P r o f e s s i o a l P r a c t i c e Ethical & Professioal Obligatios for RDs Whe Completig SDA Forms Deborah Cohe, M.HSc., RD Practice Advisor & Policy Aalyst cohed@cdo.o.ca 416-598-1725/ 800-668-4990, ext. 225 Whe completig SDA forms, RDs must esure that cliets meet the eligibility criteria at the time the form is filled out ad that there is documeted proof to cofirm the eed for SDA fudig. If a cliet is ieligible for fudig, RDs ca work with their team to explore other optios. The purpose of the Special Diet Allowace (SDA) is to help cliets with the costs related to the dietary maagemet of a medical coditio. Followig govermet social assistace cutbacks i 2000, SDA applicatios sigificatly icreased. The Miistry of Commuity ad Social Services (MCSS) estimated a excess of 25 millio dollars aually as a result of icreased applicatios for SDA fudig. The 2009 Aual Report of the Office of the Auditor Geeral of Otario oted at least oe orgaizatio which held cliics where heath care professioals automatically completed forms that etitled recipiets to the maximum $250/moth cotributio. 1 The audit showed that oe of the 318 health care professioals who siged the 1,000 applicatios from this cliic was resposible for completig 20% of the applicatios. As a result of these ad other abuses oted i the 2009 Audit, the MCSS revamped the program to iclude ew accoutability measures ad to comply with the Huma Rights Tribual of Otario order i the Ball decisio (February 2010). The ew SDA program took effect April 1, 2011. While the itet of health care professioals who abused the program may have bee oble, exploitig the SDA program s vulerabilities for cliets who are i fiacial eed is uethical ad uprofessioal. Professioals must ot sacrifice hoesty ad itegrity to meet cliet eeds. Professioal decisios must respect the purpose of the SDA program ad other govermet-sposored programs. This article gives a summary of the SDA program chages ad outlies what the Miistry expects of Registered Dietitias who are resposible for sigig the SDA applicatio forms. INCREASED ACCOUNTABILITY The ew accoutability ehacemets to the SDA iclude a ew applicatio form. O the ew form, health care professioals must sig a declaratio that they believe the iformatio o the form is true. There are also improved methods for obtaiig iformatio ad trackig health care professioals who are fillig out the forms. As of April 1, 2011, applicatios based o the previous form will ot be processed. Aother key ehacemet to the SDA program is that cliets must coset to the access of their medical records by the MCSS. Without this coset, which is part of the form, their applicatio will ot be processed. If a RD has siged the SDA form, the coset gives the MCSS legal authority to review the RD s record if there is reaso to questio the iformatio o the applicatio. résumé SPRING 2011 College of Dietitias of Otario 5
SDA ASSESSMENT AND DOCUMENTATION OBLIGATIONS The MCSS expects that health professioals sigig a form have appropriately assessed a cliet for special diets ad that they have adequately documeted their assessmet. Whe determiig eligibility for the SDA program, RDs must rely o curret assessmet iformatio ad oly sig forms for cliets who meet the eligibility criteria i keepig with the purpose of the program. Assessmet Whe determiig eligibility for the SDA program, RDs are resposible for: Determiig the reliability of the assessmet iformatio; Collectig additioal assessmet iformatio as required; ad Makig cliical judgmets about the ature of the utritio disorder ad the utritio care pla. Prior to 2005, the SDA program was ot tightly cotrolled ad the schedule of diet types o the applicatio form was fairly geeral. The program review resulted i chages to the list of eligible medical coditios. There are ow 29 medical coditios o the ew SDA schedule versus 43 o the previous oe. These chages resulted from the work of a medical advisory pael which was established to esure there was evidece to support the icreased cost of maagig a coditio with a special diet. I additio to sigig the applicatio form, a RD must cofirm each medical coditio by iitiallig relevat sectios of the form. This is to verify that the RD cofirms the diagosis of each coditio. If the MCSS feels that there is a highly improbable combiatio of coditios idicated o a cliet s SDA form, the RD may be flagged ad the miistry may ask a third-party medical professioal to commet. Documetatio RDs are also accoutable for documetig their decisio to support a cliet s eligibility for SDA fudig. They may gather the assessmet iformatio themselves or