16 August 2010

Submission from the Dietitians Association of Australia
to the Productivity Commission: Disability Care and Support

Context
The Dietitians Association of Australia (DAA) is pleased to provide a response to the Productivity Commission on their inquiry ‘Disability Care and Support’. The Commission’s issues paper clearly outlines the current issues facing Australians with a disability and raises many valid questions. DAA agrees that the current system could be improved through the development of a national scheme. DAA agrees a range of support options and services should be provided including individualised approaches and supports a focus on early intervention. DAA is particularly interested in high quality nutrition and dietetic services being accessible to all Australians with or without disabilities and this demand has implications for the required workforce to deliver these services.

Contact Details
Contact person:	Kate Paul
Position:		Professional Services Dietitian
Address:		1/8 Phipps Close, Deakin ACT 2600

Key Recommendations
1.		That Australians with disabilities have timely, equitable access to adequate and nationally consistent, evidence based nutrition and dietetic services. 
2.	That Accredited Practising Dietitians (APDs) are considered part of the essential health professional workforce required to deliver disability services, namely evidence based nutrition and dietetic services.
3.	That accreditation standards and/ or quality frameworks across the disability sector provide incentive for organisations to undertake routine nutrition risk screening and deliver evidence based nutrition and dietetic services.
4.	That organisation level and preventative nutrition services for Australians with disabilities are adequately funded. Activities such as establishing routine nutrition risk screening systems; menu assessment; health promotion; education and training of support staff/ community based care providers on fundamental nutrition principles, accurate client weighing; feeding skills. 
5.	That individualised medical nutrition therapy for Australians with disabilities is adequately funded. For example, expansion of government funded, community based services and expansion or adaptation of the Medicare Chronic Disease Management items. 
6.	That the Commonwealth monitor and report on nutritional status of Australians with disabilities. 
Introduction
DAA is responding to the following key issues/questions from the issues paper:

1.	Services/Workforce: a) The kinds of services that need to be included as part of a national disability scheme. b) What types of skills and workers are required ?c) How should service providers be monitored and regulated with respect to quality, outcomes and cost effectiveness?
2.	Assessment and Early Intervention: a) How should the long term care and support needs of individuals be assessed? b) What are the appropriate features of assessment tools? c)Who should use assessment tools?d) Ways of achieving early intervention

1.	Services/Workforce
a)The kinds of services that need to be included as part of a national disability scheme.

Nutritional status of Australians with disabilities 
People with disabilities, like the wider population, experience issues with food and nutrition. Nutrition status largely determines quality of life, independence and overall health. Nutrition should be regarded as an integral part of health and well-being in a holistic evaluation of health. Access to food is a fundamental human right1. Some people have special, individualised dietary needs. Conditions and issues which may be experienced by Australians with disabilities include but are not limited to:
•	Malnutrition / underweight / unintentional weight loss
•	Overweight and obesity
•	Swallowing difficulty requiring tube feeding or texture modified foods and fluids
•	Food allergies and intolerances
•	Poor food preparation knowledge
•	Chronic diseases, e.g. diabetes.
•	High blood pressure
•	High cholesterol

Poor nutritional status has significant consequences including increased hospital admissions, increased lengths of stay and increased risk of pressure ulcers. People with disabilities require access to evidence based nutrition and dietetic services.

Equity
Currently access to nutrition and dietetic services for Australians with disabilities is inconsistent. There is inequity between states and territories and between regions. One example is access to Home Enteral Nutrition (HEN) services and equipment, as described in detail in a 2009 DAA submission2. Australians with disabilities should have timely, equitable access to adequate nationally consistent, evidence based nutrition and dietetic services.

b)What types of skills and workers are required ?

Accredited Practising Dietitians are the experts in nutrition
Accredited Practising Dietitians (APDs) are recognised professionals with sound university qualifications and specialised skills to provide expert nutrition and dietary advice. APDs undertake ongoing professional development and comply with the DAA guidelines for best practice. They are committed to the DAA Code of Professional Conduct3 and Statement of Ethical Practice4, and to providing quality service. APD is the only national credential recognised by the Australian Government, Medicare, the Department of Veterans Affairs (DVA) and most private health funds as the quality standard for nutrition and dietetics services in Australia. It is a recognised trademark protected by law. 

APDs are qualified to provide tailored medical nutrition therapy for individuals and their families. To meet the individual needs of people, APDs also work at an organisation or systemic level, for example, assessment of a group home menu to ensure it meets the nutritional requirements of the residents. See Appendix 1 for a list of nutrition and dietetic activities at both individual and organisational levels.

Service and workforce gaps
There are inadequate numbers of dietitians currently employed in the public health system to meet existing service demands from Australians with disabilities with nutrition needs. Last year a NSW nutrition policy evaluation project identified that ‘lack of access to suitable dietetic services was a major concern for community accommodation staff and external stakeholders’5. 

