internship preceptor provides the opportunity topass on the legacy of our careers to new dietitians. It is ourresponsibility to the profession to continue the supply ofoutstanding registered dietitians.

The advantages of working with dietetic interns are count-less! Turning the negative into the positive is crucial inworking with interns. Any limiting area can be turnedaround as a learning opportunity. An example that manyconsultant RD’s deal with is the lack of work space. Show-ing your flexibility in this area will teach the intern the at-tribute in a unique way. Strong organizational skills arerequired when working as a consultant by having yourwork items narrowed down to a manageable

notebook/binder. Also, lack of space is prevalent in allareas of healthcare from acute care hospitals to skillednursing facilities; interns are used to being squeezed in.Another negative to accepting interns is lack of time. In-terns require supervision and guidance in learning a newarea of dietetics. Interns ask many questions and need ex-planations in many areas, however the time required indoing such decreases the longer your intern is with you.

The first day is the most time consuming for the preceptor.I suggest scheduling time with other health care profes-sionals for your interns on the first day, such as the speechtherapist, dietary manager, a dietary aide, the MinimunData Set (MDS) nurse and the wound nurse. These “mini-breaks” will allow you to reorganize and catch up on as-sessments. Students enjoy learning how different teammembers collaborate on resident care in each setting. Also,as your time with your student progresses, you will be ableto assign them more tasks and will be ahead of your workschedule after just a few days! Delegating project workand research will make up for unproductive work hours.

A final example of a negative aspect of taking students isyour role as consultant in the facility. Registered dietitiansmight not want to ask the administrator if they can have astudent with them. They may feel their role as consultantcontradicts a teaching atmosphere. Certified nursing assis-tants, nurses, and administrators have to participate insome type of rotation where they worked side-by-sidewith professionals. They understand the learning processthat is needed in health care professions. Help teach theadministrator the value acquired with having students inthe facility: another word-of-mouth marketer, a fresh set ofeyes to assist with your projects and initiatives, and theprestige they can acquire from sharing the experience withregional staff members. There may be other areas thatpush us from taking interns, however be creative andchange the pessimism into optimism – a student can al-ways feel when they are viewed as a burden.

Being in the field of dietetics, it is our business to be life-long learners and instructors. Preceptorship is a learningexperience for the intern and preceptor alike. Interns learnthe newest food science, clinical topics and trends in nutri-tion. Ensure you are open and approachable when dis-cussing topics because the intern may have a different

How to navigate the challenges and optimize your experience as a preceptorby Jamie McGinn, MS, RD, CSG, LDN


How to navigate the challenges and optimize your experience as a preceptorcontinued from page 11

perspective and way of thinking that you can learn from.The saying “you learn something new every day!” appliesto all parties involved. All interns have particular areas ofinterest and have completed numerous projects in previ-ous rotations or volunteer experiences. Encourage thosemoments to foster enthusiasm. You may find yourself refer-ring back to these areas in teaching moments in order tocommunicate principles in terms the student will remem-ber for a lifetime. Oftentimes, teaching a concept to a stu-dent will help you be able to teach a concept to apatient/client more effectively. There may be projects youhave been meaning to start, but were lacking the time.More times than not, interns want to help you and aremore than happy to take on your tasks and challenges.

It is important to foster an environment conducive to opencommunication as it can encourage learning for the internand for you as the preceptor. Encourage your intern toshare what they know about topics as they are pertinent.For example, an intern may have attended a recent semi-nar on vitamin D or may have worked with an expert in en-teral feeding complications. Listen and be open to theirexperience; you never know when you will learn some-thing that may enhance your current practices. This willallow the intern to develop more confidence in their edu-cational experiences and will further the idea that all expe-riences are a learning opportunity. Not only will theireducation directed towards preceptors teach them how toexplain theories but it will also help them to realize howthe knowledge is applied and put it into action. For exam-ple, if a student has special interest in vitamin D, ask themto evaluate vitamin D requirements for the patients/resi-dents they are assessing. If resistance from staff and physi-cians is anticipated in the area, have the intern summarizecurrent research, reasons for the current recommenda-tions, and create a sample protocol. What a great experi-ence for the student and a great tool for you to use in yourfacility!

The NCP is designed to be used in multiple areas of dietet-ics, thereby involving an array of cultures, populations, andage groups (ADA, 2008). The NCP may be utilized in yourfacilities but if it is not, then dietetic interns will be of greatassistance in transitioning into this documentationprocess. Interns are taught and tested on the NCP. Assignyour students to come up with an alternate assessment

form for new admissions or quarterly reviews. If the assess-ment form in your facility is non-optional, then ask the stu-dent to create the “DIME” portion of the NCP to includediagnosis, intervention, monitoring and evaluation. Thiswill allow you to learn from their documentation. It is im-portant that we find ways for interns to be of value to us.

