April 2016 Issue

Home Health Care — Dietitians at the Forefront
By Lindsey Getz
Today's Dietitian
Vol. 18 No. 4 P. 38

As new health care models that include the expertise of dietitians continue to develop, more opportunities will become available for those who want to work in home health care.

There was a time when doctors' house calls were the norm. In the 1930s, about 40% of all doctor-patient interactions were in homes. This practice went by the wayside when medical insurance replaced pay-as-you-go service and malpractice insurance fees increased so much that doctors could no longer afford to work solo, but had to band together in groups. While it remains rare for physicians to make house calls, a home health care movement is growing and the most forward-thinking institutions are including dietitians in that model.

According to the National Association for Home Care & Hospice, today approximately 12 million individuals receive health care services in their home. It's believed that by 2020, home health care professionals will have grown by more than 1.3 million (a 70% increase), according to the Bureau of Labor Statistics. Though nursing positions have been the primary role in home care, many agencies bring in dietitians on an as-needed basis. But some are already employing them full-time.

There's great opportunity for dietitians in the field of home health care. According to Sara Swiderski-Dandinidis, MBA, RDN, LDN, director of dietitian services for Dietitians at Home, a home-based nutrition therapy and education company based in Chicago, their dietitians work full eight-hour days seeing patients ranging in age from 30 to 100 (though most are between 65 and 80 years old). The only difference is the setting—it's the patients' homes.

"We are reviewing charts in the morning or night before we go to see the patient and then driving to our appointments for the day," Swiderski-Dandinidis says. "We want our practitioners to see at least six patients per day, and they usually see 100 to 120 per month. During the day you may answer calls from patients, doctors, and nurses, and you may be calling to ask doctors about the patient you're seeing and what the plan of care goals are for that patient. Also, we have opportunities for dietitians to do presentations to groups that are interested in our services or on nutrition topics in general."

Swiderski-Dandinidis says that pay levels can vary based on the type of position being covered. For example, home care dietitians may be paid per visit, one-half base salary and one-half compensation, or a flat salary. She adds that Dietitians at Home does a one-half base and one-half compensation pay model.

An Ever-Changing Environment
Angel Planells, MS, RDN, has been working in home-based primary care since 2008 for the VA, first in New York and more recently (since 2011) in Seattle. He works with elderly veterans who have any condition that may require the services of a dietitian. That includes obesity, diabetes, malnutrition, or sometimes just aging and the need for a better dietary plan. Planells admits it's hard to describe a typical day since no two days are alike. Each day can bring new people and a new direction. That's one thing he loves about his job, but he says it can be either a benefit or a drawback, depending on the person.

"Any time you walk into someone's home—their environment—you need to be prepared to think on your feet," Planells says. "It's very different from a clinical setting where, for the most part, you know what to expect when you walk into a room. In the home-based setting, you can't just walk in and begin dictating what they need to do. It's more important in this setting to develop a rapport first. There's a lot more relationship building and trust that needs to be established in the home setting."

Some tasks Planells says he may perform during a typical in-home visit include not only discussing nutrition and daily eating habits but also looking inside the patient's pantry and refrigerator to "get an accurate snapshot of the life of the client." Planells says he's looking to see whether the client eats lots of fruits and vegetables or mostly processed foods. "If the client consumes a lot of processed foods, we will try to make gradual changes toward a better quality diet," Planells says. "If the client consumes a lot of fruits and vegetables, we can provide support and encouragement for the great effort already being done."

But even before that, Planells says he focuses on relationship building, so the majority of the first visit may include just talking. Since visits are longer and there's drive time to account for, Planells says the home health care model means seeing fewer people in one day. That's a big difference from the clinical setting, but Planells feels a home visit can have a major impact and is incredibly valuable despite seeing fewer patients in one day.

Another big difference when working in the home care setting is that dietitians don't have immediate access to other members of a health care team. Sarah Hults, RDN, LDN, CDE, senior dietitian with Dietitians at Home, says that in the clinical setting you have easy access to doctors and colleagues when you need to consult one another, but she says modern technology helps bridge the gap.

"We are outfitted with mobile phones and are able to still converse with doctors and our fellow dietitians," Hults says. "We are lucky that we work with doctors who really appreciate the dietitian's role and are always willing to take our call."

And of course there's the fact that going into someone's home can—at times—feel unnerving. There's the question of safety that dietitians don't have to worry about in a hospital setting.

"In a clinical setting, there are police and security on staff that are always available should a patient become unruly or a provider find him or herself in a violent situation," Planells says. "When you're going into someone's home, you're going in alone. The VA offers safety training courses to prepare us. You must always be mindful of your situation, from where you park your vehicle, so that you can quickly leave if you have to, to where you stand in the home, so that you can't be cornered or trapped."

Sowmya Venkat, MS, RDN, LDN, senior dietitian with Dietitians at Home, agrees that it's always a challenge to walk into the unknown. She says dietitians who provide care in the home need to be able to "think fast on their feet and have a lot of mental strength and self-confidence."

"Our training emphasizes that safety comes first," Venkat adds. "If you walk into a home and get this sense that something isn't right, then we'd say to trust that sense. Maybe there's another family member in the home that seems aggressive or something about the situation is uncomfortable—then it's always best to leave. We're trained to recognize a potentially dangerous situation and to trust our instincts."

Making a Difference
There's no doubt that working directly in the home can pose some challenges, but it also can create opportunities ripe for success. Working with patients in their own environment and developing a true sense of trust with them can open the door for real change. Swiderski-Dandinidis says that working in the home setting gives you "information at your fingertips"—and that can be invaluable when making a difference in patients' lives.

