Medical Nutrition Therapy (MNT)

Service Standard

Subcategories	Service Units
Medical Nutrition Therapy - Counseling	Per 15 minutes
Medical Nutrition Therapy - Supplements (Supplements recommended by someone other than a licensed dietitian should be funded and recorded under Food Pantry/Voucher with Nutritional Supplements.)	Per transaction

Health Resources & Services Administration (HRSA) Description:

Medical Nutrition Therapy (MNT) includes:

Nutrition assessment and screening;
Dietary/nutritional evaluation;
Food and/or nutritional supplements per medical provider’s recommendation; and
Nutrition education and/or counseling.

These services can be provided in individual and/or group settings and outside of HIV Outpatient/ Ambulatory Health Services (OAHS).

Program Guidance:

All services performed under this service category must be pursuant to a medical provider’s referral and based on a nutritional plan developed by the Registered Dietitian (RD) or other licensed nutrition professional
Services not provided by a registered/licensed dietitian should be considered Psychosocial Support Services under the Ryan White HIV/AIDS Program (RWHAP)
In the State of Texas, the only allowable nutrition professional recognized for Medical Nutrition Therapy service category is a licensed Registered Dietitian

Language assistance must be provided to individuals who have limited English proficiency and/or other communication needs at no cost to them in order to facilitate timely access to all health care and services.

Subrecipients must provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area to inform all individuals of the availability of language assistance services.

All AAs and subrecipients must establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organizations’ planning and operations.

Limitations:

Services must be provided by a Registered Dietitian or other licensed nutrition professional pursuant to a medical provider’s written referral. Nutritional services and nutritional supplements not provided by an RD shall be considered a support service under Psychosocial Support Services under the RWHAP.

Food provisions and nutritional supplements not provided pursuant to a physician's recommendation and a nutritional plan developed by an RD also shall be considered a support service under Food Bank/Home-Delivered Meals.

Services:

The application of MNT as a part of the Nutrition Care Process is an integral component of the medical treatment for management of specific disease states and conditions and should be the initial step in the management of these situations. Efforts to optimize nutritional status through individualized medical nutrition therapy, assurance of food and nutrition security, and nutrition education are essential to the total system of health care available to people living with HIV through the continuum of care.

MNT is individualized dietary instruction that incorporates diet therapy counseling for a nutrition-related problem. This level of specialized instruction is above basic nutrition counseling and includes an individualized dietary assessment performed by a RD.

Services include providing nutritional supplements and food provisions based on the medical care provider's recommendation:

Nutritional supplements include medical nutritional formula, vitamins, and herbs;
Food provisions consist of recommending significant change in daily food intake based on a deficiency, which may directly affect HIV/co-morbidities.

Telehealth and Telemedicine is an alternative modality to provide most Ryan White Part B and State Services funded services. For the Ryan White Part B/SS funded providers and Administrative Agencies, telehealth and telemedicine services are to be provided in real-time via audio and video communication technology which can include videoconferencing software.

DSHS HIV Care Services requires that for Ryan White Part B or SS funded services providers must use features to protect ePHI transmission between client and providers. RW Providers must use a telehealth vendor that provides assurances to protect ePHI that includes the vendor signing a business associate agreement (BAA). Ryan White Providers using telehealth must also follow DSHS HIV Care Services guidelines for telehealth and telemedicine outlined in DSHS Telemedicine Guidance.

Service Standard and Measure

The following Standards and Measures are guides to improving healthcare outcomes for people living with HIV throughout the State of Texas within the Ryan White Part B and State Services Program.

