Academy Urges HRSA to Revise Health Center Patient Survey

September 23, 2019

Lisa Wright-Solomon
HRSA Information Collection Clearance Officer
Room 14N136B
5600 Fishers Lane
Rockville, Maryland 20857

RE: Information Collection Request Title: Health Center Patient Survey, OMB No. 0915–0368—Reinstatement

Dear Ms. Wright-Solomon,

The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit comments to the Health Services & Resources Administration (HRSA) regarding reinstatement of the Health Center Patient Survey (HCPS), OMB No. 0915-0368. Representing over 107,000 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 practitioners committed to accelerating improvements in global health and well-being through food and nutrition.

The Academy supports surveying patients of HRSA-supported health centers to assess access to and utilization of services and satisfaction with health care received and, specifically, nutrition services. We urge HRSA to leverage this opportunity to revise the survey tool to better evaluate access to valuable medical nutrition therapy (MNT)2 and other nutrition interventions provided by RDNs to patients receiving care at these health centers and their satisfaction with these services. Such data may assist HRSA with policy, funding and planning decisions that will ultimately increase access to these vital and cost-effective services.

Currently, Registered Dietitian Nutritionists' (RDNs) services are inconsistently represented in HRSA, Bureau of Primary Health Care programs as they fall under the category of "additional health services,"3 leaving it up to each health center to determine if and how to address the nutrition needs of the population served. As a result, many vulnerable people do not receive the most effective and appropriate preventive and primary care. Populations served by these health centers suffer from nutrition-related chronic diseases that are positively impacted by nutrition services provided by RDNs. The four most common of these - hypertension, high cholesterol, asthma, and diabetes - each have an evidence-based nutrition treatment component.4 Obesity, prediabetes and malnutrition are additional nutrition-related national health epidemics that also impact the populations served.

Data show that MNT provided by RDNs for prevention and disease management improves patient health and increases productivity and satisfaction levels through decreased doctor visits, fewer hospitalizations and re-admissions, and reduced prescription drug use. RDNs' expertise and extensive training enable them to deliver coordinated, cost-effective care for a variety of chronic diseases, including obesity, hypertension, diabetes, disorders of lipid metabolism, HIV infection, unintended weight loss in older adults and chronic kidney disease.5 RDNs are recognized as the most qualified food and nutrition experts by the National Academy of Medicine (formerly IOM), most physicians, numerous clinical guidelines, and as evidenced by recommendations of the United States Preventive Services Task Force (USPSTF), providing nutrition care more effectively at a lower cost than physicians, nurse practitioners, and physician assistants.6

While the current HCPS instrument includes questions regarding nutrition and food security, the Academy offers the following recommendations for revisions to the survey tool to enhance the quality, utility and clarity of the information to be collected:

  1. Module D: Conditions
    1. CON4: Recommend including a response option of "I don't know" as many individuals do not weigh themselves on a regular basis. If forced to provide a response, the validity is likely to be diminished beyond that already compromised by self-reported data.
    2. CON7: For all questions about weight status and weight management, recommend HRSA staff consult resources from the UConn Rudd Center for Food Policy & Obesity,7 if they have not already done so, to ensure the survey questions are free from weight bias.
    3. CON6b: Add to SHOWCARD CON1 "Met with a Registered Dietitian Nutritionist"
    4. CON8a6:
      1. Change "nutritionist" to "registered dietitian nutritionist" as the former term lacks a uniform definition.
      2. Add a question, like other ones in the survey, exploring reasons why the patient did not visit with a registered dietitian nutritionist.
    5. CON9c: Recommend moving "personal trainer" to the end of the question to read "In the past 12 months, did you seek help from a dietitian, nutritionist, doctor or other health professional or a personal trainer to help {you/NAME} lose weight?" While we recognize that patients/the public may receive weight loss advice from personal trainers, only nationally certified personal trainers have the proper training to address the nutrition aspects of weight management. We feel it is inappropriate to send the message via this question that personal trainers should be the first resource for assistance with weight loss.
    6. CONF5e section: Add 2 questions about (1) referral to a registered dietitian nutritionist for medical nutrition therapy (MNT) and (2) a referral for diabetes self-management training (DSMT) to teach how to take care of their diabetes. Provision of MNT by RDNs and DSMT is part of the standards of care for all individuals with diabetes.8,9
    7. For all nutrition-related chronic conditions (i.e., high blood pressure, high cholesterol, asthma), add a question about referral to a registered dietitian nutritionist.
  2. Module G: Health Center Services
    1. HEA7d: Add to list of basic needs "adequate access to food." While Module O includes questions about patient ability to afford food, adding this question will help to assess whether the health center staff screened for food security in this vulnerable population.

The Academy appreciates the opportunity to comment on reinstatement of the Health Center Patient Survey (HCPS), OMB No. 0915-0368 and strongly urges HRSA to revise the survey instrument to enhance the quality and utility of the information collected about nutrition services to inform future policy, funding and planning decisions to improve access to such vital and cost-effective services provided by RDNs.

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 has 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 Medical nutrition therapy (MNT) is an evidence-based application of the Nutrition Care Process. The provision of MNT (to a patient/client) may include one or more of the following: nutrition assessment/reassessment, nutrition diagnosis, nutrition intervention and nutrition monitoring and evaluation that typically results in the prevention, delay or management of diseases and/or conditions. Academy of Nutrition and Dietetics’ Definition of Terms list updated May 2017. Accessed September 5, 2019.

3 https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section254b&num=0&edition=prelim. Accessed September 15, 2019.

4 National Association of Community Health Centers. Community Health Centers Chart Book. January 2019.

5 Academy of Nutrition and Dietetics Evidence Analysis Library. Medical Nutrition Therapy Effectiveness Systematic Review 2009, 2013-2015. Accessed September 15, 2019.

6 Committee on Nutrition Services for Medicare Beneficiaries. "The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population." Washington, DC: Food and Nutrition Board, Institute of Medicine; January 1, 2000 (published).

7 http://www.uconnruddcenter.org/weight-bias-stigma

8 American Diabetes Association. 5. Lifestyle management: Standards of Medical Care in Diabetesd2019. Diabetes Care 2019;42(Suppl. 1):S46–S60

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.