Nutrition Services in the Outpatient Setting: The RDN Private Practice

To enhance the patient’s care on a day-to-day outpatient setting, it is important to team up with a registered dietitian nutritionist (RDN) within a practice or within the community. Diabetes, GI (gastrointestinal) diseases such as IBS (irritable bowel syndrome) and IBD (inflammatory bowel disease), heart disease, and weight loss are just a few of the many conditions that can be treated with nutrition care provided by an RDN. The RDN can work with patients in groups or individually to help reduce chronic medical complications, improve and enhance the patient’s level of care and outcomes, and provide a source of outpatient connection that would otherwise be difficult to receive in an inpatient setting. Often, the RDN in the hospital has limited time to spend with the patient in providing individualized diet instructions for home, which makes referral to the outpatient RDN invaluable. For the RDN working outside the hospital, referral sources can be from hospitals, home care, individuals, or physician or clinic practices. Patients may self-refer as well.

This chapter will provide information for the RDN and for other healthcare professionals on working with an RDN. For the RDN, this may provide you with concepts you may use in creating or building a private practice. For other healthcare professionals, this information may help you find an RDN and design the practice option that fits your practice/clinic best.

RDN PRACTICE SETTINGS

There can be several approaches health professionals can take to work with RDNs. Two key steps to consider would be the type of practice the RDN has, and the type of work relationship that would fit best for both parties. An RDN may have a private office to see patients individually and/or as a group. The RDN may be a contracted provider for Medicare, Medicaid, or other commercial insurance plans or patients may self-pay to see the RDN in their own office. RDNs may alternatively use the physician’s office and work as an independent contractor and/or work as an employee for the practice. Other RDNs offer a combination of options as both an independent contractor or as a part-time employee with clinic hours at a practice sight location. Whichever the type of relationship, the nutrition and diet counseling and therapy are beneficial for patient outcomes.

For an RDN contemplating private practice, consider what practice area to focus in (e.g., general, diabetes, weight management, renal, enteral nutrition, eating disorders, sports nutrition, oncology, allergies, etc.). For the healthcare provider working with the RDN, consider whether his/her practice fits with the services the practice provides. Also, it is important to determine if a practice wants to work with the RDN as an independent contractor seeing patients in the practice, or separately at the RDNs office.

Similarly, the RDN may have a specialty such as diabetes or GI disease and want to focus only on this area. In this case, the RDN will want to seek out those practices that would provide the best fit for their expertise. Depending on the practice, the RDN may want to work in the office or be available in the RDN practice office separate from the referral source. There is no one way to provide nutrition care in the outpatient setting and it is best to decide what works best for the practice, the RDN and the patient.

FINANCIAL AGREEMENTS

The next step is to determine what financial agreement would be necessary. Some facilities bill for the RDNs services, some RDNs bill insurance or the patient for their services directly, and some practices have a combination. It is also important to make sure the RDN is licensed, maintains professional liability, maintains their continuing education hours, and is in good ethical standing. This helps reduce liabilities for both parties and provides some assurance that patients receive reliable science-based and up-to-date counseling services that maximize patient outcomes. More information on billing will be provided later in this chapter.

LOCATION

One of the simplest methods to start working with an RDN is bringing them onboard as an independent contractor seeing patients at the practice location. In this type of work relationship, the RDN conducts nutrition consults in an office within the practice. The RDN maintains their own hours and schedule, and can coordinate with office staff for room and scheduling if necessary. The practice can decide how involved they want their staff to be in this process. In most cases, physicians provide the space and allow the RDN to maintain their own schedule to reduce the workload on their staff. In turn, the RDN provides a nutrition evaluation note for each visit, which is important to add to the patient’s chart and medical information. Having the RDN in the practice office helps the physicians and staff communicate more readily about client or patient cases, thus increasing the possibility for better patient outcomes and greater level of care.

RDN IN OFFICE AS STAFF OR INDEPENDENT CONTRACTOR

Having an RDN in-house can enhance patient care in several ways. The physician can refer patients directly to the RDN during consults, or for follow-up visits so nutrition recommendations, goals, and patient care can occur faster and increase patient adherence and enhance (or improve) health outcomes. Another important benefit of having the RDN in-house is that patient information such as laboratory data, past medical and family history, and medication lists can easily be obtained by the RDN in-house to help customize and enhance medical nutrition advise and therapy approaches. This also allows improved communication between the patient and physician since in several instances patient’s medications can affect nutrition recommendations. An important benefit of having an RDN in-house is that the private patient information stays in-house, and it’s easier to meet HIPAA (Health Insurance Portability and Accountability Act) compliance. The main differences with the RDN as staff or as an independent contractor RDN include type of office hours and level of control by practice, payment or reimbursement of services, and type of outcomes and expectations for the practice patients. However, this can be managed by developing a contract and patient outcome guidelines by the practice that helps explain expectations, and by building a relationship and level of trust over time.

There are several additional added benefits of having an RDN either on staff or within the practice as an independent contractor. The RDN can also provide nutrition and fitness clinics and classes on various topics such as diabetes, cardiovascular diseases, weight management, eating disorders, digestive disorders, and many other nutrition and preventive related topics throughout the year to both patients and staff. Additionally, RDNs can help provide nutrition information, updates, and tips that can be included in patient medical health records, practice website, email blasts, newsletters, and patient brochures and flyers. The benefits of employing or contracting with an RDN in-house can truly enhance a practice and patient outcomes, especially now that so much of insurance and the Affordable Care Act is driven by prevention and patient outcomes.

RDN PRIVATE PRACTICE

A medical practice can also choose to simply refer patients out to an RDN with their own private practice. This alternative decreases the burden on the practice to have another employee on the payroll, less staffing and scheduling issues, and reduces the liability of the practice. The RDN will usually have his/her own office space he/she rents off-sight or even near or within the same building as the medical practice. In this case the RDN is completely working independently and receives referrals from various sources such as medical practices and doctors, other health professionals, the Internet, or from word-of-mouth from other clients. The independent RDN private practice model is typically one of the easiest routes medical doctors and facilities choose to team up with. The RDN sees their own patients, practices independently, and has their own liability, office space, and bills for their services independently from the physician’s office. To obtain more information regarding business models for RDNs working in physicians’ offices, the publication “RDNs in the New Primary Care: A Toolkit for Successful Integration,” published in 2016 by the Academy of Nutrition and Dietetics, may be helpful.

PROFESSIONAL OBLIGATIONS

All RDNs must maintain their registration and/or licensure and continuing education as well as keeping current with the latest science-based information, which can enhance patient care and public safety. When deciding to work with an RDN it is important to determine if they have licensure, registration, and liability insurance, and what their specialization or area of expertise. Understanding the RDN’s expertise can also help a practice group or physician match their patients with someone that understands their medical conditions or complications, such as diabetes, renal disease, cardiovascular issues, or cancer. This is why it’s important to find an RDN and not just a nutritionist. Someone who does not have the RDN credentials could be anyone claiming to be a nutrition expert, and more importantly would not be legally allowed to be a provider for insurance or submit claims to insurance. The next section looks at these differences.

NUTRITIONIST VS. REGISTERED DIETITIAN NUTRITIONIST

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