Dietitians in Home Care
Many dietitians are unfamiliar with home care. They likely never learned about this career opportunity in their didactic education or completed rotations in home care during their dietetic internship. But home care is a unique and ever-expanding opportunity for dietitians. Home care is different in all the best ways- you see the patient in their environment. You get to know them, their families, and their stories on a completely different level. You get to work with the patient exactly where they are at.
Where is Home?
Most dietitians working in home care provide services in all settings, with the exception of hospitals and skilled nursing facilities. Many patients live independently in their home- this may be an apartment, a house, a retirement community, an RV, a trailer, or even a yurt in the woods. Other patients may live in an assisted living facility or medical/adult foster home. Home can be many places.
While the home care patient can be any age, a majority are older adults. These patients served by home care may live alone or they may live with a significant other. They may live independently but may have caregivers providing episodic or around the clock care. They may be receiving Meals on Wheels to provide nutritious meals and to support them in staying at home. They may live with their children or even with a caring friend. Each patient and home are truly unique.
Opportunities in Home Care
Who are these dietitians who are currently going into the home? Where do they work and what opportunities currently exist in the home care setting? There are many different opportunities in home care ranging from Medicare’s Home Health Care Program to the Department of Veteran Affair’s Home Based Primary Care Program to dietitians in private practice.
Medicare’s Home Health Care
The Center for Medicare and Medicaid Services offers home health services by certified home health agencies under the Medicare home health benefit. Common services provided through home health include wound care, nutrition therapy, injections, and monitoring of serious illnesses (1). A home health team often includes nurses, physical therapists, speech therapists, occupational therapist, and dietitians.
Home health is not intended to be a long-term program. It’s often used to bridge the gap between when a patient is no longer clinically indicated for being in a hospital, but isn’t quite well enough to be at home independently. Home health fixes specific problems then discharges a patient as soon as their problem has resolved. Home health agencies may employ dietitians full time, part time, or on a per diem basis.
Veteran Affair’s Home Based Primary Care Program
Home Based Primary Care (HBPC) is a program under the Department of Veteran Affairs. HBPC provides longitudinal, comprehensive medical care in the homes of Veterans with complex, chronic disease. The goal of HBPC is to maximize function, minimize institutionalization, reduce hospitalizations, support caregivers, and enhance quality of life (2). Veteran’s in HBPC are often served long-term just like they would be followed in an outpatient setting.
The HBPC interdisciplinary team includes a medical director, primary care provider, nurses, social worker, rehabilitation therapist, dietitian, pharmacist, and mental health professional. Of note, the dietitian is a required member of the team. A full-time dietitian is indicated for every 95-125 Veterans enrolled in an HBPC program. The dietitian is a core member of the team and responsible for overall nutrition care of patients enrolled in HBPC (2).
A study was conducted by HBPC dietitians in 2017 looking at the prevalence of malnutrition in Veterans enrolled in HBPC. The study used the Mini Nutrition Assessment (MNA) short form to screen for malnutrition in 2,252 Veterans age 65 and over. They found that 15% of enrolled Veterans screened positive for malnutrition and 40.3% were at risk for malnutrition. This study highlighted the importance of dietitians in home care as an opportunity to prevent and treat malnutrition thereby reducing overall healthcare costs (3).
Other Opportunities in Home Care
While Medicare and the Department of Veteran Affair’s have some of the biggest programs in home care, there are other opportunities for dietitians. The Home and Community Based Services program under Medicaid includes nutrition-related services including nutrition counseling (4). The tricky part with this program is how the states use the waivers; all states conduct business a little different. While the option is there, whether or not these waivers are used specifically for nutrition counseling is completely up to the individual state.
There are also opportunities for dietitians working with home infusion services where the dietitian manages nutrition support. More often the dietitian is consulted over the phone, but there are opportunities for home visits. And then you have entrepreneurs and private practice dietitians who are paving the way into the home. There are innovative people and programs all over the place, so you never know where an opportunity may arise for a dietitian in home care.
Future Opportunities in Home Care
The model the Department of Veteran Affairs uses for HBPC has been very successful in decreasing cost, reducing hospitalizations, and improving patient satisfaction (5). The program has been so successful that it has been trialed for Medicare beneficiaries under the Independence at Home (IAH) Demonstration. The goal of the IAH trail was to test the effectiveness of delivering comprehensive primary care services at home and if doing so improves care for Medicare beneficiaries (6).