Maximizing the preceptor-intern relationship is crucial toproviding a positive experience for all parties. Send a de-tailed calendar to your student ahead of time to includework hours, locations, and possible tasks. As consultants,we may change our schedule frequently; therefore, let yourstudent know about this aspect of your work. It is also im-portant to communicate your appreciation of their flexibil-ity on this topic. On the first day of precepting, give theman orientation to the facility including staff introductions. Itis acceptable to treat them as a new employee for day one.Show them the systems in place for the menus (selectiveor non-selective, etc), obtaining meal preferences, the dietchange system, new admission notification, your protocolsfor completing assessments, and other responsibilities ofthe registered dietitian. Discuss the way in which youwould like questions asked – for example, I communicateto my interns that I prefer an open relationship where wework as equals and questions are addressed as they comeup.

From experience and through feedback from Internship Di-rectors, students learn best from on-going, specific cri-tiques of their documentation and interactions withpatients/residents. Explain the positives in each area, andthen mention the area that needs improvement, and fol-lowed by another positive statement. An example is, “Youdid a really great job of being compassionate because yousat on their bed and you spoke to them very kindly, how-ever you did forget to ask about their appetite and if theyhave any gastrointestinal problems. You also did a fantasticjob explaining why it’s important to eat a well balanceddiet and why protein is needed for wound healing, goodjob!” Allow time for the student to ask you questionsabout how the interaction went and discuss their recom-mendations for each patient/resident.

Dietetic interns will be registered dietitians in a matter ofweeks or months after working with you. Their experienceas an intern is challenging and difficult, however you can


How to navigate the challenges and optimize your experience as a preceptorcontinued from page 12

be responsible for making it enjoyable and a lasting mem-ory for both of you. Knowing you are partially responsiblefor their success is extremely satisfying. Being a positiverole model for an upcoming RD cannot be expressed inwords. It is a wonderful feeling knowing that a registereddietitian chooses to work in your field because of you, orthat they choose to become a preceptor because of yourimpact on them.

If you are currently accepting dietetic interns, thank youand keep up the great work. I encourage those of you whoare not currently working with internships to find the localprograms and contact their directors. If you have yet toserve as a preceptor for an internship, I challenge you toaccept the opportunity using this article as a guideline toachieve the optimal experience.

Jamie is the current Chair of the North Carolina Chapter ofDHCC, and serves as a preceptor for three internship pro-grams. She can be reached at [email protected].

Jamie would like to thank and recognize Anne Mosteller,who was her intern while writing the article. She was in-strumental in the process and graciously titled and editedthe paper.

ReferencesThe American Dietetic Association. (2008). Accreditation StandardsFoundation knowledge and competencies for entry level dietitians.http://www.eatright.org/uploadedFiles/CADE/CADE-General-Con-tent/3-08_RD-FKC_Only.pdf Accessed 13 December 2011, 2011.

Registered Dietitian Safety in Home Careby Krista Jablonski, MS, RD, LDN

Most likely, we all do general safety training and go overorganizational protocols: avoid going into bad neighbor-hoods, always keep a cell phone with you, make suresomeone knows where you are going, etc. However, givenour unique and ever changing work environment, notevery safety concern can be listed in a manual. Manytimes, there are unsafe situations which are not black andwhite and we go against our better judgment in the effortto serve the patient.

As clinicians we suppress our uneasiness because we areso passionate about helping our patients. Remember, it isin the best interest of you and the patient to have a safeplace to conduct nutrition therapy. Think about startingan open dialogue with your Home Care colleagues to dis-cuss safety strategies and learn from situations others havebeen in.

I urge you to think about what you would do in the follow-ing scenarios that I or my colleagues have been in. Con-trast concrete safety scenarios (for example a loaded gun

or weapon in the home) to more subtle safety concernssuch as the ones below.

Scenario One: You enter the home of a patient on oxygenwho is smoking a cigarette.

Scenario Two: You have just finished visiting a patient, butwhen you go outside, you find that your car was stolen ortowed.

Scenario Three: You need to see a patient. However, thepatient’s nurse has told you the house is infested with bedbugs.



To conclude, unsafe situations catch you as a surprise and you do not have time to consult a manual or think about thebest plan of action. In your team discussions, consider developing guidelines like the ones below to help you make theseimportant decisions as they come up. Also consider having conversations with Home Care registered dietitians (RD’s) atother organizations. As home care professionals our work setting can often be quite different from other RD’s, throughthese kinds of discussions, we can benefit from the communal wisdom of this sub unit.

References:2009 Joint Commission Comprehensive Accreditation Manual for Home Care.Becker P. “Caring for the safety of staff in the home”. Office of Geriatrics and Extended Care, Patient Care Services. Department of Veterans Affairs.May, 2011. http://www.patientcare.va.gov/Geriatrics.asp Attention Home Care registered dietitians! My name is Krista Jablonski and I am the Chair of the Home Care sub-unit. I would like to hear from you.What topics would you like to know more about? Are there any topics you have researched that you would like to share? Do you know of a HomeCare seminar that you think others should be aware of? Please contact me at [email protected]

Registered Dietitian Safety in Home Carecontinued from page 13

Guidelines for helping you make a Safe Decision:

Is there immediate danger? If possible, LEAVE and call 911. If unable to leave, find an area which can be locked from the inside (for example, a bedroom), lock the door and call 911.

