April 2014 Issue

Virtual Nutrition Counseling
By Lori Zanteson
Today’s Dietitian
Vol. 16 No. 4 P. 42

More dietitians are offering telehealth services for convenience and to meet their clients’ changing needs.

Counseling clients and patients in a private practice, classroom, hospital, or other clinical setting is the most common way in which nutrition professionals provide nutrition counseling services. But due to the rapid advances in technology, more and more dietitians are branching out of the traditional office and clinical setting and are offering virtual nutrition counseling services remotely. They’re counseling clients via cell phone and the Internet, meeting them in local coffee shops and other public venues, and even making house calls.

In this fast-paced digital age, almost everyone stays connected through handheld devices that allow for immediate communication in real time. So it makes sense that cell phones, smartphones, tablets, and other wireless technologies are expanding the ways in which RDs perform their jobs. Technology has made the provision of nutrition counseling more convenient and accessible for both the provider and the client.

Virtual Health Care
Offering virtual health care services, also known as telemedicine or telehealth, isn’t new, as other medical professions already are doing it. Physicians provide remote health care via e-mail, smartphones, and two-way video conferencing. Psychologists and psychiatrists offer virtual mental health services, known as e-therapy, e-counseling, or cyber counseling, over the Internet, through e-mail or video conferencing, or by phone. Patients also have access to telenursing, telepharmacy, and telerehabilitation services.

The growing demand for virtual health care services in these and other professions has prompted many telecommunications companies to begin offering video conferencing services. Vsee.com and Securevideo.com are just a few of the well-established services available, which many health care practitioners use to meet with and counsel clients and patients.

In the context of dietetics, nutrition professionals practice telehealth and telenutrition, which, according to Heather R. Mangieri, MS, RDN, CSSD, LDN, owner and nutrition consultant at Nutrition CheckUp and a spokesperson for the Academy of Nutrition and Dietetics (the Academy), is defined by the Academy Definition of Terms List as follows:

Telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health, and health administration. Telehealth will include both the use of interactive, specialized equipment, for such purposes as health promotion, disease prevention, diagnosis, consultation, therapy, and/or nutrition intervention/plan of care, and non-interactive (or passive) communications, over the Internet, video-conferencing, e-mail or fax lines, and other methods of distance communications for communication of broad-based nutrition information.

Telenutrition involves the interactive use, by a RD or RDN, of electronic information and telecommunications technologies to implement the Nutrition Care Process (nutrition assessment, nutrition diagnosis, nutrition intervention/plan of care, and nutrition monitoring and evaluation) with patients or clients at a remote location, within the provisions of their state licensure as applicable.

Before delving into telenutrition, Mangieri says “Registered dietitians should do their homework before determining if this is an area they want to explore. The Academy of Nutrition and Dietetics offers extensive information on this area of practice, including practice tips.”

Meeting Clients’ Needs
According to Ruth Frechman, MA, RDN, CPT, owner of On the Weigh, a nutrition consulting service in Burbank, California, and a national spokesperson for the Academy, “The best way to counsel clients is the way that best suits their needs to receive information. If a client prefers to stay home and is willing to chat by phone or computer, it makes sense to accommodate them.”

However, beyond a client’s personal preferences, they may have other limitations that prevent them from leaving home, such as a broken-down car or no one available to pick them up after their appointment—both of which can lead to cancelled appointments. “[In many cases], using a virtual service can be a win-win for everyone,” Frechman says.

The option to eliminate a face-to-face appointment is a convenience many people prefer, she says. Virtual nutrition counseling can allow for a quick session between activities or during a lunch break, and it requires fewer adjustments to daily schedules and eliminates commuting time.

Moreover, virtual nutrition counseling enables dietitians to see clients who travel frequently for work or who live in remote areas and wouldn’t be able to commute to a dietitian’s office. Amanda Austin, RDN, CLT, a Michigan-based certified LEAP therapist and food sensitivity specialist, recently counseled a patient who worked out of the country. The patient suffered from migraines, digestive problems, fatigue, heartburn, and other symptoms for more than 10 years. She needed to see a dietitian right away but couldn’t do so in a traditional setting. “She found me, and within 10 days of implementing the dietary recommendations that I provided her, her symptoms were reduced by 66%,” Austin says. “By six weeks, all of her symptoms were gone. If she hadn’t been able to work with me over the phone, there’s no question in my mind that she would still be suffering.”

