Private Practice with a Focus on Eating Disorder Treatment - PowerPoint Presentation

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Private Practice with a Focus on Eating Disorder Treatment

Nicole Lefever, MS RDN LDN

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Intro- Nicole in a Nutshell

ED Treatment Experience

Remuda Ranch

Private Practice Experience

Mid Atlantic Nutrition Specialists, LLC

Disordered Eating

Pediatrics

PCOS

Other Nutrition Experience

Bariatrics & Weight Management

Lancaster General Health

Heart of Lancaster Regional Medical Center

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Now it’s your turn….

Brand New RDNs?

Outpatient nutrition counseling in a hospital or clinic setting?

Private Practice RDNs?

Want to be a private practice RDN, but haven’t taken the leap yet?

RDNs who don’t want to touch eating disorder treatment with a 10 foot pole?

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Objectives for Today

Overview of Private Practice- is it for you?

Basics of treating clients with eating disorders

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Private Practice

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You might be a private practice RDN if…

You love the idea of getting paid for empowering clients to change their lives

You have a “the sky’s the limit” mentality

You aren’t scared to take risks

You can handle uncertainty with income and benefits

You are ready to be the boss (and the billing specialist, and the receptionist, and the janitor…)

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PROS & CONS

PROS

Set your own hoursUnlimited earning potentialLimited Red TapeYOU are the decision maker

CONS

You do EVERYTHING

PTO? What’s that?

Limited checks & balances

Healthcare benefits, etc.

Professional Isolation

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Consider when you’re getting started…

Physical LocationPrices/RatesReimbursement- insurance vs. self payReferral SourcesSpecialties

Hours/Schedule

Marketing

Accounting

Business Policies

Medical Records

Your Insurance

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Private Practice Location Options

Doctor/Provider’s OfficeOffice Share/ SubletIn Home (yours or theirs)Private OfficeOther Company: gym, spa

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Rates & Reimbursement

How to set your rates?

Consider your Expenses:

Rent

Phone/Internet

Marketing Materials & Business Supplies

Professional Insurance, Dues, CEUs

Private Pay Model

vs. Insurance Reimbursement

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Private Pay

Cash/Credit/CheckPayPal SquareTraditional Credit Card MachineSuper bill/Medical Receipt

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Insurance Reimbursement

CAQH ProView (proview.caqh.org) & Credentialing

NPI:

https://

nppes.cms.hhs.gov

/

NPPES

Which companies cover MNT?

What are the CPT Codes? 97802, 97803, 97804

ICD-9/ICD-10- October 1, 2015!!!!

Verifying Benefits/Coverage

Submitting Claims & Handling Denials

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ICD-10

F5000 AN, unspecifiedF502 BN, unspecifiedF509 Eating Disorder, unspecifiedE509 Vitamin A DeficiencyE559 Vitamin D Deficiency282 PCOS

ER635

Abnormal Weight

Gain

R634 Abnormal Weight Loss

E669 Obesity, unspecified

E663 Overweight

E6601 Morbid (severe) obesity due to excess calories

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ICD-10, cont.

Z6851 BMI, Pediatric less than 5%ile for ageZ6852 BMI, Pediatric, 5%ile-85%ile for ageZ6853 BMI, Pediatric, 85%ile- less than 95%ile for ageZ6854 BMI, Pediatric, Greater than or equal to 95%ile for age

Z681 BMI 19 or less, adult

Z6820 BMI 20-20.9, adult

Z6821 BMI 21-21.9, adult…

Z6839 BMI 39-39.9, adult

Z6841 BMI 40-44.9, adult

Z6842 BMI 45-49.9, adult

Z6843 BMI50-59.9, adult

Z6844 BMI 60-69.9, adult

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Academy ICD-10 Resource

http://www.eatrightpro.org/~/media/eatrightpro%20files/practice/getting%20paid/icd-10-cm-codes-for-rdns.ashx

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Referrals

Are referrals needed?

Establishing referral sources

Example marketing packet

Does this work??

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Establishing Specialties

Find your niche

Refer to other RDNs!

Collaborate with other professionals

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Hours & Schedule

Who do you treat?

When are they available?

Work/Life Balance

Set Boundaries!

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Marketing

Business Cards

Website

Logo Design

Promotional Materials

Online Presence

Media Presence

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Accounting and Business Entity Types

Sole Proprietor

Partnership

Corporation

C Corp

S Corp

LLC

Slide22

Business Policies/Forms

Referral FormIntake SheetPatient DemographicsHIPAAClient Agreement/Policies

Communication

Session Forms/Packets

Fax Coversheets

Consent for Release of Healthcare Information

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Medical Records

EMR through a service/company

Office Ally

Practice Fusion

EMR via your own set up

Paper charts

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Your Insurance

Liability Insurance

Malpractice Insurance

Life/Health/Dental, etc.