Is there a policy in place? If yes, consider keeping a copy of your policy in your car. If there isn’t a policy, consider creating one or keeping note of circumstances you encounter and how to handle them in the future.

Can you contact another member of the home care team? Consider keeping a contact list in your car. If possible, you can contact members of your home care team (or keep a list of appropriate contacts such as a psychologist or social worker) to help you decide appropriate action.

Always trust your gut. You can always reschedule or contact the patient by phone.

T

Universal Protocol:

Always take your cell phone Take note of your surroundings Go early in the morning if the neighborhood is known to be unsafe Do not park in the driveway where you can get blocked in Only take what you need into the home Place your keys to your vehicle in an easily accessible place. Do not place keys in a bag or removable

article that could be left behind Note where the exits are Ask if there are any family members or visitors in the home Note any guns or unsecured/displayed knife collections in the home


The Institute of Medicine (1991), defines failure to thrive (FTT)late in life as “a syndrome manifested by weight loss greater than5% of baseline, decreased appetite, poor nutrition, andinactivity, often accompanied by dehydration, depressivesymptoms, impaired immune function, and low cholesterollevels.” According to statistics collected in 2006 the prevalenceof geriatric FTT increases with age. It affects 5- 35% ofcommunity-dwelling elders and 25- 40% of nursing homeresidents.

Originally the term “failure to thrive” referred to infants andyoung children with failure to grow or gain weight at theexpected rate. The term was later adapted for older adults in the1970s. A key difference between the uses of the term failure tothrive in these two distinct populations: pediatric FTT describesa patient who has not attained functional status; and geriatricFTT describes a patient who has not maintained functionalstatus.

Generally speaking, FTT is a state of decline that is multifactorial.It is considered to be a condition where elderly begin to declinefor no one specific reason and may be caused by co-existingchronic diseases and functional impairments. Geriatric FTT hasalso been described as a decline in health and emotional well-being where fully grown adults face wasting of their bodies,minds, and spirits.

The decline may be gradual; family & caregivers often do notnotice the subtle changes in condition. Signs & symptoms ofFTT may include decreased appetite, loss of interest in one’ssurroundings, physical inactivity, poor nutrition or loss ofinterest in food, depression, weight loss, and a disconnectionfrom family and friends. If changes are observed, the older adultoften denies there is anything wrong and treatment may bedelayed until there is an acute illness or event (i.e., fall, fracture,pneumonia).

There are four main syndromes that are considered prevalentand predictive of adverse outcomes in FTT patients: 1) impairedphysical function, 2) malnutrition, 3) depression, and 4) cognitiveimpairment. As registered dietitians (RD) we are aware thatmalnutrition creates an increased infection risk, decreasedrecovery from illness, injury, or surgery, decreased strength &energy, and diminished muscle strength. It is important tomonitor body weight & weight trends, muscle wasting, changesin food preference, poor fitting dentures, swallowing problems,financial or social problems, and medication use that may causeanorexia.

By the time a FTT patient becomes appropriate for hospiceservices the condition is irreversible. Part of my role as a hospiceRD is to help families or caregivers provide loving care thatdoesn’t always have to focus on calories consumed. I encouragefamilies to include their loved one in cooking as a positive

experience or offer favorite foods & dishes. We also talk aboutinvolving them in things they enjoy doing and keeping them asactive as possible in hobbies, outings, or social interaction.Sometimes just a friendly visit to reminisce about positivememories can be uplifting for patients. I also reassure familiesand caregivers that despite everything being done to assist theirloved one some people may not be able to overcome it.

Another role of the dietitian is to help other clinicians becomemore familiar with signs & symptoms of FTT and in the case ofhospice, appropriate documentation of decline. This declineincludes not only weight trends but significant weight changeswhich may be difficult to assess in community-dwelling elders.When body weight is unable or unsafe to obtain, mid-arm andcalf circumference measurements are used to assess musclemass. Also important are functional indicators of decline such asrequiring more assistance with eating or modifications in diettexture.

For my part, I often use the Mini Nutritional Assessment (MNA)by Nestle and the failure to thrive worksheet for hospice to helpprovide more detailed information on a patient’s nutritionalstatus. I’ve chosen to use the MNA because of its proven validity,user- and reader-friendly format, and concise, quantitative result.I’ve received positive feedback from my nurse co-workers that itis easy to understand and helpful in care conference discussions.At this time I do not consistently assess FTT patients upon theiradmission to hospice but I do make visits if they approach their6-month recertification.

It is important for all to remember that failure to thrive in anelderly person is no one’s fault and should not be considered anormal consequence of aging. It is equally important forphysicians to remember that a medical diagnosis of failure tothrive is a permanent documentation that will follow elderslong-term and is not intended for acute failure in older adults.

