Leading the Vision into Future Practice HOD Backgrounder 2017 HOD Future... · A Bright...

_____________________________________________________________________________ A Bright Future-Leading the Vision into Future Practice

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Leading the Vision into Future Practice

HOD Backgrounder House of Delegates Spring 2017 Introduction For over a decade, the Academy has collectively worked towards a vision of future education and practice that will elevate the profession and its credentialed nutrition and dietetics practitioners. Some areas such as nutrition and dietetics education and practice competencies have already begun shifting to this vision and other changes will be implemented over the next several years and decades. In addition, the Academy has also just now entered its Second Century (1), further emphasizing the importance of elevating the nutrition and dietetics profession. Meeting Objectives: Delegates and Meeting Participants will be able to: 1. Share current efforts underway by the Academy and its organizational units to identify and meet the needs of the Second Century workforce. 2. Create a vision of a Second Century workplace. 3. Generate ideas to close the gap between current and future practice. 4. Recognize skills and professional development needed for current and future practitioners.

Mega Issue Question How can credentialed nutrition and dietetics practitioners elevate the profession, expand

opportunities, and enhance practice for the Second Century?


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The Academy, Accreditation Council for Education in Nutrition and Dietetics (ACEND), Commission on Dietetic Registration (CDR), and the Council on Future Practice (CFP) have each investigated the current and future landscape to determine education and practice opportunities. Many common themes emerged from their work. A quote from the 2013 Consensus Report (2) from the CFP stated these commonalities best, “If the nutrition and dietetics profession is not moving forward, it is being left behind.” The Landscape According to the Academy’s 2016 Needs Satisfaction Survey (3), half of working RDNs indicated their primary practice area as clinical practice, with 19% in inpatient, 22% in outpatient, and 9% in long term care. When asked to indicate all of the practice areas in which RDNs spend at least 20% of their time, the results were as follows [Exhibit 012]:

27% acute care, inpatient

11% acute care, outpatient

17% ambulatory/outpatient care

15% long term/extended care

7% rehab facility

14% community/public health program

9% government agency

6% non-profit agency

12% private practice

9% college/university faculty Looking ahead, the implications document related to the Commission on Dietetic Registration’s Work Force Demand Study identified the aging population, health care reform, increasing prevalence of certain conditions (including obesity), and growth in the food industry as key factors affecting the demand for nutrition and dietetics practitioners (4). This excess demand will provide opportunities for non-registered practitioners (e.g., naturopathic physicians, athletic trainers, health coaches, health educators, and other health professionals) to provide nutrition and dietetics services. The task force study authors recommended proactive interventions that included: increasing the supply of RDNs by increasing the number of dietetic

Question #1: What do we know about the current realities and evolving dynamics of our members, marketplace, industry, and profession

that is relevant to this decision?

Academy’s 2016 Needs Satisfaction Survey- ReadEx Research


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internship positions, marketing new employment opportunities to potential nutrition, and dietetics students and creating professional growth opportunities (5). In addition the CFP Visioning Report 2017: A Preferred Path Forward for the Nutrition and Dietetics Profession (6) was recently released and consisted of input from Academy members, CDR credentialed nutrition and dietetics practitioners, Academy organizational units, CFP think tank members, and Academy external organization liaisons. The change drivers identified in the report are listed in the table below. Each change driver provides opportunities for the dietetics practitioner now and in the future. The recommendations within the report are not meant to be all-inclusive, but rather specific, actionable items that can be pursued in the next 10-15 years to advance the profession.


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The House Leadership Team has been and will continue to utilize the change drivers for mega issues discussed by the House of Delegates. Work continues as a result of many of these mega issues and will drive us to our desired future. See examples below.

Education In 2012, ACEND began exploring the education needed to best prepare graduates for future practice in nutrition and dietetics. ACEND released the Expanded Standards Committee Background Report in July 2014 (8) reviewing three themes that emerged from their environmental scan, as it related to the future educational requirements for nutrition and dietetics practitioners:

1. Continuous high-speed advancements in healthcare, technology, medicine, and food systems warrant additional information and a higher level of education may better prepare nutrition and dietetics practitioners to meet the needs of the public.

2. There is a broadening and increasing complexity in public health nutrition, food safety, disease prevention, food production, and health promotion that may impact the practice of nutrition and dietetics.

3. Many health professions have identified differing skills levels needed by their practitioners in the marketplace. As a result many accrediting agencies have differentiated knowledge and skill requirements at bachelor’s and graduate levels.

ACEND proposed a model for future nutrition and dietetics education with new graduate level standards to prepare generalist and specialist dietitians for these future roles in their Rationale Document (9). The proposed model also includes new associate and bachelor’s level standards to better prepare graduates for emerging roles in community nutrition and health, wellness, business and industry, and management. Figure 2 on the next page depicts the recommended future model for education in nutrition and dietetics. The model includes development of programs starting at the high school level and continuing through the doctoral degree level.

Examples of Mega Issues with a Connection to the Change Drivers and Other Trends Recent HOD Mega Issues (7) have addressed many opportunities for the future including:

Wellness and Prevention (2016)

Technological Innovations (2016)

Malnutrition (2015)

Business and Management Skills (2014)

Engaging Members in Research (2014)

Nutrition Services Delivery and Payment (2013)

Food and Nutrition Insecurity (2013)

Public Health Nutrition (2012)

Continuum of Professional Progression and Growth (2012)

http://www.eatrightpro.org/resource/leadership/house-of-delegates/mega-issues-and-backgrounders/archived-mega-issue-backgrounders


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Figure 2. Proposed model for future education in nutrition and dietetics

*Current focus is on the Associate to Master’s level, but other areas will be determined at a later time.


