Clinical dieticians' roles across acute, long-term, and outpatient care settings

Roles of a Clinical Dietician in-Patient and Out-Patient Settings

In preparation for this fieldwork report, I visited and spoke with clinical nutritionists at Veterans Affairs Medical Center, an acute, in-patient care facility; Cobble Hill Health Center, a long-term in-patient care facility; and Long Island College Hospital's Atlantic Hemodialysis Center, an out-patient care facility in Brooklyn, New York. At each facility, the nutritionist and supporting staff were kind enough to go through the admissions, diagnostic, treatment and documentation procedures, which varied in detail but were similar in essentials across facilities. For example, because Veterans Affairs Medical Center serves veterans only, applicants are required to submit proof of service and discharge documents, in addition to a standard application. Meanwhile, Cobble Hill Medical Center cares for elderly individuals-many with severe health problems -- and the Atlantic Hemodialysis Center at Long Island College provides dialysis services for people with severe kidney disease or kidney damage, requiring prior diagnostics from a licensed physician. As patient needs vary greatly between facilities, so the role of a clinical dietician varies also.

Acute in-Patient Care

Applicants to the Veterans Affairs Medical program begin by submitting an Application for Health Care Benefits online, by mail or in person at the Eligibility Office. The application consists of several parts, to include Personal Information, Insurance Information, Employment History, Military Service History, Demographic Information, and a Financial Assessment page. The purpose of this application is to determine the applicant's eligibility for care at this particular facility. In addition to the application, applicants are required to submit a copy of both sides of their current insurance card, and a copy of their Armed Forces Report of Transfer or Discharge (DD214) form. Purple heart recipients are also required to submit a copy of their award letter.

After all documents have been submitted and reviewed, the patient can make an initial appointment by calling the number provided on the website. During this appointment, the patient discusses all pertinent medical issues and concerns with a licensed physician and/or clinical dietician. Once admitted, the patient is given the option of creating an Advance Directive, i.e. A written document describing the care they wish to receive, should they become unable to express those wishes-due to physical or mental incapacity-during their stay. An Advance Directive can be written in the form of a living will-describing in detail the care one wishes to receive or not receive, should one become incapacitated-or a durable power of attorney document granting permission to another person to make decisions regarding one's health care. An Advance Directive is particularly important for elderly patients or the severely ill.

Once in residency at Veterans Affairs Medical Center, patients are paired with a clinical nutritionist and full medical staff. The primary responsibility of a clinical nutritionist in an acute care setting is to educate patients about health and nutrition, towards the primary objective of giving patients the tools to make informed decisions on their own. With this in mind, Veterans Affairs residents are given access to a Health and Wellness Library, professionally staffed with a Patient Health Education Coordinator and a supporting Librarian. In addition, My HealthVet website allows residents to fill prescriptions, monitor personal health data-such as blood pressure and pain levels-create a nutrition and activity journal, and maintain a self-entered health record. Additional services provided include physician and clinical nutritionist-led educational courses, and an on-Demand video series for more visual learners. By encouraging residents to assume a proactive role in regards their own health, Veterans Affairs prepares patients to make the transition from resident to home life.

Clinical nutritionists at Veterans Affairs work closely with physicians, nurses, educational staff, social workers, mental health professionals and patient representatives. In this way, nutritional education is merely one component of a comprehensive care approach. The typical stay for Veterans Affairs residents is less than 30 days, with an anticipated date of discharge determined at the time of admission. As this anticipated date approaches, the clinical dietician provides counsel for how to follow a healthy diet at home, and works to address any questions or concerns of the patient. In cases of severe illness, plans for follow-up care are also made at this time. In every case, the Release Information Staff educates patients about how to access medical records, obtain copies of medical records, process requests for amendments to records, and also how to complete forms for benefits and insurance purposes.

Out-Patient Ambulatory Care

The Atlantic Hemodialysis Center at Long Island College Hospital is one of 167 Centers for renal dialysis within a 35-mile radius. The vast number of centers allows for convenience-both emergency and otherwise-for dialysis patients in the Brooklyn and New York areas. In order to become a patient at the Atlantic Hemodialysis center, patients must be under the care licensed physician and submit all medical records, in addition to an application and relevant insurance information.

In this setting, clinical nutritionists interact with the patient's primary care provider, in addition to a full nursing and administration staff. As patients in need of renal dialysis suffer from severe kidney disease and/or kidney damage, it is the role of the clinical nutritionist at these facilities to compose a diet designed to relieve stress of the kidneys and promote kidney health. As kidney disease is a chronic condition that requires ongoing, long-term care, dialysis treatment is also long-term, though the frequency of treatment depends on the severity of the condition. Regardless of the frequency of dialysis, it is the responsibility of the clinical nutritionist to support patients in adhering to the prescribed diet over the course of treatment. As was the case at Veterans Affairs and Cobble Hill medical centers, proper nutrition is merely one component of a multi-faceted approach to treatment.

Comparatively Speaking

While the role of the nutritionist differs in the details at each of these facilities, the primary objective of prescribing and supporting a healthy lifestyle remains the same. In an acute care setting, such Veterans Affairs, this objective is executed by educating patients about how to maintain a healthy diet and lifestyle after the leave the facility, while in a long-term care setting-such as Cobble Hill-this objective is executed on a daily basis by providing nutritious meals for elderly residents. And finally, in an ambulatory, out-patient care setting-such as Atlantic -- the clinical nutritionist works to support patients in maintaining a diet that addresses their personal healthcare needs, while still living independently within a larger community. Perhaps the most significant similarity between facilities is the notion of nutrition as merely one component of a comprehensive care program; hence the necessity of a clinical nutritional to work in conjunction with a full medical, administrative, and social support staff. The apparent goal of such an approach is to promote multiple aspects of health and well-being among patients, regardless setting or subjective health concerns.