American Dietetic Association

Nutrition Care Process

and Model
Making Our Assumptions Explicit

Acknowledgements
ADA Nutrition Care Process & Model
Workgroup
Karen Lacey, Chair, Suzanne Bertocchi, Elvira
Johnson, Kessey Kieselhorst, Mary Jane
Oakland, Tamara Otterstein, Carlene Russell,
Patricia Splett

ADA Staff
Ellen Pritchett, Esther Myers, Karri Looby,
Harold Holler

Quality Management Committee

ADA House of Delegates 2002/2003

Making Our Assumptions

Explicit
The Nutrition Care Process
How do YOU do nutrition care?

WHY a Standard Process

for Nutrition Care?
For the Dietetics
Profession
consistent,
systematic structure
& method
assure quality
performance
higher probability of
positive outcomes

For Others
the patient/client
multidisciplinary
team
administrators,
payors, regulators

Toward Common Dimensions

of Nutrition Care

Common language
Expected nutrition care process

Identified indicators can be measured,

analyzed and interpreted

Professional autonomy
Preferred provider

ADA Nutrition Care Process and

Model
Screening
Screening and
and Referral
Referral
System
System
!
! Identify
Identify risk
risk factors
factors
!
! Use
Use appropriate
appropriate tools
tools
and
and methods
methods
!
! Involve
Involve interdisciplinary
interdisciplinary
collaboration
collaboration
Nutrition
Nutrition Assessment
Assessment
!
!Obtain/collect
Obtain/collect timely
timely and
and
appropriate
appropriate data
data
!
!Analyze/interpret
Analyze/interpret with
with
Evidence-based
Evidence-based standards
standards
!
! Document
Document

Nutrition
Nutrition Diagnosis
Diagnosis
!
!Identify
Identify and
and label
label problem
problem
!
!Determine
Determine cause/contributing
cause/contributing
risk
risk factors
factors
!
!Cluster
Cluster signs
signs and
and symptoms/
symptoms/
Defining
Defining characteristics
characteristics
!
! Document
Document

Relationship
Relationship
Between
Between
Patient/Client/Group
Patient/Client/Group &
&
Dietetics
Dietetics
Professional
Professional
Nutrition
Nutrition Monitoring
Monitoring and
and
Evaluation
Evaluation
!
! Monitor
Monitor progress
progress
!
! Measure
Measure outcome
outcome indicators
indicators
!
! Evaluate
Evaluate outcomes
outcomes
!
! Document
Document

Nutrition
Nutrition Intervention
Intervention
!
! Plan
Plan nutrition
nutrition intervention
intervention
!
! Formulate
Formulate goals
goals and
and
determine
determine aa plan
plan of
of action
action
!
! Implement
Implement nutrition
nutrition intervention
intervention
!
Care
is
delivered
and
! Care
-- is delivered and
actions
are
actions
are carried
carried out
out
!
Document
! Document

Outcomes
Outcomes
Management
Management System
System

!
!Monitor
Monitor the
the success
success of
of the
the Nutrition
Nutrition Care
Care
Process
Process implementation
implementation
!
!Evaluate
Evaluate the
the impact
impact with
with
aggregate
aggregate data
data
!
!Identify
Identifyand
and analyze
analyze causes
causes of
of less
less than
than
optimal
optimal performance
performance and
and outcomes
outcomes
!
!Refine
Refine the
the use
use of
of the
the Nutrition
Nutrition Care
Care Process
Process

4-7-03
4-7-03

Definition
The ADA Nutrition Care Process
is . . . . . . .
A systematic problem solving
method that dietetics professional
use to critically think and make
decisions to address nutrition
related problems and provide safe,
effective, high quality nutrition care.

ADA Nutrition Care

MODEL
Nutrition Care Process
Central core
Outer rings
Supporting systems
Screening and referral (access)
Outcomes management (CQI)

Central Core
Patient/client & Dietetics
Professional relationship
Collaborative
Patient-focused
Individualized

Outer Rings
Dietetics professionals strengths
brought to process:
dietetics knowledge
skills of critical thinking, collaboration,
communication
evidence-based practice

External environment constraints

health care system, practice setting
social support, economics, education

ADA Nutrition Care

Process
Four Steps
1. Nutrition Assessment
2. Nutrition Diagnosis
3. Nutrition Intervention
4. Nutrition Monitoring and Evaluation

Step 1. Nutrition
Assessment
Purpose
Obtain, verify, and
interpret data
to make decisions
about the nature
and cause of
nutrition-related
problems