ReferencesInstitute of Medicine (U.S.), Committee on a National Research Agenda onAging, Lonergan et. “Extending life, enhancing life: a national research agendaon aging.” Washington, D.C.: National Academy Press, 1991.

Robertson, Russell G., M.D and Marcos Montagini, M.D. “Geriatric Failure toThrive.” Medical College of Wisconsin, Milwaukee, Wisconsin. American FamilyPhysician. Volume 70, Number 2; July 15, 2004. www.aafp.org/afp.

“A Physician's Guide to Nutrition in Chronic Disease Management in OlderAdults.” Copyright ©2002 by the Nutrition Screening Initiative (NSI).

“Mini Nutrition Assessment.” NESTLÉ® and MNA® are trademarks of Société desProduits Nestlé S.A., Vevey, Switzerland.

Bethany Morris RD LD lives in Iowa and has been working in the area ofdietetics for over 2 years. She holds a bachelor’s degree in nutrition fromOklahoma State University and is currently working to finish her final master’sproject/thesis from the University of Minnesota, School of Public Health.

Hospice Corner - Geriatric Failure to Thriveby Bethany Morris, RD, LD


Raise Your Voices!by Dana Fillmore, RD, CP-FS

Dietetics in Health Care Communities (DHCC) is such agreat Dietetic Practice Group (DPG) because of its mem-bers. Each of you makes us who we are. It is important forall members to have an avenue to voice opinions andshare ideas and best practices with other members. Livemeetings like the recent DHCC conference at the 2011Food & Nutrition Conference & Expo (FNCE) in San Diego isone way you can accomplish this. But how can you do thaton a regular basis? It’s easy, and you don’t even have toleave your desk! Here are four ways to stay connected withother members and share your comments on a regularbasis.

ADA’s e-Mentoring Program – Participate as a mentor ormentee for another DHCC member. Sign up at www.adae-mentoring.com. You can identify DHCC as match criteria.

EML (Electronic Mailing List) – This is a fast way to get aquestion or discussion out to your peer members of DHCC.Answers come back almost instantaneously. Sign up atwww.dhccdpg.org under Resources. Don’t be shy – sendout your questions. Participating in answering the emailsis greatly appreciated. Be sure to respect professional ne-

tiquette guidelines (see Netiquette guidelines onwww.dhccdpg.org under Resources/EML.)

DHCC’s E-Blasts - Watch your email for e-blasts from DHCCasking for your input. E-blasts are important messagesthat go out to all members from the DHCC Executive Com-mittee. One of the important reasons we use e-blasts is tocommunicate mega issues from ADA’s House of Delegates(HOD). Often they need our Dietetic Practice Group feed-back that reflects our memberships concerns. In order toprovide the HOD with those comments, we need to hearfrom you!

Connections Newsletter and UPDATE! – Share your ex-pertise to help others by writing an article on current stan-dards of practice or hot topics. Contact Bonnie Gunckel [email protected]

DHCC is a dynamic group because we all share the same vi-sion to empower members to be the nation’s food and nu-trition leaders. No matter what the talent a member shareswith others, it helps to sustain our DHCC culture of rela-tionship-building and networking among our membersand the profession.

50 Years with ADA!A lot has changed in the past 50 years, but not the fact thatthe American Dietetic Association (ADA) is the world'slargest organization of food and nutrition professionals.ADA and its members are still optimizing the nation’shealth through food and nutrition. Congratulations to allof those celebrating 50 years with ADA, especially to thoselisted below who are DHCC members.

June G. Bosarge, Mobile, ALYolanda A. D'Aquila, Hillsdale, NJBeatriz U. Dykes, Monroe, OHFlorencia F. Keppner (Fernandez), Gulfport, MSGloria D. King, Volcano, HILinda B. Kraemer, Cincinnati, OHPhyllis A. Nickels (LeMay), Apple Valley, MNRuth F. Rauscher, Lincoln, NEJean C. Robinson, Ormond Beach, FLCarolyn T. Roper, Atlanta, GAElizabeth H. Schenck, Valparaiso, INFlora S. Steigman, Skokie, IL

Check out these fun facts from 50 years ago!

Average Cost of new house $12,500.00 Average Income per year $ 5,315.00 Cost of a gallon of Gas $ 0.27 Average Cost of a new car $ 2,850.00 Eggs per dozen $ 0.30

Popular Films Popular TV• The Guns of Navarone • Wagon Train • The Parent Trap • Andy Griffith • The Absent-Minded Professor • Candid Camera • Breakfast at Tiffany's • My Three Sons • The Misfits • The Twilight Zone • The Hustler • Mister Ed


DHCC 2011 Award Recipientsby Lisa W. Eckstein, MS, RD, LD

DistinguishedMember—Linda Handy, MS, RDLinda is past Chair of theConsultant Dietitians ofCalifornia. She has madecontributions to manyDPG meetings, publicationsand committees includingpresenter at pre-FNCE in 2008, contributor to the NutritionCare of the Older Adult revised in 2009, and author of anupcoming newsletter article “New Dining PracticeStandards”. She has contributed to the association as amember of the committee that developed the Scope ofPractice/Scope of Professional Responsibility for RegisteredDietitians in extended care. Linda also supports educationas an Instructor at San Diego Mesa College in DieteticService Supervisor Program.