Standard	Measure
Medical Nutrition Therapy Assessment: An initial MNT assessment will be conducted by an RD pursuant to a medical provider’s referral. MNT provider will contact the client for the initial nutritional assessment within five (5) business days of the referral. The initial MNT assessment must be completed within ten (10) business days of the initial appointment with the RD. MNT provider obtains and documents HIV primary medical care provider contact information for each client. MNT services must be provided in consultation with the medical care provider for medical coordination. MNT provider collects and documents assessment history information with updates as medically appropriate prior to providing care. This information must be based on the Academy of Nutrition & Dietetics (AND) Evidence Based Guidelines that include, but not be limited to: *Anthropometrics:* height and weight; pre-illness usual weight and goal weight; and body muscle and fat. *Clinical data:* medical history. *Dietary data:* individual’s food preferences including ethnic and cultural food preferences and practices; information about allergies, food intolerances, and food avoidances; exercise frequency; food security. *Biochemical:* lab data from the primary medical care provider.	Percentage of clients accessing MNT with documentation of the medical provider’s referral to MNT in the client’s primary record. Percentage of clients accessing MNT with a documented completed MNT assessment conducted by an RD in the client’s primary record.
Nutrition Plan: A nutritional plan will be developed appropriate for the client’s health status, financial status, and individual preference. A Nutritional Plan is completed within ten (10) business days of Nutrition Assessment and includes, but is not limited to: Nutritional diagnosis Measurable goal Date service is to be initiated Recommended services and course of medical nutrition therapy to be provided to include the planned number and frequency of sessions Types and amounts of nutritional supplements and food provisions. The plan will be signed by the RD developing the plan. The Nutrition Plan will be updated as necessary, but no less than at least twice per year, and will be shared with the client, the client's primary care provider, and other authorized personnel involved in the client's care.	Percentage of clients accessing MNT services have a documented nutrition plan developed in the client’s primary record. Percentage of clients accessing MNT services have an updated nutrition plan at least twice per year as documented in the client’s primary record.
Services Provided: According to the American Dietetic Association’s HIV-related protocols in Medical Nutrition Therapy Across the Continuum of Care nutritional services will be provided. The frequency of contact with the RD will be based on the level of care needed per the initial assessment. Nutritional intervention will focus on set standards of medical nutrition therapy that targets measurable goals, recommended services, and course of medical nutrition therapy as outlined in the Nutrition Plan. Emerging problems such as lipodystrophy syndrome will be addressed and added to the nutrition plan as needed. Services will be documented in the client’s chart and signed by the RD providing care at each visit.	Percentage of clients accessing MNT services that have documentation in the client’s primary record of frequency of contact with the RD to review the nutritional plan and goals as indicated in the initial assessment. Percentage of clients accessing MNT services with RD notes documented in the client’s primary record of nutritional interventions and recommendations. Percentage of clients accessing MNT services show improvement in issues identified in the initial assessment as documented by the RD in the client’s primary record.
Provision of Nutritional Supplements and Food Provisions: Nutritional supplements and food provisions deemed medically necessary may be provided per written orders from a prescribing physician. Upon receipt of the written referral by the primary medical care provider to the RD, clients may receive up to a 90-day supply of nutritional supplements at one time in accordance with their MNT developed nutritional plan. Nutritional supplements and food provisions must be outlined in the written nutrition plan by the RD. The written nutritional plan must be communicated with the primary HIV prescribing provider.	Percentage of clients accessing MNT services that are prescribed nutritional supplements in accordance with the nutritional plan developed by the RD have documented evidence of supplements provided to the client in the client’s primary record.
Nutrition Education: Client nutritional health education will be offered to each client a minimum of once a year that includes, but is not limited to: Benefits of good nutrition Special dietary needs of people with HIV/AIDS Supplementation Coping with complications	Percentage of clients accessing MNT services with documented evidence of nutritional health education provided in the client’s primary record.
Referrals: At a minimum, clients will receive referrals to specialized health care providers/services as needed to augment MNT that includes, but is not limited to: Other medical professionals such as social workers, mental health providers, or case managers Community resources such as food pantries; SNAP/food stamps; Women, Infants and Children Supplemental Food Program (WIC), etc. Nutrition classes Exercise facilities Other education and economic resource groups MNT provider will document referral and outcome in the client’s record.	Percentage of clients accessing MNT services that had documentation of referrals to other services as indicated in the client’s primary record. Percentage of clients accessing MNT services have follow up documentation to the referral offered in the client’s primary record.
Discharge: An individual is deemed no longer to need MNT if one or more of these criteria is met: Client’s medical condition improves and MNT services are no longer necessary Client deceased Client moves out of the service area Date of discharge, reason, and any recommendations for follow up shall be documented in the client’s record and the primary medical provider notified.	Percentage of clients accessing MNT with documentation of discharge noted in the client’s primary record as applicable.

Standard

Measure

Medical Nutrition Therapy Assessment: An initial MNT assessment will be conducted by an RD pursuant to a medical provider’s referral.

MNT provider will contact the client for the initial nutritional assessment within five (5) business days of the referral.

The initial MNT assessment must be completed within ten (10) business days of the initial appointment with the RD.

MNT provider obtains and documents HIV primary medical care provider contact information for each client. MNT services must be provided in consultation with the medical care provider for medical coordination.

