PDPM, Malnutrition, & the RD

In acute care facilities, RDs play an essential role in the diagnosing, treating, and documenting of malnutrition appropriately. By helping physicians and nurse practitioners diagnose more quickly and accurately, RDs can earn facilities higher reimbursement for malnutrition care, especially as health care shifts to a patient-driven payment model (PDPM) based on value rather than services. This is another opportunity for RDs to advocate for the importance of their position in acute care settings.

Establishing Malnutrition Criteria
The PDPM doesn’t specify how to define or diagnose malnutrition, so it’s up to facilities and providers to choose their preferred criteria and support that criteria in their progress notes. RDs can help providers choose the most appropriate and validated nutrition screening tool.

Research is in support of the use of the Malnutrition Screening Tool (MST), which consists of two questions related to weight loss and appetite that can be completed by any health professional (including a nurse) when a patient is admitted to a facility. The score can indicate that a patient is at risk of or has a malnutrition diagnosis, requiring referral to the RD for nutrition assessment and intervention.

RDs may choose to use two more comprehensive guidelines to help make the nutrition diagnosis: the American Society for Parenteral and Enteral Nutrition (ASPEN)/Academy of Nutrition and Dietetics (the Academy) criteria and the Global Leadership Initiative on Malnutrition (GLIM) criteria, which complements the ASPEN/Academy criteria. Both use food intake, weight loss, and reduced muscle mass as part of a comprehensive set of criteria used to diagnose malnutrition. Using these criteria, RDs can recommend that a formal diagnosis of malnutrition be made.

RDs in Postacute Care
RDs wear many hats in postacute care, with nutrition assessment, intervention, and monitoring and evaluation key to their role—and this has been occurring long before PDPM, from evaluating a patient’s weight history and food and fluid intake vs needs to meal observation, to determine whether a patient is having difficulty chewing/swallowing, self-feeding, and more.

Nutrition-Focused Physical Exam
Nutrition-focused physical exam (NFPE) is another area in acute care where RDs shine. NFPE evaluates nutrition status based on physical signs and symptoms of malnutrition, helping to determine whether fat, muscle, fluid, and micronutrient status of a patient has diminished due to inflammation, illness, or poor nutrient intake. Using NFPE in combination with an evaluation of weight history and meal intake, the RD can provide support for the malnutrition diagnosis based on the MST, ASPEN/Academy criteria, or GLIM criteria.

The PDPM and Nontherapy Ancillary Component
RDs can play a critical role in helping facilities manage the PDPM under the nontherapy ancillary component. Early assessment and identification of comorbidities such as malnutrition can help maximize payment for resident care. Nutrition interventions (eg, honoring food preferences and adding additional food, fortified food, or oral nutrition supplements) and routine monitoring and evaluation of those interventions will result in proper treatment of malnourished patients. RDs, with support from the interdisciplinary team and facility staff, are critical to ensuring appropriate identification and treatment of residents and patients with malnutrition.

— Becky Dorner, RDN, LD, FAND, is widely known as one of the nation’s leading experts on nutrition and long term health care. Her company, Becky Dorner & Associates, Inc, is a trusted source of valuable continuing education, nutrition resources, and creative solutions. Visit to sign up for free news and information.

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