Unit 4: In-Patient Counseling

Amy Bridges, MS, RD, LDN

Kaplan University Instructor

Chapter 10

Inpatient Counseling and The Continuum of

Care

Benefits of Clinical Nutrition Services in Acute Care

Early detection of nutrition-related problems and appropriate nutrition interventions are effective in helping the patient recover more quickly and decrease the length of stayMNT is an integral part of disease prevention, treatment, and recovery, and is necessary to maintain quality of care and achieve cost savings

Changes in Health Care Climate

Health care has been increasingly affected by regulatory changes, increased market competition for patients & hospital mergers and affiliationsAlready the US has spent approx 15.3% of its gross domestic product in 2003 on medical care & it may increase to 18.7% by the year 2014The opportunities to provide inpatient nutrition counseling continue to decrease as patients are discharged from acute care settings sooner & sicker

Survival Nutrition Counseling

Patients and physicians expect (and accrediting agencies require) that appropriate nutrition education takes place, if possible in the hospital setting so the patient and his or her family do not aggravate, but instead encourage improvement of the patient’s physical stateSurvival nutrition counseling may include basic types of foods to limit or avoid, portion sizes, and meal frequency

Value of Screening in Patient Outcomes and Cost

ContainmentA nutrition screening program is an inexpensive method to streamline clinical nutrition care and identify those patients at nutritional risk who are most likely to benefit from special nutrition intervention during their hospital stay

Considerations for Inpatient Counseling

When Time is Short…

The typical abbreviated, but essential need to know information used in inpatient counseling involves:– Establishing behavioral diagnoses– Assessing what the client wants to

learn

Practice Guidelines, Protocols, and Nutrition Care Process

Nutrition practice guidelines provide systematically developed assistance to dietetic practitionersThe Nutrition Care Model identified the components of what dietetic practitioners do in the Nutrition Care ProcessDietitians should evaluate the outcomes of nutrition interventions so that cost effectiveness and cost benefits can be delineated

Locations for Counseling Have Been Changing

As hospital stays become shorter, clinical dietitians need to change where they counsel patients.Several other factors also have contributed to shifts from inpatient acute care to outpatient acute care to outpatient ambulatory care. Factors to be considered are:– The aging population– Advances in medical technology– Increased health care costs– Increased focus on prevention and wellness– The AIDS epidemic– The coexistence of malnutrition with chronic disease

Quality Improvement

Continuous Quality Improvement (CQI) is the process of continual information feedback, evaluation, and improvement of delivery systems and outcomes based on objectively measured quality parametersQuality management is synonymous with a commitment to continuous improvement

Quality Improvement can be Determined from Structure, Process, or

Outcomes

Structure consists of tangible or organizational components involved in patient careProcess denoted what actions are carried out in the provision of careOutcomes are the effects on the health status of the patient

Impact of Regulatory Requirements

The basic functions of external controls in health care are to:– Offer formal standards– Survey the providers of care– Assess the degree of compliance with

those standards– Impose sanctions or incentives in

response to reported deviations from the standard

Documentation of Patient Care

The primary purpose of documentation is to direct the care of the client, especially when multiple disciplines are involved, and to record the client’s status or response to the interventions

Nutrition Plan of Care

The typical components of the plan of care include:– Problem statement– Outcome criteria and goals– Interventions– Evaluation

Why Charge for Inpatient Clinical Services?

Diagnosis-specific coding for reimbursement is vital to documenting alterations in nutritional statusAlthough dietetic specific codes have been proposed, current systems in the majority of acute care settings dictate that documentation by dietetic practitioners use medical-specific coding

Chapter 11

Group Therapy

Group Therapy

Where individuals with similar nutrition-related problems come together to work through those problemsGroup therapy members discover that the group has the capacity to support and love, and to provide a release for anger or problem solvingGroup therapy usually attracts a population at less nutritional risk than those who require intense, individualized care

Confrontation Group

A type of group therapy used to confront group members with honest views about themselves, which can be disconcerting and even traumatic for some individuals

Group Process

The series of actions or operations that lead growth in a group therapy setting– Humor breaks the tension and helps people share

common pleasurable moments– Sensitivity to the needs and feelings of others in the

group– Participation by every member of the group is the

backbone of good group process– Experience is the key to learning in the small group

setting – Risk should be minimized– Openness should be encouraged

Group Process Continued

Step 1: Establish a productive counselor-participant relationshipStep 2: Balance the facilitator generated and group generated informationStep 3: Design problem-solving strategiesStep 4: Provide the opportunity for group members to practice new skillsStep 5: Use positive role models and good pacing to keep the group motivatedStep 6: Ask for evaluation and feedback

Advantages of Groups

TimesavingCost EffectiveMore social and peer supportMembers feel accepted, loved and not aloneMore viewpoints and problem-solving opportunitiesSharing with others can help with coping or changing thoughts or behaviors

Disadvantages of Groups

May be uncomfortable to disclose information to so manyMay get lost in a group and not deal with problemsMay get bored because discussion not on topics of interest to the memberSessions may be productive or not, depending upon personalities involved

Why People Join or Leave Groups

Factors that increase the attractiveness of the group:– Cooperation– Interaction– Size– Success

Interactive Techniques to Try

Posting on a flip chart of blackboardRole-playingSociodrama or psychodramaReplay dramaRole reversalThe buddy system

Potential Problems with Groups

The sluggish groupThe hostile groupThe timid memberThe domineering memberSilence serves a purpose

Chapter 15Empowerment Counseling

- Using the Feminist Therapy Perspective

Feminist Therapy

Eclectic, endorsing theoretical positions that encourage empowerment and self-growth, but also recognizes a woman’s more interdependent way of living and relating

Women and Weight Issues

The feminist viewpoint believes that those painful personal experiences arise from the social setting into which females are born and within which they develop to become adult women

The fact that compulsive eating and eating disorders are overwhelmingly a woman’s problem suggest that it has less to do with individual experiences and more to do with the social context in which girls and women live their lives

Two Guiding Assumptions of Feminist Therapy

Feminist therapy has two guiding assumptions:

1. The woman is highly influenced by her environment

2. The woman is still responsible for her own life and the decisions she makes in her life

First Assumption: Look to the Environment

The primary source of women’s pathology is social, not personal; external, not internal

Second Guiding Assumption: Each Individual Must Still Take

Responsibility

The importance of this second assumption is that the focus on environmental stress as a major source of pathology is not used as an avenue of escape from individual responsibility

Where Does the Nondiet Fit?

Originated from the 1970s women’s movement when people started recognizing that women were treated differently than men regarding weight & health issuesOver the past 30 years this movement has developed into what is referred to as Health At Every Size (HAES). The basic conceptual framework includes acceptance of:– The natural diversity in body shape and size– The ineffectiveness and dangers of dieting– The importance of relaxed eating in response to internal

body cues– The critical contribution of social, emotional, and spiritual,

as well as physical, factors to health and happiness