they may rely o iformatio collected by MDs, RNs ad other Need to Kow The revised SDA program demads icreased accoutability from RDs for the assessmet ad supportig documetatio. Cliets must meet the SDA program s eligibility criteria at the time of applicatio. RDs must have clear documetatio that cofirms a cliet s medical coditio ad resultat eed for the SDA. RDs sigig a applicatio which icludes false iformatio may be reported to the College for professioal miscoduct or charged uder the Crimial Code of Caada for a offese. professioals who are part of the cliet s care team. The documetatio must iclude: Their assessmet iformatio ad cliical decisios; Verificatio of a cliet s medical diagosis/coditio; Evidece that cliets meet the specific eligibility criteria required at the time of the SDA applicatio; ad That a SDA form was filled out for a particular cliet. CONSEQUENCES FOR MAKING A FALSE STATEMENT RDs eed to esure they are ot makig ay false or misleadig statemets i their practice, ad this icludes the completio of SDA forms. If the documetatio to cofirm a cliet s medical diagosis or coditio is ot adequate, or if there is reaso to believe that the RD is abusig the SDA program, a complait may be filed with the College for committig a act of professioal miscoduct 2 or the RD may be charged for a offece uder the Crimial Code of Caada. 3 SEEK SUPPORT It is the hope of the MCSS that o a go-forward basis all health professioals will act with itegrity ad ot abuse the SDA program. If a cliet eeds further social assistace, RDs should refer them appropriately to other programs ad resources withi the cliet s commuity, rather tha try to take advatage of the curret SDA program. 6 College of Dietitias of Otario résumé SPRING 2011
RDs who eed support i maagig patiets who are upset that they are losig moey, ca refer to other professioals (e.g., social work) who may be better equipped to hadle icome security. RDs are also free to cotact the College with iquiries about ethical practice relatig to SDA fudig, professioal miscoduct ad fidigs of fraud. The College would like to thak the Miistry of Commuity ad Social Services for providig us with iformatio about the recet amedmets to the Special Diet Allowace (SDA) program. 1. Office of the Auditor Geeral of Otario, 2009 Aual Report (p 363-4). Available from: http://www.auditor.o.ca/e/reports_e/e09/311e09.pdf 2. There are two provisios withi the Professioal Miscoduct Regulatio that would apply to RDs fillig out SDA forms. It is cosidered professioal miscoduct for RDs to be: 23. Falsifyig a record relatig to the member s practice. 25. Sigig or issuig, i the member s professioal capacity, a documet that the member kows cotais a false or misleadig statemet. 3. A ote o the SDA form states: The Crimial Code of Caada ss 380 (1) states that everyoe who, by deceit, falsehood or other fraudulet meas, whether or ot it is a false pretece withi the meaig of this Act, defrauds the public or ay perso, whether ascertaied or ot, of ay property, moey or valuable security or ay service is guilty of a offece. The Otario Works Act, (1991) 70/Otario Disability Support Program Act (1997), s59, states a perso that kowigly aids or abets aother perso to obtai or receive assistace to which the other perso is ot etitled uder this Act ad the regulatios is guilty of a offece. RESOURCES CDO ad Richard Steiecke, LLB. Jurisprudece Hadbook for Dietitias i Otario, (Olie Versio 2010) Itroductio to Professioalism, Chapter 1, p. 1. at www.cdo.o.ca > Resources > Publicatios MCSS Fact Sheet: Chages to the Special Diet Allowace What Health Care Professioals Need to Kow. ad Sample Form (February 2011), at www.cdo.o.ca > Resources > Practice Stadards & Resources > Work Place Issues Dietitias of Caada. Code of Ethics for the Dietetic Professio i Caada (1999). College of Dietitias of Otario, Professioal Miscoduct Regulatio (1991). Practice Scearios - RD Obligatios ad the SDA Program SCENARIO 1 PRE & POST-NATAL NUTRITIONAL ALLOWANCE Lily is a Public Health Dietitia workig i a pre/post-atal utritio program for low-icome wome. She has bee regularly seeig a post-atal cliet i the program who is breastfeedig well ad plas to do so util her baby is at least 6-9 moths of age. Durig a recet appoitmet, the cliet asks Lily to fill out the SDA form to obtai fudig for isufficiet/ cotraidicated lactatio. Lily has previously filled out the Pregacy & Breast Feedig Nutritioal Allowace (P&BFNA) form which gives pregat wome o social assistace fudig throughout their pregacy ad for up to 12 moths after the birth of the child if the mother is