What are CRCs?

• CRC meetings are optional meetings where RDs get together to discuss casework, new research, trends in care, etc. These meetings are a great opportunity to build community and get support from other RDs.

• While case presentation is not required to attend CRCs, collaboration is a key pillar of these meetings. We strongly encourage RDs to attend with their cameras on, ready to engage in supportive and collaborative conversation.

The following are some suggestions based on RD feedback for the Case Review (CRC) and Collaboration meetings.

• Meetings are organized by specialty area, based on the prevalence of patients at Nourish with certain conditions/disease states. These include:

  • GI (2 sessions)

  • Disordered Eating and Eating Disorders (2 sessions)

  • General (2 sessions)

  • Diabetes (1 session)

  • Weight Concerns including bariatrics (1 sessions)

• Format: Because CRCs are disease specific, with the exception of the two general sessions, priority will be given to cases that align. If there’s time remaining, it’s open floor. As well, it’s suggested that RDs follow the SBAR format to get the most out of the meetings and maximize time to collect recommendations and suggestions.

• CRC Etiquette:

  • Case Count: Type 'CASE' in the chat at the beginning of CRC for host to get a gauge how many cases we have time to review.

  • Presenting: Use SBAR format below for case review presentations

  • Engagement: Camera on & participation is encouraged. If you do not have a case to present, please ask questions or support fellow RD's with thoughts/ideas. If you need to eat lunch, please show your face & share what you are having with the group or turn your camera back on when finished.

To ensure the sessions are well-structured, the SBAR format is suggested. NO ADVANCE CASE PLANNING IS REQUIRED, but RDs should come ready to state briefly the situation, background, and assessment, and then ask the group for recommendations.

SBAR is used in clinical care environments to improve the effectiveness of communication through standardization of communication process. Published evidence shows that SBAR provides effective and efficient communication, thereby promoting better patient outcomes.

S = Situation - Concise statement of the problem

B = Background - Pertinent and brief information related to the situation

A = Assessment - Analysis and considerations of options — what you found/think (relevant general and dietary/nutrition)

R = Recommendation - Brief statement of what you’d like help with

The goal of the SBAR format to keep case work organized and make sure we are providing all the relevant information of a case so our colleagues have the relevant information needed to share feedback as well as evidenced based ideas and recommendations.

You do not need to write up your casework in SBAR format before hand, this is just the structure we recommend using to communicate your casework to the group.

• Best practice would be to have your patients chart note pulled up on your screen as you are sharing, and you can use the chart note to guide you through the SBAR format. Ideally reviewing the chart note prior to CRC meetings is best practice.

• Situation - In your chart note review relevant demographic information and patient’s chief complaint. Who is the patient? Why are they working with us?

• Background - In your chart note review assessment including relevant information from medical history, lifestyle, diet recall, and other reported information sections. What is the patient’s medical hx? What are their current eating behaviors and relationship with food? Are there any supplements/medications/dietary restrictions that may impact recommendations? What lifestyle factors impact their nutrition? What are they eating day to day? etc.

• Assessment - In your chart note review the RD assessment & Intervention section. What are our greatest concerns for this patient? What progress have they made so far? What recommendations have provided so far?

• Recommendations - Be as specific as possible about what you need support with. Are we wondering what information are we missing for this patient? Are we wanting to help with specific recommendations for this patient?

Situation: Mr. H is a 48-year-old male referred by his PCP for nutrition consultation. Patient is desiring to get help with dietary choices to manage his hypertension.

Background: 48-year-old male, self-employed businessman, with a long history of poorly controlled hypertension, first diagnosed 8 years ago. With blood pressures as high as 240/180 in the past, Mr. H’s medical history is remarkable for episodes of epistaxis, headache, and occasional palpitations. Mr. H was prescribed lisinopril, 10 mg, once daily, and nifedipine, 90 mg, extended release, once daily by his physician. His level of adherence to these medications is unknown. No known hx of DM or CKD and all routine labs are normal. His BMI is 28 kg/m².  His 24-hour diet recall and 3-day log show high prevalence of fast foods. Family medical history of early cardiovascular disease resulting in death maternal grandfather and maternal uncle. Fam hx of HTN unknown. Mr. H would like to go off all blood pressure medications and fix if HTN with diet alone. He has never tried to do this before.

Assessment: I have completed one session (intake). Patient reports in office BP is 160/100. At my suggestion he bought a home cuff and BP is 130/90 after resting for 10 minutes (sent by chat). Dietary assessment: Based on 24-hour recall and 3-day diet log: 3-5 servings of fruits and vegetables/week. High prevalence of fast food and high sodium intake. 5-8 beers/week.

Recommendations? Lots to do, where to start?

Situation – FR is a 52 YO F with pre-DM, referred by PCP for weight loss. She was told if she doesn’t lose weight she’s going to hae to go on medication. ype II DM for 15 years, along with hx of sleep apnea, HTN, high TG and high cholesterol.

Medications/supplements: berberine, cinnamon

Background – She reports having maintained a healthy weight all her life, but after menopause she began to steadily gain weight (about 10 pounds in 5 years) and her latest annual physical showed that her A1C was 6.1% and her FBG was 121mg/dL. Her doctor suggested she either lose weight or go on Metformin. Her sister has diabetes >10 years with peripheral neuropathy, and recent LEA (rt hallux). She is very anxious about developing diabetes like her sister.