Distinguished Member—Susan Straub, RD, CDSusan has served as President,Secretary, Treasurer andNominating Committee for theIndiana Dietetic Association and iscurrently serving as the Delegate.She has also served Indiana DHCCin many leadership positions. Shesupports education with presentations several times tostudents at the University of Southern Indiana on the topicof RDs in long term care, assisted living and hospice. Susanalso participated in Money Follows the Person (MFP)initiative in the state of Indiana. She mentors studentmembers of the state Affiliate and state DPG association.

Chair’s Scholarship (Sponsored by Medical NutritionUSA, Inc.)—Paula Ritter-Gooder, PhD, RD, CSG, LMNTPaula has been a DHCC member for many years. Sheexpressed the desire to “meet and learn from ourAssociation leaders and acquire additional mentors for myown leadership development” in her application. Paulaworked as a consultant in acute and long term care in ruralareas before returning to school to obtain a Master ofScience degree in 2005 and a PhD in 2009, both inNutrition. She would like to advance our practice byworking with regulatory agencies, allied healthprofessionals and our Association for best practiceoutcomes. Paula will attend ADA’s Leadership Institutenext year.

Abbott Leadership Award – Sharon Leppert, RD, CSG, LDSharon is active in the Texas Dietetics inHealth Care Communities. She has articlespublished in the Journal of the AmericanDietetic Association: Bulk Foodservice: ANutrition Care Strategy for High-Risk Dementia Residents(application article) in 2007 (02.011: 815-816) and EthicalPractice: Serving the Aging Community in 2009(08.001:1943-1944). Sharon is a past chair of the HealthyAging Dietetic Practice Group. She has worked in varioussettings in the continuum of care including home care andas a consultant. Sharon currently works as a ClinicalDietitian and serves as a preceptor for Texas Woman’sUniversity Dietetic Internship.

Circle Award—Abbott NutritionAbbott has been involvedwith the Dietetic PracticeGroup (DPG) since it wasformed in 1975. Whenspeaking with members aboutthis recipient, words used include “mentors,” “visionaries,,and “partners”. Abbott has been instrumental in puttingnot only DHCC members, but Registered Dietitians in theforefront of healthcare. The company provides thefinancial resources for the DPG newsletter Connections aswell as providing grants for projects such as recording pre-FNCE this year. The guidance and support from Abbottthrough the years have made DHCC the strong practicegroup that it is today.

Distinguished Member—Charlette Gallagher-Allred, PhD, RDCharlette has been a member of DHCC formore than 25 years, serving for a period oftime as Advisor to the Executive Committee.Her contributions to the American DieteticAssociation, Ohio Affiliate and DHCC are toonumerous to list. She was a member of the GerontologicalSpecialty Task Force that was instrumental in investigatingand providing the information needed to move forward onthe Board Certification as a Specialist in GerontologicalNutrition (CSG). Charlette was co-presenter at FNCE in2010 in the session Unintended Weight Loss in OlderAdults: ADA Evidence-Based Practice Guidelines.

Susan Straub with NewsletterEditor Bonnie Gunckel

Linda Handy with DHCC Treasurer Lisa Eckstein and

Sponsorship Coordinator Linda Roberts


National Pressure Ulcer Advisory Panel Updateby Lynn Carpenter Moore, R.D., L.D. - ADA NPUAP Alliance Representative

12th Annual National Pressure Ulcer Advisory Panel(NPUAP) Biennial ConferenceNPUAP held a successful 12th Annual Biennial Conferencein Las Vegas on February 25-26, 2011, Two concurrenttracks were available: Best Practice and Consensus.

The Best Practice Track presented information on critical is-sues about pressure ulcer assessment and risk across set-tings, unintended weight loss and nutrition care of theobese individual, support surfaces, dressings, transitions ofcare, telemedicine and patient education issues, The Con-sensus Track explored pressure ulcer prevention/treatmentin light of research and state/agency models, as well as reli-able methods for measuring quality of pressure ulcer pre-vention and treatment and data necessary for analyzingcosts and benefits of pressure ulcer prevention modalities.More than 450 healthcare professionals attended the con-ference, including registered dietitians, registered nurses,physical therapists, physicians, and industry representa-tives. There were ample opportunities for networking.

Public PolicyThe Public Policy Committee has established a relationshipwith the Centers for Medicare & Medicaid Services (CMS)and has helped with the development of a Minimum DataSet (MDS) 3.0 algorithm that is being adopted by CMS,with the goal to incorporate it into the Resident Assess-ment Instrument (RAI) manual. The Committee will also beparticipating in the development of the next phase of MDSwhich will be initiated in late 2011 to early 2012.