"In the acute care setting, where I worked for some time, you often question whether the information patients provide is fully credible. Maybe the patient forgot or purposely didn't mention certain details," Swiderski-Dandinidis says. "But in the patient's home, you get to see their actual environment. You can open their fridge, have access to their pantry, and can observe their lifestyle in real time. That kind of information at your fingertips can guide the process and make you much more effective."

In the home care setting, Swiderski-Dandinidis says dietitians can address factors inhibiting progress, such as smoking, much more in-depth. While patients can't smoke in a hospital and may even lie about the habit, it's not so easy to hide this in the home.

"Smoking is a barrier to learning and understanding how diabetes affects the body," Swiderski-Dandinidis says. "Sometimes, we first have to get over that barrier before we can really address nutritional changes. That's often a conversation that comes up based on an inspection of the home, which may have never been addressed in the acute care setting." 

The ability to implement change at the home care level can be exciting and rewarding. Dianne Cabelus, RN, CNN, a nursing supervisor at Partners Health Care at Home Private Care, located in the greater Boston area, performs nutrition assessments when visiting patients in her role as a certified nurse nutritionist. She says patients often are more receptive to information in their own home and that success is more likely achieved.

"While in the hospital, patients get a lot of information thrown at them and nutrition recommendations can easily get overlooked," Cabelus says. "But in the home, it's easier for them to listen and easier for the health care provider to truly evaluate their situation and monitor their progress. When you see modifications actually put into play in their own environment, it's incredibly rewarding. I can see that the patient did buy that diabetic cookbook we talked about or that they redid their pantry with healthier options. You don't get to see those changes come to fruition in the clinical setting."

Above and Beyond
As dietitians spend time in their patients' homes, it isn't uncommon for them to take on new roles. For example, Swiderski-Dandinidis says Dietitians at Home has expanded the dietitian's role to include new tasks and responsibilities for diabetes patients. She says that with the right resources and training, RDs easily can adopt additional roles that make them incredibly valuable in the home health care model.

"We have made dietitians competent in finger stick lab work, [taking] blood pressure, checking for edema, and running lipid panels, all in the home," Swiderski-Dandinidis says. "We're trained to assess the risk level of our patients with diabetes and we're frequently able to prevent complications as a result. We are keeping patients out of the emergency room because we're recognizing risk factors and making changes."

Julia Nicolini, RDN, LDN, sales and marketing director at Dietitians at Home, says that because dietitians working in the home care setting can look at the "big picture," they can ensure their patients' needs for social services are met.

"For instance, if the patient doesn't have much food in the home, we can explore whether they're getting Meals on Wheels or are set up with food pantries in the area," Nicolini says. "By actually going into the home, we can ask ourselves 'Is this person OK?'—not only from a nutritional standpoint but a social standpoint as well. Are they set up with the services they need? And if they're not, the question becomes, 'What calls do we need to make?'"

When working in the home, especially in ethnically diverse areas, it's also important to consider potential language and cultural differences.

"There's an important multicultural aspect to this kind of work," Venkat says. "It's important to understand what might work for a particular culture—and what might not. I speak three languages. When I see Indian patients, I'm able to connect with them in their language and because I understand their food and their culture, they're able to better connect with me. Sometimes that can play a huge part in success."

Planells says that being a "people person" may not be a skill set that's taught, but a dietitian who is one will have more success with patients.

"An introvert can still work in the clinical setting as the level of conversation doesn't have to go beyond small talk," Planells says. "You can ask your questions and still get the job done. But it would be difficult to be an introvert in the home care setting. It goes back to the importance of building relationships and trust—especially when you're seeing the patient on an ongoing basis. In rounds, you may not be with one patient more than 20 minutes, but in the home care setting I've spent as much as an hour and a half in one home. It's just a very different model."

Room for Growth
When it comes to the dietitian's role in the home health care movement, there's room for growth. Planells says the VA understands the role nutrition plays in overall health and wellness and as a result is invested in employing many dietitians. But the numbers of RDs in other health care organizations remain low. Nicolini says that to the best of her knowledge, of the approximately 600 home health agencies in their state, only two of those agencies have full-time dietitians.

"This concept of home health care is lacking when it comes to dietetics," Nicolini says. "Part of the issue is that Medicare sets guidelines as to what is covered. The majority of our patients have diabetes, though we also see those with chronic kidney disease and those who are postkidney transplant, if it's been in the last 36 months. We do hope that the future will include coverage of more diagnoses, as there are so many other conditions where nutrition can play a significant role in wellness."

Cabelus says she would love to see more dietitians become part of the team. "Nutrition isn't considered nearly as often as it should be in health care in general," Cabelus says. "Most home care agencies work with dietitians on a per diem basis, but it would be great to see more of them integrated into the whole system."

Swiderski-Dandinidis says it starts with an open mind in school. Program directors need to talk to students about home health care and discuss it as part of the future.

"With the aging baby boomer population, we do believe that home health care is the way of the future," Swiderski-Dandinidis says. "If the stars align, as we believe they will, more diagnoses are going to be covered by insurance, and dietitians will be seeing even more patients in their homes. Students need to start learning about this model and the required skill set early on—in school, but also in their internships."

In the home health care model, dietitians may truly have the opportunity to shine. "I've always felt like dietitians should pass the baton off to each other from acute care to home," Swiderski-Dandinidis adds. "With home health care, dietitians can truly challenge themselves in a big way. They have the opportunity to really make a difference and perhaps to do more in the system than they ever thought possible. We believe this is the future."

— Lindsey Getz is a freelance writer based in Royersford, Pennsylvania.