Older adults who reside in nursing facilities tend to be frail and to have multiple comorbidities, increased risk of unintended weight loss, and protein energy malnutrition. Approximately 5.8% of nursing facility residents in the United States receive enteral feedings. The prevalence is higher for residents with cognitive impairment, ranging from 18% to 34%. In cognitively impaired residents, the majority of tube feeding placements occur in the acute care setting and result in significant use of additional healthcare resources and high postinsertion mortality rates within 60 days of insertion. Nursing facilities must abide by state and federal regulations and undergo stringent survey evaluation while balancing complex decisions related to initial placement of feeding tubes. Informed choice, resident-centered care decisions, and the role of advance directives are essential in the decision-making process. In nursing facilities, it is often the registered dietitian who alerts the healthcare team to determine whether a feeding tube is appropriate. Once a tube is placed, healthcare practitioners must make careful decisions related to ordering, administering, and monitoring enteral nutrition (EN) delivery; adequacy of nutritional content; tolerance to feedings; monitoring for potential complications; and the possibility of return to oral feeding or, conversely, the decision to discontinue feedings. Further evidence-based research is needed to document effectiveness, along with research to support positive outcomes for residents in nursing facilities who receive EN. Optimal care requires careful coordination and an interdisciplinary approach across the continuum of care and between caregivers within the individual nursing facility.
In a climate of change, the elevation of post-acute and long-term care (PALTC) services offered through community-based settings has optimized health care delivery. With the population age increasing, there is a growing need for community-based and residential care services, including for older inmates in the prison system. The Dietetics in Health Care Communities Dietetic Practice Group, with guidance from the Academy of Nutrition and Dietetics Quality Management Committee, has updated the Standards of Practice (SOP) and Standards of Professional Performance (SOPP), which describe three levels of practice (competent, proficient, and expert) for registered dietitian nutritionists (RDNs) working in PALTC nutrition. The SOP uses the Nutrition Care Process and clinical workflow elements for care and management of clients/residents in PALTC settings (eg, long-term acute care hospitals, skilled nursing facilities, inpatient rehabilitation facilities, home health agencies, hospice, assisted living facilities, and corrections facilities). The SOPP describes six domains of professional performance: Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources. Within the SOP and SOPP standards, specific indicators provide measurable action statements that illustrate how the standards apply to practice. The SOP and SOPP are complementary resources for RDNs providing nutrition care and services for individuals receiving PALTC services, or in other PALTC nutrition-related areas, including research. The SOP and SOPP provide RDNs with a self-evaluation guide for assuring competence, identifying knowledge and skills to enhance expertise and advance level of practice in PALTC nutrition.
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