Since the American Dietetic Association is a member of theCollaborating Organizations within NPUAP, the Public Pol-icy Committee has been working with ADA to insure thatRegistered Dietitians will be working with CMS in the fu-ture on policies and regulations that affect the nutritioncare of persons across all care settings. The committee wasinstrumental in helping ADA secure a face-to-face meetingwith CMS to discuss member concerns about the RAIprocess.

Slide SetsNPUAP has just released its Select Treatment & PreventionTopics Slide Sets. Ten topics are included:• Pressure Ulcer Prevalence and Incidence —Data

Reporting for Quality Improvement (29 slides)• International NPUAP-EPUAP Pressure Ulcer Classification

(31 slides)• Cleansing and Debridement of Pressure Ulcers (18 slides)• Dressings for the Treatment of Pressure Ulcers (29 slides)• Nutrition Guidelines for Pressure Ulcer Prevention and

Healing (47 slides)• Assessment and Treatment of Infection (22 slides)• Pain Assessment and Management (24 slides)• Assessing and Monitoring Healing (21 slides)• Repositioning/Support Surfaces for Pressure Ulcer

Prevention & Treatment (55)• Surgery for Pressure Ulcers (27 slides)

All slide sets include speaker notes and handouts and canbe used for presentations and training on the InternationalGuidelines. They are available as downloadable PDF filessent via email. To order, please go to http://www.re-gonline.com/npuapselecttreatmentpreventiontopic-slidesets

ResearchThe Research Committee is putting the finishing toucheson a searchable Reference Database that will allow practi-tioners to locate pertinent research papers on topics rela-tive to pressure ulcers. Inquiries will be retrievable afterentering topic, author and/or periodical. This will be an-other tool that RDs can use to keep up-to-date on the evi-dence-based research on pressure ulcers.

Pressure Ulcer Photo GalleryHigh-resolution pressure ulcer photos are now available atthe NPUAP Online Store. Images from the NPUAP PhotoGallery may be purchased for $5 each for personal or self-presentation use; or $25 each for professional use, such astext books, saleable presentations or industry.

ADA members receive a 10% discount when purchasing aphoto for commercial use for $25.00. Use the coupon codeCOC when placing an order. To purchase the pressure ulcerphotos please follow this link http://nationalpres750.corecommerce.com/cart.html.

NPUAP-EPUAP International GuidelinesCopies of the Pressure Ulcer Prevention and TreatmentClinical Practice Guidelines (CPG) and Quick ReferenceGuide (QRG) continue to be available from NPUAP. ADAmembers receive a 10% discount per book off listed prices.


Bulk orders (20 books or more) qualify for a total 20% dis-count. Use the coupon code COC when placing an order.To purchase the guidelines, go to www.npuap.org.

Agency for Healthcare Research and Quality (AHRQ)Pressure Ulcer Prevention ToolkitA new toolkit, “Preventing Pressure Ulcers in Hospitals: AToolkit for Improving Quality of Care”, is now available fromAgency for Healthcare Research and Quality. It can guide

practitioners through the step-by-step process of a qualityimprovement initiative.

Several past NPUAP members participated in the develop-ment of the toolkit. It can be accessed atwww.ahrq.gov/research/ltc/pressureulcertoolkit/.

For more information about NPUAP and its activities, sendan email to [email protected]

National Pressure Ulcer Advisory Panel Updatecontinued from page 18

2011 ADA Leadership Institute by Dana Fillmore, RD, CP-FS & Barbara Wakeen, MA, RD, LD, CCFP, CCHP

Takin’ it to a Higher Level….one of the take-away points ofthe 2011ADA Leadership Institute held in Scottsdale, AZthis past June.

DHCC nominated BarbaraWakeen, DHCC Chair Electand Dana Fillmore, DHCCMembership Coordinator toattend this spectacular event.Not the typical conferencewith lecture sessions andPowerPoint slides, this was ahigh energy, empowering, in-teractive workshop, with compulsory participation in des-ignated sessions and groups, so that at the end of theconference we had the opportunity to converse with mostof the approximate 200 attendees. The general topics ad-dressed leadership through skills, strategic influencing,powering one’s career, facilitating and cross-generationalcommunications.

This Institute presents a forum for learning, dialogue andsharing of perspectives. Participants actively engage in theexploration of ideas and discovery of new leadership con-cepts. The Leadership Institute supports ADA’s commit-ment to develop its members by ensuring they embody aleadership mindset for innovation, adaptability, empower-ment and risk-taking.

Attendance to this spectacular event is by nominationfrom, a DPG/MIG or self-nomination. DHCC was repre-sented by Barbara, Dana and many other members. In fact,the sheer size of the group of DHCC members in atten-dance demonstrates that DHCC members are born leaders!

There were five major speakers including enlighteninghumor from the Second City Communication group whosetheme revolved around many RD’s ‘hot buttons’ (such asspelling dietitian with a ‘c’). The speakers addressed leader-ship from interpersonal through group environments andtouched on decades of generations.