breastfeedig. Lily is aware of the fiacial eed of the mother, ad i attempt to assist her cliet, she fills out the SDA applicatio as requested i the hope that the MCSS will ot otice her cliet s dual applicatios for fudig. Lily based her decisio o takig a cliet-cetred approach to provide maximum fudig for someoe i eed. Are there ay cocers with Lily s actios? There are two programs that provide fudig to pregat ad breastfeedig mothers o social assistace i Otario: 1. Pregacy & Breast Feedig Nutritioal Allowace (P&BFNA): This program provides fudig to mothers who are pregat ad up to 12 moths after the child s birth if breastfeedig. The goal of the program is to esure adequate utritio of the mother durig pregacy ad lactatio. 2. Special Diet Allowace Isufficiet/Cotraidicated Lactatio: This program provides fudig to mothers who are uable to breastfeed due to isufficiet supply of breast milk or whe breastfeedig is cotraidicated (e.g., due to a résumé SPRING 2011 College of Dietitias of Otario 7
medical coditio). The goal of this program is to provide fudig to purchase ifat formula to esure the baby receives adequate utritio i the first 12 moths. As the P&BFNA program provides fudig for the mother ad the SDA program for the baby, the MCSS does ot permit cliets to receive fudig from both programs cocurretly. Despite the fact that Lily is aware that her cliet is i fiacial eed, professioal ad ethical resposibilities as outlied i the Code of Ethics for the Dietetic Professio i Caada ad the College s Professioal Miscoduct Regulatio require her to follow the SDA program s eligibility criteria. Lily must always practice i a hoest ad ethical maer ad esure that she is followig the program s eligibility criteria ad avoid providig false or misleadig iformatio whe fillig out fudig forms for cliets. Lily ca explai to the cliet that fudig eligibility is oly permissible from oe of the programs ad ecourage her cliet to carry o breast feedig as the P&BFNA fudig ca cotiue util the baby is 12 moths. Where there are other ways to assist the cliet with additioal fudig, Lily ca refer her cliet to these resources. SCENARIO 2: SDA FUNDING DISCONTINUED At the time of origial publicatioof the Sprig 2011 résumé ewsletter the MCSS s criteria for uiteded weight loss was as per Sceario 2. I late July 2011, the MCSS revised their policies ad set the College a update o their criteria for the uiteded weight loss category. Please refer to page 6 of the Summer 2011 résumé for updated details. Jack is a RD who has bee seeig a cliet for a umber of years. This cliet has bee receivig ogoig SDA fudig for uiteded weight loss related to HIV. The cliet has made cosiderable progress over the years due to ogoig utritioal cousellig from Jack ad daily itake of high-protei high-calorie oral supplemets that have bee made possible by the SDA program fudig. The cliet has bee able to maitai his weight for the past 6 moths ad while he is ot yet at his ideal body weight, his uiteded weight loss is curretly ot greater tha 5%. As the MCSS fact sheet (see Resources, p. 7) idicates, all curret SDA recipiets will have to qualify uder the ew Need to Kow Professioal ad ethical resposibilities as outlied i the Code of Ethics for the Dietetic Professio i Caada ad the College s Professioal Miscoduct Regulatio require RDs to follow the SDA program s eligibility criteria ad avoid providig false or misleadig iformatio whe fillig out fudig forms for cliets. program. Curret recipiets receivig fudig uder the old program must submit a ew form siged by a health professioal for a eligible coditio by July 31, 2011 or their SDA paymets will be discotiued. Jack reviews the MCSS fact sheet ad the ew SDA form ad determies that his cliet is ow ieligible to receive SDA fudig. Whe Jack commuicates this iformatio, the cliet expresses grave cocers that a lack of fudig will result i subsequet weight loss as he will be uable to afford the oral supplemets that have helped him gai ad maitai his curret weight. The cliet begs ad pleads with Jack to sig the form. Jack respectfully refuses, but woders if he s made the right decisio. Accordig to the Code of Ethics for the Dietetic Professio i Caada, RDs must always maitai itegrity ad empathy i their professioal practice. I doig so, Jack feels somewhat coflicted i his decisio ot to sig the SDA form for this cliet. From oe perspective, he recogizes that he is ethically ad professioally obligated to follow the SDA eligibility criteria; if a cliet does meet the requiremets for fudig the he is uable to sig the form. If Jack were to fill out the form