Nutrition Assessment-Components
Gather data, considering:
dietary intake
nutrition related consequences of health and
disease condition
psycho-social, functional and behavioral
factors
knowledge, readiness and potential for
change

Compare to relevant standards

Identify possible problem areas

Nutrition Assessment-Critical Thinking

Observing non-verbal and verbal cues to
guide interviewing methods
Determining appropriate data to collect
Selecting assessment tools and procedures
and applying in valid and reliable ways
Distinguishing relevant from irrelevant data
Organizing data to relate to nutrition
problems
Determining when problem
requires referral

Nutrition Assessment
Data Sources &
Tools

Documentation

Referral information

Data collected and

comparison with
standards

Patient interview
New data collection
Findings from
community surveys,
statistical reports,
administrative data,
research studies

Date & time

Patient perceptions
Key indicators for
follow up

Nutrition Assessment

EXPLICIT comparison of gathered

data with reference standards

Step 2. Nutrition Diagnosis

Purpose
Identify and label the
nutrition problem
Nutrition diagnosis
NOT medical diagnosis

EXPLICIT statement of nutrition

diagnosis

Nutrition Diagnosis-Components
Problem--alteration in patients
nutritional status

Etiology--cause or contribution risk

factors

Signs or symptoms--defining
characteristics

Nutrition Diagnostic
Statement
Problem -- related to -- Etiology -as evidenced by -- Signs or symptoms
Example: Unintended weight loss related
to inadequate provision of enteral products
as evidenced by 6 pound weight loss over
past month

Nutrition Diagnostic
Statement
Structure:
Adjective, human response
related to (RT)

Contributing factors
as evidenced by (AEB)

Signs or symptoms

Nutrition Diagnostic
Statement--More Examples
Excessive caloric intake related to frequent
consumption of large portions of high fat
foods as evidenced by average daily intake
exceeding recommended by 500 kcal and
12 pound weight gain in past 18 months.
Inappropriate infant feeding practices RT
lack of knowledge AEB infant receiving
bedtime juice in bottle.
Potential for weight gain RT recent
decrease in daily physical activity following
sports injury.

Nutrition Diagnosis-Critical Thinking

Finding relationships between data and
possible causes
Making inferences (if this then that)
Stating problem clearly and singularly
Being objective and factual
Ruling in/ruling out specific diagnosis
Prioritizing the relative importance
of problems

Nutrition Diagnosis
Data Sources &
Tools

Documentation

Pre-determined
list/taxonomy of
nutrition-related
diagnosis
List of validated
defining
characteristics for
each diagnostic
category

Date and time

Written statement of
nutrition diagnosis
(PES or PE format)

Step 3. Nutrition Intervention

Purpose
Plan and implement purposeful
actions to address the
identified nutrition problem
bring about change
set goals and expected
outcomes
client-driven
based on scientific principles

Nutrition Intervention-Components
1. Plan the Nutrition Intervention
Prioritize diagnoses
Determine intervention goals and expected
outcome
patient participates
type of change based on nutrition diagnosis
short or long term
reasonable to patients circumstances
reflect Evidence-Bases Guides for Practice

Select intervention strategies

what, how long, frequency of contact

Nutrition Intervention
EXPLICIT plan including intervention
strategies and specified desired
outcomes with timeline

Nutrition Intervention-Components
2. Implement the Nutrition Intervention
Communicate plan for nutrition care
Dietetics professional
directly carry out the intervention
delegate or coordinate care provided by
others

Continue data collection and modify

plan and strategies as condition or
response changes

Nutrition Intervention-Critical Thinking

Prioritizing and setting goals

Transferring knowledge from one
situation to another
Defining nutrition prescription or plan
Matching intervention strategies with
patient needs, diagnoses and values
Choosing from alternative courses
of action

Nutrition Intervention
Data Sources &
Tools

Documentation

Evidence guides for

practice/protocols
Consensus
guidelines
Current research

Date and time

Specific intervention
goals and expected
outcomes
Patient receptivity
Referrals made
Intervention
implemented
Adjustments to plan

Patient education
materials
Behavior change
theories

Step 4. Nutrition Monitoring &

Evaluation
Purpose
Determine degree of
progress is being made
toward goals or
desired outcomes
Monitoring: review and measurement of
status at scheduled times
Evaluation: systematic comparison with
previous status, intervention goals,
reference standard

Nutrition Monitoring &

Evaluation--Components
1. Monitor Progress
Check patients understanding and compliance
Determine if intervention is being implemented
as planned
Determine if patients status is or is
not changing
Identify other positive or negative responses
Gather info indicating reasons for any
lack of progress