Some of thesession high-lights in-cluded Déjàvu or Vujade’?, Leader-ship Chal-lenges, TheModelLeader,Strategic In-fluencing –the 4 BoxModel toChange,White Space, Tribal Leadership and Generational Dif-ferences. One session incorporated an assessment of indi-vidualized leadership skills that were a result of aleadership pre-test all attendees took prior to the confer-ence. Following the conference, there was a post-testwhich resulted in an ADA Certificate of Training in Leader-ship and 16 CPEU’s.

Having attended this high energy event, we encourageyou to get involved with ADA and DHCC, and to considernominating yourself to reserve a space in a future meeting.Visit www.eatright.org for information for 2012.

DHCC Members at 2011 ADA Leadership Institute

Dana and Barb atop Camelback Mountain


Have you noticed that we are living in a fast-paced world? Itseems that we are always on the run! Keeping is touch hasnever been easier; keeping in touch has never been harder.It is not really contradictory; it just seems as if it is!

We are all bombarded with information: computers, email,eblasts, blogs, Twitter, Facebook, Web sites, landlines, cellphones and even snail mail. You name it; we seem to haveit! All of these tools are designed to keep us up to date andin the know.

EBlastsOne great way to disseminate information quickly is theeblast. What is an eblast? It is a “mass email” that is sent toa list (in our case over 3,800 email addresses) that can besent through a service with one click (instead of over 3,800).In other words, it is fast, easy and a great method ofcommunicating. However, it is only effective if the emailsare opened and read.

On 14 October, we sent an email on a FREE webinar. Hereare the statistics for those 3,800+ emails:

opened 1,368 36.3% bounced 20 0.5% unopened 2,399 63.3% click rate 7.4% 280 clicks

What does this tell us? Perhaps members do not realizewhat these emails are; we might need to get more creativeon subject lines; or they may be going to your spam file.These emails come from DHCC on behalf [email protected] (might want to add that to youraddress book). These emails are important information thatwe feel are of benefit to our members. Please look forthem!

Electronic Mailing ListsFORUM The Electronic Mailing List (EML) has nearly 800 subscribers.You can sign up for this member benefit atwww.dhccdpg.org – under resources, EML. This is a GREATsource of information. Subscribers can ask questions andget input from others. You have the option of receiving allthe emails or getting them in digest form.

Corrections & Home Care Mailing ListsThese lists are through Yahoo Groups. You must sign up forthem as well. You can sign up at the Web pages listed here.• http://groups.yahoo.com/group/Corrections_DHCC• http://groups.yahoo.com/group/DHCC_Home_Care

Blog (a blend of the term web log) At least some of youalready blog in various areas. Did you know that DHCC hasa blog? Look at the bottom of the home page atwww.dhccdpg.org. We are going to publicize this more!Check it out!

EmailYou can email members of the DHCC Executive Committee(EC). Access this information at www.dhccdpg.org underAbout Us (you must sign in as a member to access thisinformation). You can also send a generic email [email protected] also available under About Us, Contacts.

Member Email AddressesWe access these addresses through the ADA Data Base.Please be sure that your information there is correct. Signin at www.eatright.org, then click on My Profile (under yourname). Don’t have an email listed? Consider adding one!You might want to use a free account (yahoo, gmail,Hotmail, etc.) if your regular email account is just too busy!

Web siteThere are still questions about signing in onwww.dhccdpg.org. The sign in is the same as what you useon www.eatright.org. It may be easiest to sign in ateatright.org – if you are successful use the sameinformation at the DHCC site. If not, you can easily resetyour password.

Member MarketplaceThis is a great venue for members to offer their products forsale. Please – look and see what is there now and considershowcasing your products for a nominal fee.

Access this at www.dhccdpg.org. Online store/membermarketplace.

Let’s Keep In Touch Electronically


Dietetics in Health Care Communities (DHCC) is looking fornewsletter authors. Our practice group is large and di-verse; members work in long term care, corrections, homecare and hospitals and work as consultants, employees andentrepreneurs serving a wide range of client ages. Submis-sions from all aspects of practice are welcome. Whetheryou are new to the profession or have been practicing forseveral years, if you have a passion about what you do, areconducting evidence-based research, have a success storyto share, or best practice outcomes please submit yourideas.

We have developed some simple guidelines for submis-sion:• Article length can vary, however most articles are around

1000 words. Of course if you have an exciting topic that will take more space please let us know so we can plan accordingly.

• Please spell out all words. If the word has an abbreviation, spell out the word and then put the abbreviation after the words. For example: Minimum Data Set (MDS) or pound instead of #.

• We expect our members to be familiar with regulations and with best practices, however if you are writing on a specialized topic it is best to explain terms, forms and jargon, that relates specifically to your topic area.

• Federal regulations govern all across the nation; however, remember that all states have regulations that may differ from another state. If you write something that is specific to your state or local area, please note thatand let us know how this applies to the nation. For example, one state regulation may say that fresh fruits and vegetables must be available daily; another state may not have that same regulation.