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Office Flow: Client Initiates

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Office Flow: Referral

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Eating Disorder Treatment Basics

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Role of the RDN

Varies with level of care

Varies from client to client

Nutrition THERAPIST

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ED Types: AN

Anorexia Nervosa

Restriction of energy intake, leading to significantly low body weight

Intense fear of gaining weight

Disturbance in the way body shape is evaluated or perceived

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ED Types: BN

Bulimia Nervosa

Recurrent episodes of binge eating characterized by both:

Eating in a discrete amt. of time (2 hr.) large amounts of food

Sense of lack of control over eating during a binge

Recurrent compensatory behavior to prevent weight gain

Binge and Purge both occur, on average, 1/wk. for 3 months

Self evaluation unduly influenced by body shape/weigh

Disturbance does not occur exclusively during episodes of AN

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ED Types: BED

Binge Eating Disorder

Recurrent episodes of binge eating

Binge eating associated with 3 or more of these:

Eating more rapidly than normal

Eating until uncomfortably full

Eating large amounts of food when not hungry

Eating alone because of feeling embarrassed by quantity

Feeling disgusted with oneself, depressed, or guilty afterwards

Distress regarding binge eating

Occurs, on average, at least 1/wk. for 3 months

Not associated with compensatory behavior or occur exclusively with AN or BN

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ED Types: Otherwise Specified Feeding or Eating Disorder (OSFED/EDNOS)

Disorder characterized by behaviors that don’t necessarily fall into another specific diagnosis

Atypical AN: All criteria of AN met except despite weight loss, weight is within or above normal range

BN low frequency: All criteria of BN met except bxs occur less than 1/wk. or less than 3 months

BED low frequency: All criteria of BED met except bxs occur less than 1/wk. or less than 3 months

Purging Disorder: Recurrent purging behavior in absence of binging behavior

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Dieting & ED Statistics

In US, 20 million women and 10 million men suffer from an ED in their lifetime

40-60% of elementary school girls (ages 6-12) are concerned about their weight or becoming too fat.

For females between 15 and 24 yoa who suffer from AN, the mortality rate is 12 X higher than the death rate of all other causes of death

There has been a rise in incidence of AN in women ages 15-39 in each decade since 1930

Incidence of BN is 10-39 yoa women TRIPLED between 1988 and 1993.

In college aged men, rate of EDs is 4-10%

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Dieting & ED Statistics

Girls who diet frequently are 12 times as likely to binge as girls who don’t diet

35-57% of adolescent girls engage in crash dieting, fasting, SIV, diet pills or laxative use

95% of all dieters will regain their lost weight in 1-5 years

35% of “normal dieters” progress to pathological dieting. Of those, 20-25% progress to partial or full eating disorders.

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Goals for MNT

Establishing Ideal Weight

Initial Meal Plan

Cessation of ED behaviors

Overcoming Fear Foods

Make Peace with Numbers/Body Image

Intuitive Eating

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IBW

Weight History

Family Report

BMI

HAMWI

Body Compositions

Resolution of Menses, when applicable

Natural Set Point

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Meal Plan Formats

Determining Calorie Needs

Calorie Counts

Exchanges

Daily/Weekly Servings

Servings per meal

Main and sides/Items

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Meal Plan Increases: Wt. Gain

Supplement v Food

250-350 kcal/week

Wt. Gain goal: outpatient ½-2#/week

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Eating Disorder Behaviors

RestrictionBingingPurging: SIVLaxativesDiureticsOver Exercise

Food Rituals

Caffeine

Abuse

Chewing & Spitting

Gum Chewing

Self Harm

Drugs/Alcohol

Medication/Insulin Abuse

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Fear Foods: You tell them to eat WHAT??

Exposure Response Prevention Therapy

Hierarchy of Fear Foods

Systematically challenge fear foods

1:1

Restaurant Challenge/Snack Challenge

Independently

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Volunteer for Activity

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Make Peace with Numbers

Coordinate with therapist

Understand significance of specific numbers to the client

Awareness of Weight

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Intuitive/Normal Eating

Tribole & Resch

Ellyn Satter

Eat the foods you truly want when you’re hungry, stop when you’re full. Allow yourself access to food the next time you’re hungry. Neutral emotion in response food.

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First Session: Assessment

Medical HistoryED HistoryBehaviors: current/historyOnsetTriggering EventFunctionTreatment HistoryFood likes/dislikes (fears?)Motivation Assessment

Family of origin

Attitudes about food

Weight

relationship

Current core family

Attitudes about food

Weight

relationship

Food Recall

Anthropometric Data

Built Rapport

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Follow Up Sessions

Frequency

Length of Time

Average Length of Treatment

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Useful Tools & Assignments

Eat 26

Hierarchy of Fear Foods

Food Rules Lists

ED Pros/Cons

Victory List/Challenge List/Challenge Calendar

Thought Challenging

Food Logs/Hunger & Emotion Tracking

Hunger Scale

Weight Life Story

Normal Eating definition

Exercise Prescription

Behavior Analysis

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Coordination of Care

Doctor/NP/PA specializing in ED care

Therapist/Counselor

Psychiatrist

RDN

Coaches, Teachers, Support People

Family

Slide48

Barriers to MNT

Readiness for change

Underlying need still present

Co-morbidities

Difficult relationships

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Tips for the Tough Ones

Reflective Statements & Motivational Interviewing

Agreeing on Common Goals

Confronting. Directly. Repeatedly.

What is the next small step?

Assess a higher level of care

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Client Resources

Apps: Recovery Record

Books: Life Without Ed, Intuitive Eating

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Professional Resources

Books: Intuitive Eating (Tribole & Resch), Guide to Private Practice (Academy), Counselling for Eating Disorders (Sara Gilbert), Eating Disorders: A Clinical Guide to Counseling and Treatment (Woolsey), How to Get your Child to Eat…but not too Much (Satter)

Websites: nationaleatingdisorders.org (NEDA)

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Thank you! Questions?