Susan Linke, MBA, MS, RD, LD, CLT, a certified LEAP therapist and certified LEAP therapist mentor, has an office in Dallas but does most of her counseling virtually. Because Dallas is such a large city, teleconsulting has enabled her to expand her practice by reaching clients who otherwise may spend too much time trying to reach her office. “It can save someone an hour commute if they can schedule a phone consult,” she says. “If they don’t have to dress up to come see me, it saves them even more time.”

The clients Linke counsels in her office often prefer follow-up visits by phone, which usually don’t last one hour like a typical in-person office visit does. Phone calls enable Linke to see more clients and charge less per session. “Clients benefit from that, and I can fit more clients in, so I benefit as well,” she says.

However, the nonverbal physical cues and the absence of eye contact during counseling sessions by phone or audio-only video conferencing isn’t ideal for all clients. Jan Patenaude, RD, CLT, director of medical nutrition at Oxford Biomedical Technologies in the Grand Junction, Colorado, area, says she doesn’t conduct long-distance consults for problems such as eating disorders because making eye contact with the patient and observing the patient are essential.

Clients must be considered on an individual basis to determine whether virtual counseling will be effective. “[Virtual nutrition counseling] isn’t appropriate for every counselor or client, and we need to be good judges of when to refer out to somebody for a face-to-face consult,” she says.

Making House Calls
Lisa Raum, RD, owner of RD To Go, a mobile version of an office-based private practice, makes house calls and provides on-site services in the Richmond, Virginia, area. She says her clients feel more comfortable in their homes than in a clinical setting. “Clinical settings have a clinical feel. The home is a soothing, warm environment that’s more conducive to receiving information,” she says.

And counseling sessions at home are more convenient for clients. Often, they’re scheduled at the end of the day or in the evening when clients are relaxed and not preoccupied with the day’s activities, Raum adds. Also, she invites and encourages family members to join in the conversation at no additional cost. “Nutrition is not specific to the individual,” she says. “There’s an improved likelihood of buy-in when the whole family is involved.”

When Raum is allowed to see her clients’ pantries, she helps them identify healthful foods and shows them how to read food labels. Sometimes she takes clients grocery shopping and helps them choose healthful foods for the week. This positive reinforcement gives them the support they need to make healthful dietary changes.

RD Perks
Virtual and nontraditional nutrition counseling have as many benefits for RDs as for clients. After moving to the rural mountains of Colorado, 30 miles from the nearest small town, Patenaude searched online for work she could do from home. Serendipitously, she found a company looking to help their clients find nutrition services in remote parts of the country. She began working with them and has been providing nutrition counseling by phone for 12 years now.

The ability to work remotely is a huge plus for Patenaude, who often travels between two homes and accompanies her husband on his business trips. “My laptop essentially is my office,” she says. “If I have [my laptop] and a cell phone, I’m in business.”

Counseling by phone enables Patenaude to make her sessions as long or as short as necessary to meet her clients’ needs. When clients meet in a traditional office setting, sessions typically run for a set amount of time, regardless of what clients may need. “It’s easy to do five to 10 quick Q & A consults when a client just has a quick question,” she says. These quick sessions give her time to garden or hike during the day and schedule longer appointments as early as 6 AM or as late as 11 PM if a client lives in a different time zone.

The flexibility of working remotely is a major reason Raum chooses to counsel clients in their homes. “I’m interested in having time to pursue multiple interests and having variety in my day,” she says. Raum also teaches community college courses and is in graduate school pursuing two master’s degrees.

Because of all these activities, she chooses to practice nutrition counseling part-time but says she makes “what many may make full-time.” She believes there’s enough demand for these services that she could increase her client base tremendously if she chose to aggressively market her business.