In addition, there are inadequate subsidised services available to Australians with disabilities. The current chronic disease Medicare items are inadequate to meet service demands. Australians with a chronic disease can access five visits to allied health practitioners per year. These limited item numbers are currently shared across all allied health professionals. People with a chronic disease often require multiple visits with a number of allied health service providers to achieve improved health outcomes and better management of their chronic condition/s. A recent study focusing on private practice dietitians’ experiences of the Medicare Chronic Disease Management items concluded that “eligible patients have limited access to low-cost dietetic services” and also found that dietitians’ acceptance of the program was low6.DAA calls for expansion of the Medicare Chronic Disease Management program. DAA understands that the MBS is currently under review including the development of a quality framework and will be contributing to this process.

c) How should service providers be monitored and regulated with respect to quality, outcomes and cost effectiveness?

Quality and outcomes monitoring
DAA recently made a submission on the National Quality Framework for Disability Services in Australia7. DAA supports the attempt to achieve a nationally consistent framework and the evidence based approach of the draft National Standards. Nutrition guidance for the disability sector should be included in the supporting documents to the National Standards.

The quality of nutrition and dietetic services could be measured referring to the individual service provider holding the Accredited Practising Dietitian (APD) credential. This credential is the marker of quality accepted by Medicare and DVA. 

DAA also recommends that nutrition related quality/ clinical indicators, such as weight, incidence of diabetes and number of choking incidents be considered in a monitoring program. Medical and allied health staff should be consulted to develop appropriate indicators.

2. Assessment and Early Intervention
 a) How should the long term care and support needs of individuals be assessed? 

Nutrition screening is required
DAA supports provision of services based on individual needs. In order to identify individuals requiring nutrition and dietetic services, a nutrition risk screening process and referral pathway must be implemented. Regular screening of all new and ongoing clients would help to ensure early identification of nutrition issues and early dietary intervention as needed. 

b) What are the appropriate features of assessment tools? 
Screening tools should be validated, that is they need to be accurate in the setting for which they were designed and should be implemented appropriately. There are numerous validated nutrition risk screening tools available. Common features include questions regarding recent weight loss, BMI, appetite and recent dietary intake. APDs are best placed to advise on appropriate tools. 

Dietitians use an individualised approach to assessment of an individual’s dietary intake and nutrition requirements. Assessment tools used by dietitians commonly include medical history, signs and symptoms, weight, height, biochemistry, diet history and social/lifestyle factors.
 
c) Who should use assessment tools?
In relation to nutrition risk screening, various people can implement the screening process provided they have received appropraite training, e.g. allied health/ nutrition assistants, admin staff, carers, doctors and nurses.

An Accredited Practising Dietitian (APD) is best placed to implement a nutrition assessment to assess an individual’s dietary intake and nutrition requirements.

d) Ways of achieving early intervention
Nutrition screening should be part of any initial assessment process to identify support services required by people with disabilities, their families and carers. 

References
1.	Dietitians Association of Australia. June 2009. Submission to the National Human Rights Consultation. Available at http://www.daa.asn.au/index.asp?pageID=2145870837 
2.	Dietitians Association of Australia. May 2009. Submission to the Australian Health Ministers Advisory Council. Available at http://www.daa.asn.au/index.asp?pageID=2145870837 
3.	Dietitians Association of Australia. May 2006. Code of Professional Conduct. Available at http://www.daa.asn.au/index.asp?pageID=2145833461 
4.	Dietitians Association of Australia. May 2006. Statement of Ethical Practice. Available at http://www.daa.asn.au/index.asp?pageID=2145833461 
5.	Centre for Disability Studies, University of Sydney. Evaluation of the Ensuring Good Nutrition Policy. Executive Summary. May 2009. Available from http://www.dadhc.nsw.gov.au/dadhc/ 
6.	Dietitians Association of Australia. June 2010. Submission to the National Quality Framework Project Team. Revision of the National Standards for Disability Services. Available at http://www.daa.asn.au/index.asp?pageID=2145878624  
7.	Cant, R. Today’s Profession: Views and practices of private practice dietitians re Medicare Chronic Disease management program. Nutr Diet. 2010; (67):77-83.
Appendix
Services that may be provided by dietitians in relation to Australians with disabilities:
Organisation level
•	Development of organisation food and nutrition policy
•	Development of streamlined systems/models of care e.g. weight monitoring, nutrition risk screening, nutrition referral pathways, dietary intake reporting. 
•	Education of nursing and food service staff, volunteers and carers on nutrition issues such as nutrition risk screening, food safety, recipe formulation (e.g. high energy, modified texture), height and weight measuring techniques, dietary intake monitoring, appropriate nutrition supplement use.
•	Community organisation/hospital/disability group home menu assessment, evaluation and advice to ensure the menu meets appropriate nutritional recommendations.
•	Quality improvement projects, e.g. evaluation of nutrition screening and interventions; plate wastage surveys; food satisfaction surveys. 
•	Health Promotion, e.g. advise organisations on activities to promote nutritional health and wellbeing.
•	Advise organisations on how to establish a meal time environment that promotes good nutrition and adequate fluid consumption.

Individual level
•	Individualised dietetic interventions, such as medical nutrition therapy. 
•	Participation in multidisciplinary team care meetings with GPs, nurses, care staff and other allied health professionals to discuss and develop plans for individuals.
•	Regular review of individuals with nasogastric or percutaneous endoscopic gastrostomy feeding regimens.
•	Monitoring of individuals’ weight status over time.
•	Assist individuals in the community to order appropriate nutritional supplements.