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Golden Opportunity — The Demand for RDs in Assisted Living
By Lynn Grieger, RD, CDE
Today’s Dietitian
Vol. 8 No. 8 P. 40

Dietitians with expertise in food system management are prime candidates to fill the nutrition services gap in today’s assisted living facilities.

Blame it on the Baby Boomers. Those are the folks driving the boom in assisted living, according to the Assisted Living Federation of America (ALFA), which defines assisted living as “combining housing, support services, and healthcare as needed for independent seniors looking for customized assistance, benefits that enrich their lives, and maintaining connections with family.”1 Also known as residential care facilities, adult congregate living facilities, continuing care retirement communities, personal care homes, retirement care homes for adults, boarding homes, and community residences, they all have one thing in common: They’re not your typical long-term care facility.

More than 1 million Americans currently reside in assisted living facilities (ALFs). Most facilities have 25 to 120 residences, ranging from a single room to a full-size apartment.1 The two most important distinguishing characteristics of ALFs compared with skilled nursing facilities are the cost and atmosphere. Assisted living bills itself as a lower-cost, more residential, and homelike option for seniors who need some assistance with daily living.

A Jigsaw Puzzle of Regulations
Each state develops its own regulations for ALFs, including nutrition, foodservice, and sanitation guidelines. Shirley Chao, MS, RD, LDN, director of nutrition service at the Massachusetts Executive Office of Elder Affairs, is widely recognized as the leader in researching nutrition services in assisted living. In an article in the Fall 2004 issue of The Journal of the American Society on Aging titled “Food and Nutrition Services in Assisted Living Facilities: Boon or Big Disappointment for Elder Nutrition?” coauthors Chao and Johanna Dwyer, DSc, RD, professor of medicine and nutrition science at Tufts University, note, “Compared to nutrition services in nursing homes and hospitals, provisions for these services in ALFs often seem to be an afterthought, and there remains little consensus on what codified and uniform standards for nutrition services are necessary and appropriate in these settings.”2

According to Amy Nickerson, MS, RD, CD, senior planner with the Vermont Department of Disabilities, Aging and Independent Living, “the net is cast broadly” in regard to nutrition standards. Using Vermont as an example of one state’s guidelines, the regulations for residential care homes are designed to foster personal independence on the part of residents and a homelike environment. Vermont includes guidelines for regular and therapeutic menus, healthy meal patterns, adequate fluid intake, meal service, sanitation, and food safety. The ALFs and residential care homes in Vermont are subject to an annual review by the state Division of Licensing and Protection, which also oversees nursing homes and home health agencies.3

Valerie K. Smith, RD, LD, who consults with ALFs in Maryland and the District of Columbia, notes, “In many areas, assisted [living facilities] want an initial nutrition assessment but often lack the resources to provide adequate follow-up on those that you see as high risk.” On the positive side, she finds that because residents in ALFs are not critically ill patients, they are willing and eager to learn because they know the consequences of the diseases they face and understand that eating habits play a vital role in maintaining their health.

What the Research Shows
In 2003, Chao published data in The Journal of Nutrition for the Elderly from a survey of state regulations governing nutrition in ALFs to discover criteria for foodservice, general nutrition service, and therapeutic nutrition service. She used data from the National Academy for State Healthy Policy’s survey of state licensing agencies, as well as follow-up phone calls, to obtain information from all 50 states.4

In Chao’s evaluation, foodservice regulations were assessed on criteria in six areas: food handling, food safety, standardized purchasing requirements, the use of standardized recipes, qualifications of foodservice personnel, and requirements for in-service education for foodservice workers. Each criterion was scored 1 if present and 0 if absent, with a maximum score of 6.4

General nutrition standards were evaluated in five areas: menus meeting specified standards for menu planning, standards for recording meal consumption, nutrition assessment, nutrition education, and standards specifying the preparation of menus for the usual house diets be supervised or evaluated by an RD.4

Therapeutic nutrition services were scored on two criteria: whether the state required that ALFs provide therapeutic diets and whether RDs were required to review these menus, and whether the facility provided medical nutrition therapy and diet modifications as specified in the nutrition care plan.4

The median overall score was 4, and the mean was 4.2 ± 2.5 out of a perfect score of 13. Forty-five out of 50 states had some relevant nutrition and/or foodservice regulations. Only 28% (n = 14) of the states had regulations mentioning more than six criteria. Out of a maximum score of 6 for foodservice regulations, the median score was 1 and the mean was 1.4 ± 1.6. Forty-two percent (n = 21) had no foodservice regulations and only 12% (n = 6) had regulations mentioning more than four of these criteria. For general nutrition services, the median score was 1 and the mean was 1.4 ± 0.9 out of a maximum score of 5. Out of a maximum score of 2 on therapeutic nutrition services, the median score was 2 and the mean was 1.4 ± 0.8. More than 80% of the states (n = 40) required that ALFs provide therapeutic diets. Sixty percent (n = 30) required that RDs review menus and the menus meet the therapeutic needs specified in the residents’ care plans.4

RDs in the Trenches
Marilyn Ferguson-Wolf, MA, RD, CD, has been a consultant to long-term care facilities and ALFs for 26 years with Dietitian Consulting Services, LLC. She is the current CD-HCF liaison to the American Health Care Association, a nonprofit group that represents more than 10,000 ALF providers, with a goal of improving standards of service in these facilities. Ferguson-Wolf is not aware of any dietetic practice group resources specific to ALFs and notes that it’s essential for RDs to consult their individual state regulations. She uses the American Dietetic Association’s (ADA) position paper on liberalized diets, along with nutrition assessment and food safety and sanitation programs, in her work with ALFs, emphasizing the need to remember that “this is the person’s home, and food should be provided in a homelike setting.”

