Private Practice with a Focus on Eating Disorder

Private Practice with a Focus on Eating Disorder Treatment Nicole Lefever, MS RDN LDN

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

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?

Objectives for Today Overview Basics of Private Practice- is it for you? of treating clients with eating disorders

Private Practice

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…)

PROS & CONS PROS Set your own hours Unlimited earning potential Limited Red Tape YOU are the decision maker CONS You do EVERYTHING PTO? What’s that? Limited checks & balances Healthcare benefits, etc. Professional Isolation

Consider when you’re getting started… Physical Location Prices/Rates Reimbursementinsurance vs. self pay Referral Sources Specialties Hours/Schedule Marketing Accounting Business Policies Medical Records Your Insurance

Private Practice Location Options • Doctor/Provider’s Office • Office Share/ Sublet • In Home (yours or theirs) • Private Office • Other Company: gym, spa

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

Private Pay Cash/Credit/Check Pay. Pal Square Traditional Super Credit Card Machine bill/Medical Receipt

Insurance Reimbursement CAQH Pro. View (proview. caqh. org) & Credentialing NPI: Which https: //nppes. cms. hhs. gov/NPPES 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

ICD-10 F 5000 AN, unspecified F 502 BN, unspecified F 509 Eating Disorder, unspecified E 509 Vitamin A Deficiency E 559 Vitamin D Deficiency 282 PCOS ER 635 Abnormal Weight Gain R 634 Abnormal Weight Loss E 669 Obesity, unspecified E 663 Overweight E 6601 Morbid (severe) obesity due to excess calories

ICD-10, cont. Z 6851 BMI, Pediatric less than 5%ile for age Z 6852 BMI, Pediatric, 5%ile-85%ile for age Z 6853 BMI, Pediatric, 85%ile- less than 95%ile for age Z 6854 BMI, Pediatric, Greater than or equal to 95%ile for age Z 681 BMI 19 or less, adult Z 6820 BMI 20 -20. 9, adult Z 6821 BMI 21 -21. 9, adult… Z 6839 BMI 39 -39. 9, adult Z 6841 BMI 40 -44. 9, adult Z 6842 BMI 45 -49. 9, adult Z 6843 BMI 50 -59. 9, adult Z 6844 BMI 60 -69. 9, adult

Academy ICD-10 Resource http: //www. eatrightpro. org/~/media/eatrightpro %20 files/practice/getting%20 paid/icd-10 -cmcodes-for-rdns. ashx

Referrals Are referrals needed? Establishing referral sources Example marketing packet Does this work? ?

Establishing Specialties Find your niche Refer to other RDNs! Collaborate with other professionals

Hours & Schedule Who do you treat? When are they available? Work/Life Balance Set Boundaries!

Marketing Business Cards Website Logo Design Promotional Materials Online Presence Media Presence

Accounting and Business Entity Types Sole Proprietor Partnership Corporation C Corp S Corp LLC

Business Policies/Forms Referral Form Intake Sheet Patient Demographics HIPAA Client Agreement/Policies Communication Session Forms/Packets Fax Coversheets Consent for Release of Healthcare Information

Medical Records EMR through a service/company Office Ally Practice Fusion EMR via your own set up Paper charts

Your Insurance Liability Insurance Malpractice Insurance Life/Health/Dental, etc.

Office Flow: Client Initiates Phone Call/Email Contact MD Insurance Verification Inform Client & Schedule Begin Treatment

Office Flow: Referral Receive Referral Contact Client Insurance Verification Inform & Schedule with Client Begin Treatment

Eating Disorder Treatment Basics

Role of the RDN Varies with level of care Varies from client to client Nutrition THERAPIST

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

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

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

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

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%

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.

Goals for MNT Establishing Ideal Weight Initial Meal Plan Cessation of ED behaviors Overcoming Fear Foods Make Peace with Numbers/Body Image Intuitive Eating

IBW Weight History Family Report BMI HAMWI Body Compositions Resolution of Menses, when applicable Natural Set Point

Meal Plan Formats Determining Calorie Needs Calorie Counts Exchanges Daily/Weekly Servings per meal Main and sides/Items

Meal Plan Increases: Wt. Gain Supplement v Food 250 -350 kcal/week Wt. Gain goal: outpatient ½-2#/week

Eating Disorder Behaviors Restriction Binging Purging: SIV Laxatives Diuretics Over Exercise Food Rituals Caffeine Abuse Chewing & Spitting Gum Chewing Self Harm Drugs/Alcohol Medication/Insulin Abuse

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

Volunteer for Activity

Make Peace with Numbers Coordinate with therapist Understand significance of specific numbers to the client Awareness of Weight

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.

First Session: Assessment Medical History ED History Behaviors: current/history Onset Triggering Event Function Treatment History Food likes/dislikes (fears? ) Motivation Assessment Family of origin Current core family Attitudes about food Weight relationship Food Recall Anthropometric Data Built Rapport

Follow Up Sessions Frequency Length of Time Average Length of Treatment

Useful Tools & Assignments Eat 26 Hierarchy of Fear Foods Food Rules Lists ED Pros/Cons Victory List/Challenge Calendar Thought Challenging Food Logs/Hunger & Emotion Tracking Hunger Scale Weight Life Story Normal Eating definition Exercise Prescription Behavior Analysis

Coordination of Care Doctor/NP/PA specializing in ED care Therapist/Counselor Psychiatrist RDN Coaches, Teachers, Support People Family

Barriers to MNT Readiness for change Underlying need still present Co-morbidities Difficult relationships

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

Client Resources Apps: Recovery Record Books: Life Without Ed, Intuitive Eating

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)

Thank you! Questions?