The Medicare Home Care program is short term addressing specific problems while IAH is long term addressing comprehensive medical care. IAH has been trailed in 14 different sites and has shown considerable promise in Medicare; reducing hospitalizations and readmissions and saving money (7).
In 2017 a bill was introduced to amend title XVII of the Social Security Act providing a permanent IAH program under the Medicare Program. While the bill did not specifically include dietitians as require IAH team members, it includes “other health staff as appropriate” (8). This leaves opportunities for dietitians to be on home care teams in this program if it is implemented in the future.
What is the current update of the IAH? The 2017 bill was never passed, but instead in February of 2018 the Bipartisan Budget Act authorized a two-year extension to the IAH demonstration. The trial is anticipated to end on December 31, 2020 (6). It is anticipated that another bill will then come forward, opening the door for future opportunities in health care.
What does a home care dietitian do?
The role of the home care dietitian varies by program and service. Since the primary patient population served through home care is the older adult, the main role of the dietitian is to aid in keeping aging seniors at home. This is done through the prevention and treatment of malnutrition, improving nutrition status, and improving quality of life. Dietitians have many skills to improve the nutrition status of home care patients.
The dietitian typically completes a comprehensive assessment including information on how food is purchased and prepared, food insecurity, difficulty chewing and swallowing, the nutrition focused physical exam, and a recall of food and fluids. They round out the nutrition care process with a diagnosis, intervention, and determining steps for monitoring and evaluation.
One of the great things about home care is that the “no show” rate is pretty low. Unlike a clinic where the client comes to you, you go to them. Of course, there may be instances where the patient is unexpectedly ill or out of the home- but for the most part you will see your patient during their scheduled time.
Safety in the home
When considering home care as a potential job opportunity, people are often concerned about the safety aspect of going into a stranger’s home. This is absolutely an area of concern; there are elements in the home you cannot control and often people in the home, aside from the patient, that would not be there in a clinical setting.
Any good home care program should have an admission process that evaluates for safety concerns and sets up safety expectations prior to making any home visit. Are there animals in the home? Are there weapons? Who else will be in the home? Does anyone smoke in the home? Guidelines can be set to ensure animals are put away, weapons are locked and kept in a safe, smoking is not done during home visits, etc.
When in the home, the clinician should always wear good shoes, be between the patient and exit, have an escape plan, carry a phone, speak up with concerns, and always trust your gut instinct to leave if you are feeling unsafe. The reality is this should be done in a clinical setting as well. Safety is an important topic regardless of setting and shouldn’t shy you away from this field, as long as the proper precautions are taken.
Wrapping it up
Home care is rewarding career for dietitians and will likely continue to grow with the aging of our population and desire to help keep older adults at home and out of institutions. The future of geriatric nutrition care is truly at home.
REFERENCES
1. What’s home health care? Medicare website. https://www.medicare.gov/what-medicare-covers/whats-home-health-care. Accessed May 21, 2019.
2. VHA Directive 1411: Home-Based Primary Care Special Population Patient Aligned Care Team Program. Department of Veteran Affairs. June 5, 2017. Revised September 20, 2017.
3. Win AZ, Ceresa C, Arnold K, Allison TA. High prevalence of malnutrition among elderly veterans in home based primary care. The journal of nutrition, health & aging. 2017 Jun 1;21(6):610-3.
4. Niedert K, Carlson M. Nutrition Care of the Older Adult: A Handbook for Nutrition Throughout the Continuum of Care. 3rd ed. Chicago, IL: Academy of Nutrition and Dietetics; 2016.
5. Edes T, Kinosian B, Vuckovic NH, Olivia Nichols L, Mary Becker M, Hossain M. Better access, quality, and cost for clinically complex veterans with home‐based primary care. Journal of the American Geriatrics Society. 2014 Oct;62(10):1954-61.
6. Independence at Home Demonstration. Centers for Medicare & Medicaid Services website. https://innovation.cms.gov/initiatives/independence-at-home/. Accessed May 21, 2019.
7. Taler G, Boling P, Kinosian B. Primary Care in the Home: The Independence at Home Demonstration. In: Primary Care for Older Adults 2018 (pp. 143-157). Springer, Cham.
8. Independence at Home website. http://www.iahnow.org. Accessed May 21, 2019.