• Product brand or company names cannot be used in articles if it is not pertinent to the subject matter. Product names cannot be used in a promotional manner.

• All references need to be cited at the end of the article. Ifyou use a quote, use standard footnote documentation.

• Evidence based articles are especially needed as we all become more familiar with using evidence based research in our practice.

• The entire newsletter is reviewed by DHCC EC members and ADA staff members. All articles must be approved by reviewers prior to publishing.

• Items that are published are copyrighted by DHCC for our use and all authors must sign an author release form.If you submit an article that you have copyrighted, you will need a signed release form indicating that DHCC has your permission to use the article.

• DHCC cannot advertise your business or your product in an article. As the author of an article we can give information about you and what you do in an informative manner and in a way that people can contact you for further information.

• Deadlines are about 45 days prior to the publishing date of the newsletter.

• Sending in a photo of yourself is appreciated and we will include it with your article.

Please consider submitting your ideas or articles to me. Ilook forward to hearing from you.

Bonnie Gunckel, RD, CDConnections Newsletter [email protected]

Call For Authorsby Bonnie Gunckel, RD, CD


FNCE 2011 in San Diego

Abbott Nutrition has provided the funding for printing and mail-ing the DHCC newsletter from the first edition of The ConsultantDietitian in 1975. THANK YOU to Abbott Nutrition!

DPG/MIG Showcase at FNCE. Angela Sader and Barbara Wakeen.

DHCC Exhibit Booth at ADA’s Food & Nutrition Conference &Expo (FNCE) in San Diego

Product Market Place at FNCE. Krista Jablonski and Katy Adams

DHCC joined with ADA to exhibit at the American Health CareAssociation (AHCA) conference in Las Vegas before traveling onto FNCE.

DHCC Executive Committee 2011-12Front: Joanne Zacharias, Barbara Wakeen, Cynthia Piland, BrendaRichardson, Lisa Eckstein, Linda Roberts.Back: Diane Tallman, Marla Carlson, Maggie Gilligan, Jane Jarrett,Angela Sader, Joseph Montgomery, Krista Jablonski, Dana Fillmore, Bonnie Gunckel.

Chair*Cynthia Piland, MS, RD, CSG, LDLa Grange TX

Chair-Elect*Barbara Wakeen, MA, RD, LD, CCFP, CCHPN. Canton OH

Past Chair*Brenda E. Richardson, MA, RD, LD, CDPekin IN

Secretary*Lisa W. Eckstein, MS, RD, LDCanton GA

Treasurer*Joanne Zacharias, MS, RD, LDNBrunswick, MD 21758

Membership Coordinator*Dana Fillmore, RD, CP-FSWyoming MI

Professional Development CoordinatorsJane Jarrett, RD, LDNSt. Charles, IL

Multi-Media CoordinatorMaggie Gilligan, RD, LDNCharlotte NC

*Elected DHCC EC member with voting privileges.

HOD DPG Delegate*Carolyn Breeding, MS, RD, LD, FADARichmond KY

Public Policy CoordinatorAngela Sader, MBA, RD, LDWichita KS

Regulatory Lynn Moore, RD, LDPort Gibson MS

Sponsorship CoordinatorLinda Roberts, MS, RD, LDNWheaton IL

Connections (Newsletter)Managing EditorBonnie H. Gunckel, RD, CDFort Wayne IN

Cont. Ed. Editor: Marilyn Ferguson-Wolf, MA, RD, CSG, CD Seattle WA

Manager DPG RelationsSusan DuPraw, MPH, RDAmerican Dietetic Association Chicago IL 800-877-1600 ext 4814, 312-899-4814, 312-899-5354 (F)[email protected]

AdvisorDiane Tallman, RDAbbott NutritionHudson OH

Executive DirectorMarla Carlson2219 Cardinal DrWaterloo IA 50701-1007319-235-0991, 319-235-7224 (fax)(Central time zone)[email protected]

ADA Web Page:www.eatright.org

DHCC Web Page: www.dhccdpg.org

Newsletter ReviewersSusan DuPraw, MPH, RDBrenda Richardson, MA, RD, LD, CDCarol Elliott, RD, LD/NCynthia Piland, MS, RD, CSG, LDLisa W. Eckstein, MS, RD, LDMaggie Gilligan, RD, LDN

Dietetics in Health Care Communities (DHCC)Executive Committee and Officers 2011-2012

Connections

The quarterly publication of Dietetics in Health Care Communities (DHCC), a dietetic practice group of the AmericanDietetic Association.

Viewpoints and statements in this publication do not necessarily reflect policies and/or official positions ofDHCC/ American Dietetic Association

If you have moved recently, or had a change of name, please notify ADA Membership Team as soon as possible byemailing [email protected] or at ADA's Web site at www.eatright.org “Edit Profile.”

© 2012 Dietetics in Health Care Communities, a dietetic practice group of the American Dietetic Association.

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