Money Matters and Legal Issues
For all the advantages virtual and nontraditional nutrition counseling provide, it doesn’t come without challenges. Nutrition counseling, whether virtual or not, is a business, and it requires a business-minded professional to run it effectively. For example, cancellations can be an issue. A house call can take up to four hours of Raum’s day because of the time it takes to drive to the client. If the client cancels while Raum is standing on the doorstep, she suffers a financial loss. Experience has taught her to require all payments in advance. She sends out an electronic invoice, which gives clients 24 hours to cancel their appointment. The client signs it and pays online using PayPal, which is a free payment service.

In addition, many insurance plans don’t cover virtual counseling services, so clients may have to pay out of pocket. If this is the case, not everyone will be able to work with you. Rather than view this as a deterrent, Austin and Raum have found virtual nutrition counseling to be a positive experience. Raum works with clients who want and value her services, so payment isn’t an issue. Austin’s clients can pay for bundled services in advance, which makes them more committed to her program. “Commitment means better outcomes,” she says.

Then there are the legal issues surrounding virtual nutrition counseling. Because telehealth is a relatively new field, it’s critical that RDs become familiar with HIPAA and its privacy and security rules. The HIPAA Privacy Rule protects the privacy of individually identifiable health information, and the HIPAA Security Rule sets national standards for the security of electronic protected health information.

Nutrition professionals must take special care when counseling clients via e-mail and the Internet and in public settings such as coffee shops or other eateries, where conversations may be overheard, potentially compromising a client’s privacy. When it comes to cell phone and Internet use, dietitians must ensure they have a secure Internet connection when speaking with clients and practice security measures, such as using passwords and installing firewalls on devices.

While there are health care practitioners who use Skype, it isn’t considered HIPAA compliant, so nutrition professionals shouldn’t use it to counsel clients. There’s been much concern about using Skype to provide health care services due to the implementation of the HIPAA Final Rule in March 2013, which enhances a patient’s privacy protections, provides individuals new rights to their health information, and strengthens the government’s ability to enforce the law. Those who don’t abide by the HIPAA Final Rule can be fined up to $1.5 million per violation.

The good news is that there are many HIPAA-compliant services available that health care practitioners can use, such as VSee, which offers video conferencing. It also enables practitioners to use documents to assist the counseling process while ensuring a secure connection. Subscribers to this service can connect from a desktop computer, laptop, or 3G/4G cellular phone. SecureVideo, Vidyo, and Talk to an Expert are similar HIPAA-compliant services.

In addition to being HIPAA compliant, Frechman advises dietitians interested in telehealth to follow the rules in their individual states, which may differ from state to state. For example, in California, Frechman says RDs are required to get a referral from a medical doctor to provide medical nutrition therapy, although it isn’t necessary when offering weight-loss and wellness services.

When general nutrition education becomes medical nutrition therapy, it’s important for dietitians to know and follow their state’s licensure laws. Counseling outside state boundaries for a house call or even by phone or videoconference may violate state licensure laws, though some states will allow RDs to apply for reciprocity to practice in another state.

An Emerging Trend
“Telehealth is an emerging area of practice for many health care professionals,” Mangieri says. “Regulations, policies, and standards are in flux until a gold standard becomes consensus, but that hasn’t stopped technology from entering into mainstream practice.” Dietitians who are considering adding a telehealth or telenutrition service to their practice should use the Scope of Practice Decision Tool offered online by the Academy, Manigieri says.

Virtual nutrition counseling is ripe with potential, but it’s a relatively new field and there’s room for improvement, Mangieri adds. It would be easier if there were “more online documents and communications that allowed the RD to remain HIPAA compliant,” Patenaude says.

Frechman says she’d like to see more insurance reimbursement in this area. “Thinking outside the box with creative ways of doing business will ultimately benefit clients,” she says. “In order for new ideas to take place, insurance reimbursement has to be in agreement with innovation.”

Despite some of the challenges and legal issues concerning virtual nutrition counseling, it continues to be a growing trend. Dietitians say the advantages far outweigh the disadvantages, and they plan to continue counseling clients and patients by phone and over the Internet or in an otherwise nontraditional manner. They embrace the potential for increasing the accessibility of their services to meet their needs and ultimately the needs of their clients.

— Lori Zanteson is a food, nutrition, and health writer based in southern California.

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