Nutrition Monitoring &

Evaluation--Components
2. Measure Outcomes
Select outcome indicators that are
relevant to the nutrition diagnosis, signs or
symptoms, nutrition goals, medical diagnosis
and outcomes or quality management goals

Use standard indicators

increase the validity and reliability of
measure
facilitate electronic charting, coding and
outcomes measurement

Nutrition Monitoring &

Evaluation--Components
3. Evaluate Outcomes
Compare current findings with previous
status, intervention goals, and/or
reference standards
EXPLICIT documentation of progress
using defined indicators

Nutrition Monitoring &

Evaluation--Critical Thinking
Selecting appropriate
indicators/measures
Using appropriate reference
standards
Defining where patient is now
Explaining variances
Determining factors that help or
hinder progress

Nutrition Monitoring
& Evaluation
Data Sources & Tools

Documentation

Patient records
Measurement:anthropometric, laboratory tests,
questionnaires
Patient, guardian,
caregiver interviews,
survey, pre-post test
Evidence-based
sources
Data collection forms,
computer programs

Date and time

Specific indicators
measured and results
Progress toward
goals
Factors affecting
outcomes
Future plans for care,
monitoring, follow up
or discharge

ADA Nutrition Care Process and

Model
Screening
Screening and
and Referral
Referral
System
System
!
! Identify
Identify risk
risk factors
factors
!
! Use
Use appropriate
appropriate tools
tools
and
and methods
methods
!
! Involve
Involve interdisciplinary
interdisciplinary
collaboration
collaboration
Nutrition
Nutrition Assessment
Assessment
!
!Obtain/collect
Obtain/collect timely
timely and
and
appropriate
appropriate data
data
!
!Analyze/interpret
Analyze/interpret with
with
Evidence-based
Evidence-based standards
standards
!
! Document
Document

Nutrition
Nutrition Diagnosis
Diagnosis
!
!Identify
Identify and
and label
label problem
problem
!
!Determine
Determine cause/contributing
cause/contributing
risk
risk factors
factors
!
!Cluster
Cluster signs
signs and
and symptoms/
symptoms/
Defining
Defining characteristics
characteristics
!
! Document
Document

Relationship
Relationship
Between
Between
Patient/Client/Group
Patient/Client/Group &
&
Dietetics
Dietetics
Professional
Professional
Nutrition
Nutrition Monitoring
Monitoring and
and
Evaluation
Evaluation
!
! Monitor
Monitor progress
progress
!
! Measure
Measure outcome
outcome indicators
indicators
!
! Evaluate
Evaluate outcomes
outcomes
!
! Document
Document

Nutrition
Nutrition Intervention
Intervention
!
! Plan
Plan nutrition
nutrition intervention
intervention
!
! Formulate
Formulate goals
goals and
and
determine
determine aa plan
plan of
of action
action
!
! Implement
Implement nutrition
nutrition intervention
intervention
!
Care
is
delivered
and
! Care
-- is delivered and
actions
are
actions
are carried
carried out
out
!
Document
! Document

Outcomes
Outcomes
Management
Management System
System

!
!Monitor
Monitor the
the success
success of
of the
the Nutrition
Nutrition Care
Care
Process
Process implementation
implementation
!
!Evaluate
Evaluate the
the impact
impact with
with
aggregate
aggregate data
data
!
!Identify
Identifyand
and analyze
analyze causes
causes of
of less
less than
than
optimal
optimal performance
performance and
and outcomes
outcomes
!
!Refine
Refine the
the use
use of
of the
the Nutrition
Nutrition Care
Care Process
Process

4-7-03
4-7-03

Support Systems--

Screening and Referral System

Identification of those who could benefit
from special nutrition intervention
Standardized test or procedures
Used by dietetics professionals
and others
Established system to
connect people to
nutrition care

Support Systems--

Outcomes Management System

Management information system that links
care processes and resource utilization
with outcomes
Relevant data aggregated from many
patients to determine overall effectiveness
& efficiency of process
Summary findings sent to
providers and reported to
administrators, payors
Infrastructure required

Making Our
Assumptions Explicit
Accountability

Identify gaps
Name nutrition problem/diagnosis

Define goals, intervention strategies &

timeline
Report progress made

Take Away Points

Standardized process, individualized care

Common language

Documentation of:
needs
problems/diagnosis
intervention
progress
toward goals

High quality care, positive outcomes