Assessment -Reports a healthy diet without having ever given much thought to food. She eats when she’s hungry and enjoys variety as well as her favorite foods (whole grains, fruit & fruit smoothies, fish, red meet about once a week, and raw vegetables, with less of an interest in cooked veggies). She lives with her husband who also enjoys healthy foods and they share shopping and cookies responsibilities. They go out to eat about 1x/week. She’s never been on any type of weight achievement program but a lot of her friends are on Weight Watchers with success and positive feedback. She’s not interested in a fad diet and would rather not take medicine, but also doesn’t want to lose her toes.

Recommendation-In previous sessions (Intake + 2 follow-ups) we discussed whether a plate planner, meal planning, or exchange type approach might suit her best. It appears I may have missed the mark as her feedback after the last session was “I feel overwhelmed and I just want 3 things I can do that are going to have the greatest impact on sustainable weight loss.” I would appreciate some feedback on what you think those three things should be.

Situation – JK is a 53 YO M with type II DM for 15 years, along with hx of sleep apnea, HTN, high TG and high cholesterol.

Medications include Metformin, Quinapril, Fenofibrate, Simvastatin, Losartan, Jardiance, Omega 3, aspirin, CoQ10.

Background – Has stressful job in sales. Patient has CGM (LibreView), which indicates significantly elevated glucose levels at 2pm (210mg/dl) and between 11pm-7am (200-170mg/dl). Average glucose per CGM ~190mg/dl.

Assessment -Reports stress eating during the day as response to work demands, mostly skips breakfast, in the past followed a keto diet for weight loss, currently not active d/t back pain, wife and daughter prefer to eat dinner at 9pm, reports difficulty taking medications as prescribed.

Recommendation-In previous sessions we discussed the importance of eating meals consistently during the day and carbohydrate counting. His glucose levels have not improved in the past 4 weeks even after this education and providing a sample meal plan that we agreed upon. I would appreciate some feedback here and direction of what else to discuss with this patient.

Situation: Ms. K is a 32-year-old female referred by her gastroenterologist for nutrition guidance and symptom management in the setting of IBS. Patient is desiring to identify what specific foods cause GI upset.

Background: Ms. K is a very busy mother of 2 & business owner/entrepreneur. Pt started having GI distress in early 20s with changes to dorm/college meals & meal timing. Hx of elimination diets over the past 10 years with little to no success: whole 30, gluten free, and most recently low FODMAP. Pt symptoms have slowly increased over time with current symptoms of daily bloating, abdominal pain, excessive gas and loose BM’s ~3-4x/week (Bristol 6-7). Pt is currently reliant on Imodium, 4 mg, once daily for improved quality of life in regards to BM’s. This was not recommended by GI, but a suggestion from a friend. No recent blood work, but 2015 blood work WNL. No pertinent fam med hx. Patient is hesitant to do elimination diets as they have not been helpful in the past and does not want to waste her time. Ms. K eagerly wants to feel more in control and improve day to day GI symptoms.

Assessment: I have completed one session (initial intake). Pt reports current stress of 9 (scale from 1-10) on a daily basis with no time to focus on herself or stress management as well as poor sleep habits of ~5 hours per night. Pt reports symptoms feeling sporadic, so RD recommended keeping a symptom/stress journal to further hone in on timing and frequency of symptoms.

Dietary assessment: Based on 24 hour recall, it seems pt is undereating with intake of ~ 1200-1400 kcal/day. Frequently skipping lunch meal due to busy work schedule. Avoids eating outside of the home for fear of increased GI distress.

Recommendations: Starting with the basics, how can I help this patient slow down her day & introduce stress management as a part of improving GI symptoms? Where do I start given she already feels very overwhelmed with her current responsibilities for both work and home life?

Situation: Ms. L is a 19 yo female referred by her therapist for rigid eating behaviors, and suspected reported significant weight loss. Patient has never worked with RD before, is nervous about getting nutrition support but wanting to feel less stressed about food and body image.

Background: 19 yo female, freshmen in college. Pt also dx with POTS syndrome at age 15 and ADHD at age 17. No official dx, but therapist suspects PTSD. Pt has been taking Vyvanse (30mg) for two years prescribed by psychiatrist. Pt reports appetite decreased after starting Vyvanse but noticed improvements in ability to focus. Pt reports following disordered behaviors for last year (started right before college): restricting calories daily, self-weighing every morning, feeling out of control around food 1-2x/week, avoidance of specific foods-specifically desserts and grains, rigid exercise patterns (runs and lifts weights 1-2 hours daily, no rest days), purging via self-induced vomiting 1-2x/month. Pt reports low appetite and early satiety. The patient is 5’2”, BMI of 18.5. Pt reports high levels of distress and fear around idea of weight gain. Pt reports growing up with food insecurity, reports both parents regularly discussed struggling with weight. Pt reports anxiety about seeing dietitian and gaining weight.

Assessment: I have completed one session (intake). Pt had metabolic panel completed, labs show low vitamin D (15 mg/mL).

Dietary assessment: Patient is eating 2 meals daily, ~900-1200 kcal/day**.** 1-2 servings carbohydrates daily. So far it appears avoids processed foods and fats as well is most meals.

How can I help build rapport with this patient to support continued increases in intake? Where would you start with goals when pt has high food anxiety?

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