for this cliet, it could be cosidered falsifyig a record or providig false or misleadig iformatio as outlied i the College s Professioal Miscoduct Regulatio. This is because the cliet had ot experieced a greater tha 5% uiteded weight loss at the time Jack completed the SDA form. From aother perspective, Jack is empathetic ad recogizes that without the SDA fudig, his cliet caot afford the oral supplemets that have helped gai ad maitai his weight. He fears that the cliet s utritioal status ad health coditio will declie due to this lack of fudig. Jack is cocered that his cliet s weight will decrease over time ad withi 6-12 moths his cliet will suffer from a greater tha 5% uiteded weight loss. 8 College of Dietitias of Otario résumé SPRING 2011
PROFESSIONAL PRACTICE I a attempt to assist his cliet further, Jack meets with the health care team to braistorm optios for fudig outside of the SDA program. The team explores optios for other programs i the commuity that may be able to provide fudig for the cliet to purchase oral supplemets. Jack presets these optios to his cliet, sets up a meetig with a social worker ad they obtai cotiued fudig for the cliet to purchase the oral supplemets. This sceario presets a rather optimistic outcome for outside fudig sources for the cliet. If additioal fudig was uavailable ad at a later date the cliet suffered a uitetioal weight loss of greater tha 5%, he would the be eligible for SDA fudig ad be permitted to sig the form. Although the latter outcome is ot ideal due to the potetial health risk to the cliet, the MCSS s itet for the SDA program is to treat a existig coditio, ot for prevetative meas. Where outside fudig opportuities are uavailable, Jack would have to esure that his cliet meets the eligibility criteria for SDA fudig before he is able to sig the form. Professioal Practice Questio RD Documetatio i a IPC Eviromet RDS NEED TO ASK THEMSELVES IF ANYONE WERE TO EVER REVIEW MY DOCUMENTATION, WOULD THE INFORMATION CLEARLY TELL THE STORY ABOUT THE CLIENT S NUTRITION CARE? Curretly our hospital is i the process of developig assessmet forms for the ew electroic documetatio system. The goal is to have oe (large) assessmet form for all allied health professioals, each professio havig their ow desigated area. Istead of repeatig assessmet iformatio such as past medical history, medicatios, etc., health professios will have check boxes idicatig they have reviewed iformatio. Would this meet chartig guidelies for RDs or do we eed to iclude spaces i the utritio care sectio for this iformatio? Geerally, there is o eed to repeat iformatio that exists i the chart elsewhere whe coductig utritio assessmets or follow-up care. Repeatig iformatio is ot a very efficiet use of a RD s time ad may also risk trascriptio errors for medicatio doses, lab values, etc. However, whe RDs refer to relevat iformatio elsewhere, such as past medical history or medicatios, they must commet o the sigificat iformatio they relied upo i their ow utritio care plaig ad moitorig otes. It is also importat to use professioal judgmet whe relyig o documetatio made by other team members. For example, if the weight documeted for a patiet seems too low or too high, a RD may wish to have the weight re-doe for verificatio. A weight discrepacy might idicate a error i the weight trascriptio or perhaps that the scale eeds to be serviced or calibrated. Orgaizatios have differet systems ad elemets to documet utritio care effectively. Some have a specific documetatio style or culture that RDs should follow. Others have specific policies that outlie documetatio methods such as chartig by exceptio ad chartig by referece. Regardless of the system or method chose, the documetatio should provide a clear picture of the utritio assessmet, plaig, itervetio ad evaluatio that have occurred i carig for a cliet. RDs eed to ask themselves If ayoe were to ever review my documetatio, would the iformatio clearly tell the story about the cliet s utritio care? COLLEGE RESOURCES: College of Dietitias of Otario. Record Keepig Guidelies for Registered Dietitias i Otario. http://www.cdo.o.ca/e/pdf/publicatios/guidelies /Record%20Keepig%20Guide%20ENG%20SEPTEMBE R%2024%20PM.pdf Richard Steiecke, LL.B. ad CDO, Jurisprudece Hadbook for Dietitias i Otario, Chapter 8, Record Keepig, p. 87. http://www.cdo.o.ca/e/pdf/publicatios/books/juri sprudece%20hadbook.pdf College of Dietitias of Otario. Draft Proposed Regulatio: Records Relatig to Members' Practices: http://www.cdo.o.ca/e/pdf/bylawsregs/proposedr résumé SPRING 2011 College of Dietitias of Otario 9