Lisa Monti, MS, RD, consults with various ALFs in northern New Jersey. She draws on her extensive background in long-term care to market her knowledge and expertise to the facilities. She notes that she needs to train the facility on how to best use an RD in areas such as monitoring weight gain and loss, hydration, bowel function, and consistency changes in diets.

Issues Regarding Lack of Nutrition Services in ALFs
Chao says she has not seen any significant changes in nutrition services in ALFs in the past three years. She mentions two main issues with this lack of nutrition services. First is the myth that older people should eat whatever they want and be happy. That goes along with the general feeling that healthy foods aren’t appealing. The second issue she mentions is the perception that only healthy people live in ALFs, so nutrition services aren’t a crucial part of their care.

But Chao sees a possible silver lining in these thunderclouds. Her current research is trying to establish a consensus on quality indicators from a panel of national experts who specialize in health, aging, nutrition, and assisted living. The data suggest that these experts prefer a hybrid model that combines the restaurant/resort, medical/health, and home models to best meet all the residents’ needs. One of the most important benefits of this survey is that researchers told Chao’s group that this is the first time they realized food and nutrition services can play such an important role in promoting the resident’s quality of life in assisted living.

An Open Opportunity for Nutrition Professionals
Nickerson believes the market is wide open for nutrition professionals to market themselves to ALFs, especially those that follow the hotel model. She finds that older adults are savvy about food and nutrition and believes they will begin to demand nutrition services in ALFs. The Baby Boomer generation understands that RDs are a reliable and knowledgeable source of nutrition information. Nickerson encourages RDs to creatively market their skills in menu development, nutrition assessment and counseling, and promoting health through nutrition changes.

Nancy Wellman, PhD, RD, professor and director of the National Resource Center on Nutrition, Physical Activity and Aging at Florida International University, strongly believes that food and nutrition matter at any age. Since ALFs serve residents who live there for years at a time, it’s crucial to provide food that is tasty and nutritious and ensure residents eat that food. She promotes the ADA’s position paper on liberalized diets as an essential tool for ALFs.

Wellman sees an opportunity to improve the overall quality of care in ALFs by increasing the amount of nutrition expertise in these facilities. She notes that at a minimum, there should be plans in place for nutrition screening to identify nutrition risk within a short time of admission; nutrition assessment of those at high risk; and development, monitoring, and reevaluation of nutrition care plans throughout the stay at the ALF.

Chris Kallas, RD, LDN, is one of four RDs who co-own MyRDtoGo (www.myrdtogo.com), a team of registered and licensed dietitians with more than 75 years of combined experience in food, nutrition, and healthcare-related fields who have consulted to more than 100 healthcare facilities in Florida, including ALFs. Kallas’ group works with ALFs as small as six people in a home to larger institutions. They provide a range of services, including menu development and review, food safety and sanitation training, resident assessment and nutrition care planning, and employee inservices. Kallas believes RDs can develop a niche working in assisted living. She notes that due to a rise in the cost of skilled nursing care and the emphasis on aging in place, ALFs are becoming a more attractive option for both consumers and providers.

Chao notes that familiarity with the food system management, such as purchasing, cost saving, and culinary art, is very important for nutrition professionals looking to work with ALFs. Dietitians should market themselves as experts in good nutrition, tasty foods, and cost efficiency.

The Future
Wellman says today’s hospitals are the intensive care units of the past; nursing homes are yesterday’s hospitals; ALFs are morphing into nursing homes; and home and community-based care are the future “nursing homes without walls.” Just as RDs play integral roles in hospitals and nursing homes, says Wellman, they will become just as valuable to ALFs and older adults living in their own homes in the future. How they get there—and when—is the big question.

— Lynn Grieger, RD, CDE, is in private practice in southwestern Vermont and the Healthy Eating Expert at www.ivillage.com.

24-hour supervision; three meals per day in a group dining room; and a range of services that promote the quality of life and independence of the individual, such as:

• personal care services (eg, help with bathing, dressing, toileting);

• medication management, or assistance with self-administration of medicine;

• social services;

• supervision and assistance for persons with Alzheimer’s or other dementias and disabilities;

• recreational and spiritual activities;

• exercise and wellness programs;

• laundry and linen service;

• housekeeping and maintenance; and

• arrangements for transportation.

— Source: American Health Care Association, National Center for Assisted Living, www.longtermcareliving.com/planning_ahead/assisted/assisted1.htm

Dominant Themes for ALFs2
• Restaurant/resort theme: allows food selection from a menu, features generous portions in attractive surroundings, and has a social atmosphere. Challenges: special diets and assistance with eating may be neglected or downplayed.

• Medial/health theme: accommodate therapeutic diets, special snacks, and modified food textures. Challenges: adequate consideration of social and psychological aspects of food and the eating environment.

• Home-style theme: informality, independence, and easy socialization. Challenges: health concerns are minimized or neglected.

References
1. Bright Outlook for Assisted Living Industry. May 13, 2005. Available at: http://www.alfa.org/i4a/pages/Index.cfm?pageID=3419. Accessed May 23, 2006.

2. Chao S, Dwyer J. Food and nutrition services in assisted living facilities: Boon or big disappointment for elder nutrition? The Journal of the American Society on Aging. Fall 2004.

3. Assisted Living Residence Licensing Regulations. Agency of Human Services, Department of Aging and Disabilities, Division of Licensing and Protection, Vermont. Effective March 15, 2003. Available at: http://www.dad.state.vt.us/Regulations/AssistedLivingRegsFinal.pdf. Accessed June 2, 2006.

4. Chao S, Hagisava V, Mollica R, et al. Time for assessment of nutrition services in assisted living facilities. J Nutr Elder. 2003;23(1):41-55.