Dietitian working methods

 

Legal framework:

In the Netherlands, the profession of dietician is regulated under Article 34 of the Individual Health Care Professions Act (BIG Act). The BIG Act regulates training for the profession, and contains a description of the expertise required. It states that the right to use the title of “dietician” is reserved for those who have graduated with a degree in Nutrition and Dietetics at the higher occupational education level in the Netherlands (Hoger Beroepsonderwijs, or HBO).

 

Quality:

The Quality Register for Allied Health Professionals (KP) [Kwaliteitsregister Paramedici] is a voluntary registry for a large number of allied health professional groups, including dieticians. A one-time entry is made in the Quality Register indicating whether a dietician meets the educational requirements of the BIG Act. After that, periodically (every 5 years) a record is made indicating whether a dietician’s knowledge and experience is up to date. The registered dietician retains his or her quality registration only if the requirements set by the occupational group have been met. The KP can be consulted by anyone, from (potential) patients to health care insurance companies or colleagues in health care practice. To consult the registry, one needs the dietician’s KP number (registration number) or name and birth date. For more information, see www.kwaliteitsregisterparamedici.nl.

 

Dietary treatment:

Dietary treatment covers not only not only nutrition-related disorders but also disorders, limitations and participation problems that can be impacted by nutrition and diet; i.e., all of the activities with the aim of helping prevent, eliminate, reduce or compensate for such disorders. Dietary treatment is given on medical grounds. At the foundation of dietary treatment are multi- or monodisciplinary dietary treatment guidelines. Ideally it is an evidence-based approach. The dietician bases her advice on (national) nutritional guidelines, provided that they are consistent with the dietary restrictions in the diet concerned.

 

For many people, the advice to go on a special diet has far-reaching implications. Not being able or allowed to eat “normally” is a considerable intrusion into one’s daily life and eating habits, and requires understanding and guidance. In order for the patient to stay on the diet and achieve the desired result, it is essential that the dietician work with the patient’s life circumstances. The dietician therefore customizes the diet to the patient. Additionally, motivating and stimulating the patient to make the desired behavioral changes is a major aspect of dietary treatment.

 

Dietary treatment consists of the following activities:

• Entry: Recording personal data, medical data, additional information (such as the patient’s communication limitations), etc.
• Dietetic examination: Includes investigating the patient’s expectations, reasons for seeking medical care, past medical history, current lab results, as well as metabolic data, psychological/social information, eating habits and nutritional status
• Dietetic diagnosis: Analyzing the data obtained and identifying the core problem
• Treatment plan: Determining the treatment goals and drawing up the treatment plan, informing the referring practitioner
• Implementing the treatment
• Evaluating treatment results and goals
• Terminating the treatment: Recording the end data and the reason for terminating treatment, making follow-up appointments, informing the referring practitioner

 

Treatment time:

The treatment time consists of the time that the dietician spends carrying out the activities listed under “Dietary treatment.” This means the time spent in direct contact with patients (face to face) during individual consultations or house calls and during group activities (dietary counseling in groups, courses), as well as the patient-related time spent when not in the presence of the patient.

 

The treatment time is rounded off and billed in quarter-hour units. (Travel time required for a house call is not included in treatment time.)

 

Treatment time is grouped into six levels, which we call “treatment levels.” A treatment level is the care level as defined in The Doctor’s Reference Guide to Dietetics, multiplied by individualized special care factors. If there are no special care factors, the treatment level is the same as the care level.

 

The following is an overview:

 

Treatment Level / Care Level
	1	2	3	4	5	6
Treatment time	10 quarter-hour increments	20 quarter-hour increments	30 quarter-hour increments	40 quarter-hour increments	50 quarter-hour increments	See appendix

 

 

Follow-up treatment:

Some indications benefit from  annual follow-up of 1 to 3 consultations. This involves no more than 10 quarter hours per year. The diseases to which this applies are marked with an asterisk (*) in The Doctor’s Reference Guide to Dietetics.

 

Information on Care Level 6:

In the treatment of the disabled and in psychiatry, there are a number of specific conditions that occur only in these populations. They require considerable treatment time, which is difficult to quantify in the first 5 treatment levels. Without being exhaustive, we can indicate that this involves:

• patients with a mental or physical disability
• psychiatric patients with problems such as eating disorders. They require very intensive treatment, which can be quantified on an annual basis, but may last many years. We place such disorders under care level 6. Treatment now usually is handled by specialists, because basic insurance generally does not cover a claim of 4 treatment hours.

 

Calculating a patient’s treatment level

The treatment level refers to the total time required to treat the patient. This is the time needed for high quality, responsible dietetic treatment. The treatment level is determined by the medical diagnosis (care level) in combination with any factors that impact the treatment time (special care factors). These look like this:

 

Care level + special care factor = treatment level

 

Explanation:

The care level is determined by the dietician based on the medical diagnosis. This is the base treatment time that is included with each of the disease profiles in The Doctor’s Reference Guide to Dietetics.

 

The special care factors are individual patient-related factors that require more treatment time than the care level. They come to light in the dietetic assessment.

 

The total of these equals the ultimate treatment level. A step-by-step plan has been created for this.

 

 

Step-by-step plan

 

Step	Action	Calculation of the Treatment Level (circle the correct scores)
1	Identify the medical diagnosis and the associated care level. (To do so, consult The Doctor’s Reference Guide to Dietetics)	1 / 2 / 3 / 4 / 5
2	Identify any special care factors   -          multiple diagnoses -          communication disabilities (e.g. deafness, blindness, need for an interpretor, language and speech problems) -          child -          house call (excl. travel time/surcharge for house call) -          there are no special care factors	+1 +1   +1 +1 +0   (max 2)
3	Identify whether this is a patient with a mental disability or a psychiatric patient (in association with a physical condition)?   -          yes -          no	+2 +0
4	Calculate the treatment level:   This is the sum of the scores from steps 1, 2 and 3.	(Total, max. 5)

 

Explanation:

• When there are no special care factors, the care level equals the treatment level.
• When there is a multiple diagnosis, the care level is based on the diagnosis with the highest care level. This determines the score for step 1.
• When there is one special care factor, 1 point is added.
• When there are two or more special care factors, 3 points are added.
• For a physical disorder in a psychiatric patient or a mentally disabled patient, 2 points are always added.
• In practice, the care level (Step 1) is almost never increased by more than 2 points.
• Also in practice, the number of treatment hours does not seem to increase over treatment level 5.
• The calculation applies to new patients. For follow-up treatment time (in a consecutive year), less time is needed. This has not been calculated.
• Patients who come under treatment level 6 are not in this system.