MNT provider collects and documents assessment history information with updates as medically appropriate prior to providing care. This information must be based on the Academy of Nutrition & Dietetics (AND) Evidence Based Guidelines that include, but not be limited to:

Anthropometrics: height and weight; pre-illness usual weight and goal weight; and body muscle and fat.
Clinical data: medical history.
Dietary data: individual’s food preferences including ethnic and cultural food preferences and practices; information about allergies, food intolerances, and food avoidances; exercise frequency; food security.
Biochemical: lab data from the primary medical care provider.

Percentage of clients accessing MNT with documentation of the medical provider’s referral to MNT in the client’s primary record.

Percentage of clients accessing MNT with a documented completed MNT assessment conducted by an RD in the client’s primary record.

Nutrition Plan: A nutritional plan will be developed appropriate for the client’s health status, financial status, and individual preference.

A Nutritional Plan is completed within ten (10) business days of Nutrition Assessment and includes, but is not limited to:

Nutritional diagnosis
Measurable goal
Date service is to be initiated
Recommended services and course of medical nutrition therapy to be provided to include the planned number and frequency of sessions
Types and amounts of nutritional supplements and food provisions.

The plan will be signed by the RD developing the plan. The Nutrition Plan will be updated as necessary, but no less than at least twice per year, and will be shared with the client, the client's primary care provider, and other authorized personnel involved in the client's care.

Percentage of clients accessing MNT services have a documented nutrition plan developed in the client’s primary record.

Percentage of clients accessing MNT services have an updated nutrition plan at least twice per year as documented in the client’s primary record.

Services Provided: According to the American Dietetic Association’s HIV-related protocols in Medical Nutrition Therapy Across the Continuum of Care nutritional services will be provided. The frequency of contact with the RD will be based on the level of care needed per the initial assessment.

Nutritional intervention will focus on set standards of medical nutrition therapy that targets measurable goals, recommended services, and course of medical nutrition therapy as outlined in the Nutrition Plan. Emerging problems such as lipodystrophy syndrome will be addressed and added to the nutrition plan as needed.

Services will be documented in the client’s chart and signed by the RD providing care at each visit.

Percentage of clients accessing MNT services that have documentation in the client’s primary record of frequency of contact with the RD to review the nutritional plan and goals as indicated in the initial assessment.

Percentage of clients accessing MNT services with RD notes documented in the client’s primary record of nutritional interventions and recommendations.

Percentage of clients accessing MNT services show improvement in issues identified in the initial assessment as documented by the RD in the client’s primary record.

Provision of Nutritional Supplements and Food Provisions: Nutritional supplements and food provisions deemed medically necessary may be provided per written orders from a prescribing physician.

Upon receipt of the written referral by the primary medical care provider to the RD, clients may receive up to a 90-day supply of nutritional supplements at one time in accordance with their MNT developed nutritional plan.

Nutritional supplements and food provisions must be outlined in the written nutrition plan by the RD. The written nutritional plan must be communicated with the primary HIV prescribing provider.

Percentage of clients accessing MNT services that are prescribed nutritional supplements in accordance with the nutritional plan developed by the RD have documented evidence of supplements provided to the client in the client’s primary record.

Nutrition Education: Client nutritional health education will be offered to each client a minimum of once a year that includes, but is not limited to:

Benefits of good nutrition
Special dietary needs of people with HIV/AIDS
Supplementation
Coping with complications

Percentage of clients accessing MNT services with documented evidence of nutritional health education provided in the client’s primary record.

Referrals: At a minimum, clients will receive referrals to specialized health care providers/services as needed to augment MNT that includes, but is not limited to:

Other medical professionals such as social workers, mental health providers, or case managers
Community resources such as food pantries; SNAP/food stamps; Women, Infants and Children Supplemental Food Program (WIC), etc.
Nutrition classes
Exercise facilities
Other education and economic resource groups

MNT provider will document referral and outcome in the client’s record.

Percentage of clients accessing MNT services that had documentation of referrals to other services as indicated in the client’s primary record.

Percentage of clients accessing MNT services have follow up documentation to the referral offered in the client’s primary record.

Discharge: An individual is deemed no longer to need MNT if one or more of these criteria is met:

Client’s medical condition improves and MNT services are no longer necessary
Client deceased
Client moves out of the service area

Date of discharge, reason, and any recommendations for follow up shall be documented in the client’s record and the primary medical provider notified.

Percentage of clients accessing MNT with documentation of discharge noted in the client’s primary record as applicable.