Academy Comments to HRSA Regarding Isolating Data of RDN Staffing and Utilization

November 13, 2017

Julie Wise
OMB Desk Officer, Health Resources & Services Administration
Office of Management and Budget
725 17th Street, NW
Washington, DC 20503

RE: Information Collection Request Title: Bureau of Primary Health Care Uniform Data System, OMB No. 0915–0193—Revision

Dear Ms. Wise,

The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit comments to the Health Services & Resources Administration (HRSA) regarding the revision of the Bureau of Primary Health Care Uniform Data System (UDS). Representing over 100,000 registered dietitian nutritionists (RDNs)1, nutrition and dietetic technicians, registered (NDTRs), and advanced-degree nutritionists, the Academy is the largest association of nutrition and dietetics professionals in the United States and is committed to improving the nation’s health through food and nutrition across the lifecycle.

The Academy supports collection of UDS data annually as an important means for improving health center performance and operations and reporting overall program accomplishments. Modifications to the UDS tool have the potential to bolster HRSA and health centers' ability to improve care and services, and allocate resources for the many vulnerable populations served.

The Academy recommends that the UDS data collection instrument be updated to specifically isolate nutrition care as a service category. HRSA, as well as individual HRSA-funded health centers, are currently unable to capture valuable nutrition care provided to patients or evaluate the impact of services provided by RDNs on outcomes and costs under the current reporting system. Staffing and utilization of nutrition care provided by RDNs are currently folded under "Other Health Services." Thus, although many Federally Qualified Health Centers (FQHCs) employ RDNs, the ability to measure the care provided is "lost" in the UDS data collection. To rectify this problem, we recommend that HRSA add a new line for nutrition services to the UDS Table 5 to capture and report separate data on program RDN staffing and use.

RDNs across the United States play an integral role within FQHCs to improve the health of the patients served. Populations served by FQHCs suffer from nutrition-related chronic diseases that are positively impacted by nutrition services provided by RDNs. The three most common of these - asthma, diabetes and cardiovascular disease - each have an evidence-based nutrition treatment component.2 Obesity, prediabetes and malnutrition are additional nutrition-related national health epidemics that also impact the populations served by FQHCs.

Medical nutrition therapy (MNT) provided by an RDN is linked to improved clinical outcomes and reduced costs related to physician time, medication use, and hospital admissions for people with obesity, diabetes, disorders of lipid metabolism, and other chronic diseases.3 RDN-delivered lifestyle approach to diabetes and obesity improves diverse indicators of health, including weight, HbA1c, health-related quality of life, use of prescription medications, productivity, and total health care costs.4,5,6

It has been projected that one in three individuals will develop type 2 diabetes by 2050.7 The American Diabetes Association recommends that all individuals with diabetes receive individualized MNT, preferably provided by an RDN. MNT goals are broader than weight loss goals in diabetes care, and nutrition therapy is essential throughout the disease process. The 2016 Standards of Medical Care in Diabetes include recommendations on "tailoring treatment to vulnerable populations with diabetes, including those with food insecurity, cognitive dysfunction, and /or mental illness and HIV," and the importance of addressing differences and disparities.8 RDNs also provide Diabetes Self-Management Training (DSMT) in FQHCs. The ADA recommends DSMT at 4 critical times for pts: 1) with a new diagnosis of diabetes, 2) annually for health maintenance and prevention of complications, 3) when new complicating factors influence self-management, and 4) when transitions in care occur. DSMT is cost effective and has been shown to reduce hospital admissions, improve clinical outcomes, reduce the onset and/or advancement of diabetes complications and improve the quality of life.9

RDN roles often extend beyond the traditional provision of MNT, enabling FQHCs to leverage the value of the RDN as a lower cost provider of preventive services and thereby allowing primary care providers to effectively serve a larger number of patients. RDNs have a strong clinical and counseling background and therefore can effectively provide smoking cessation education, and, when billing incident to the primary care provider, can deliver Medicare’s Intensive Behavioral Therapy (IBT) for Obesity benefit, Annual Wellness Visit, and Chronic Care Management services. RDN services are integral to the Patient Centered Medical Home and emerging health care delivery and payment models and to population health, because RDNs work hand-in-hand with referring providers and multidisciplinary health care team members to deliver coordinated and cost-effective care.

The Academy appreciates the opportunity to comment on the Bureau of Primary Health Care Uniform Data System and strongly urges HRSA to revise the UDS data collection instrument to separately recognize RDN staffing and utilization. As demonstrated, RDNs provide cost-effective nutrition interventions that improve health outcomes and assist FQHCs with meeting desirable improvements in health center performance and operations, and overall program accomplishments.

Thank you for your careful consideration of the Academy's comments on this information collection request. Please contact either Jeanne Blankenship at 312-899-1730 or by email at jblankenship@eatright.org or Marsha Schofield at 312-899-1762 or by email at mschofield@eatright.org with any questions or requests for additional information.

Sincerely,

Jeanne Blankenship, MS, RDN
Vice President
Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics

Marsha Schofield, MS, RD, LD, FAND
Senior Director, Governance
Nutrition Services Coverage
Academy of Nutrition and Dietetics


1 The Academy approved the optional use of the credential "registered dietitian nutritionist (RDN)" by "registered dietitians (RDs)" to more accurately convey who they are and what they do as the nation's food and nutrition experts. The RD and RDN credentials have identical meanings and legal trademark definitions.

2 National Association of Community Health Centers. A Sketch of Community Health Centers. Chart Book December 2014.

3 Academy of Nutrition and Dietetics Evidence Analysis Library. Grade 1 date.

4 Wolf AM, Conaway MR, Crowther JQ, et al. Translating lifestyle intervention to practice in obese patients with type 2 diabetes: Improving Control with Activity and Nutrition (ICAN) study. Diabetes Care. 2004;27:1570–1576.

5 Wolf AM, Siadity M, Yaeger B, Conaway MR, Crowther JQ, Nadler JL, Bovbjerg VE. Effects of lifestyle intervention on health care costs: The ICAN Project. J Am Diet Assoc. 2007;107(8):1365-1373.

6 Wolf AM, Siadaty MS, Crowther JQ, et al. Translating lifestyle intervention on lost productivity and disability: Improving Control with Activity and Nutrition (ICAN). J Occup Environ Med. 2009; 51(2):139–145.

7 Boyle JP, Thompson TJ, Gregg EW, Barker LE, Williamson DF. Projection of the year 2050 burden of diabetes in the US adult population: dynamic modeling of incidence, mortality, and prediabetes prevalence. Popul Health Metr 2010;8:29.

8 American Diabetes Association standards of medical care in diabetes 2016. The Journal of Applied Clinical Research and Education, Diabetes Care. January 2016; 39 (supplement 1): 1-119.

9 Powers MA, Bardsley J, et al. Diabetes Self-Management Education and Support in Type 2 Diabetes: A Joint Position Statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Journal of the Academy of Nutrition and Dietetics. 2015; 115(8):1323-1334.