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In 2016, ACEND released a first draft of standards and opened a public comment period for the future education model associate, bachelor’s and master’s degree program. The public comments were reviewed; and in February 2017 ACEND released a revised set of standards based on the input. They now seek public comment on the most recently released draft of the Future Education Model Accreditation Standards for Associate, Bachelor and Master Degree Programs in Nutrition and Dietetics. Updates and answers to questions are communicated via ACEND’s Monthly Standards Updates and Town Hall meetings (10). Below is the guiding vision that ACEND has used in the development of the proposed competencies (9):

Future master’s degree prepared nutrition and dietetics practitioner

Future bachelor’s degree prepared nutrition and dietetics practitioner

Future associate degree prepared nutrition and dietetics practitioner

Credential available: Registered Dietitian Nutritionist (RDN)

Credential available: Nutrition and Dietetics Technician, Registered (NDTR)

Facilitates inter and intra professional teamwork and collaboration

Manages the production, distribution and service of food in foodservice operations

Collects data and assists with in home screening regarding changes in: behaviors, nutrition, physical activity, substance use, medication adherence, and other issues as related to the established care plans

Develops and implements community, population, and global nutrition programs

Develops evidence-informed nutrition communications

Promotes access to community resources for clients

Reviews, evaluates, and conducts research

Assists clients with meal planning and conducts cooking classes

Assists clients with food label reading and meal preparation tips

Provides Medical Nutrition Therapy counseling that results in behavior change

Assists the RDN with client/patient screening, nutrition intervention, and client/patient education

Assists with community events such as health fairs and farmer’s markets

Demonstrates leadership to guide practice

Assumes administrative, leadership, and entrepreneurial positions in nutrition and dietetics


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Credentialing CDR changed the degree requirement for dietitian registration eligibility, from a baccalaureate degree to a master’s degree, effective January 1, 2024 (11). This action was based on the recommendations of the Council on Future Practice Visioning Report released in fall 2012. CDR calculated a five to six year window for those entering a Didactic Program in Dietetics (DPD) in 2014 to complete the DPD, followed by two years to find and complete a supervised practice program, and then two years as a cushion for any unforeseen circumstances that would interfere with submission of the registration eligibility application by January 1, 2024.

CDR also launched the Essential Practice Competencies for credentialed nutrition and dietetics practitioners. In June 2015 the new CDR registrants began using the Essential Practice Competencies (12); and those recertifying on June 1, 2016 also began the new process. By the 2020 cycle, all credentialed nutrition and dietetics practitioners will be on the competency-based system. There are 14 spheres, 55 practice competencies for RDNs (50 for NDTRs), and 352 performance indicators for RDNs (271 performance indicators for NDTRs). The Essential Practice Competencies are:

Broad enough to encompass the range of activities within the profession (e.g., clinical care, management, food service, research, education, public health, consultation, etc.) and to recognize that RDNs and NDTRs assume many unique roles (e.g., marketing for a food manufacturer, informatics for a health system, etc.).

Descriptive of the different practice roles between the RDN and NDTR credentials.

Applicable to all credentialed nutrition and dietetics practitioners. These essential competencies are just one step in preparing the profession for the changing landscape, trends and other forces driving practice.

Realities Over the years, credentialed nutrition and dietetics practitioners have expressed concern about the three Rs- respect, recognition, and rewards. This theme has remained consistent since the 1990’s (2, 13). In addition one of the themes in a supplement from the Workforce Demand Survey Study (14) noted, “Too many in the profession see dietetics as a job rather than a profession and are not ready to step up to the challenge of change.” At the same time, many practitioners are also seeking opportunities to advance practice and expand services. Many active projects and initiatives support this need, such as CDR’s Advanced Practice Credential in Clinical Nutrition, CDR’s Certificate of Training Programs in Weight Management, and the Academy’s eleven online Certificate of Training Programs in various

Question #2: What do we know about the needs, wants and expectations of members, customers and other stakeholders relevant to this decision?

“Too many in the profession see dietetics as a job rather than a profession and are not ready to step

up to the challenge of change.”


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areas of practice (levels 1 and 2 for advanced growth). Successful advocacy efforts by the Academy have created opportunities for therapeutic diet order writing privileges in both hospital and long-term care settings. In addition, the Academy has been offering hands-on training workshops on Nutrition Focused Physical Examination (NFPE). Other areas for continued expansion include integration of RDNs and nutrition services in newer models of health care delivery and payment, which include opportunities to tap into the full scope of practice of the RDN. Furthermore, Dietetic Practice Groups (DPGs) and Member Interest Groups (MIGs) offer opportunities for continuing education, sharing ideas, networking, and building relationships with colleagues. Stakeholders

ACEND interviewed stakeholders representing healthcare administration (pharmacy, nursing), deans of allied health colleges, employers of less traditional roles (communications, marketing and management), physicians, educators in allied health graduate programs and researchers

ACEND’s Environmental Scan with Stakeholders

There is an increased focus on disease prevention and integrative healthcare and the need for more knowledge in emerging areas such as genomics, telehealth, behavioral counseling, diet order writing, and informatics.

This work requires that health care professionals work more interprofessionally.

Employers indicated the need for improved communication skills in nutrition and dietetics practitioners and an improved ability to understand the patient’s community and cultural ecosystem.

Practitioners need to be able to read and apply scientific knowledge and interpret this knowledge for the public. Employers also expressed a desire for stronger organizational leadership, project management, communication, patient assessment, and practice skills.

Many of the stakeholders identified gaps in current competencies in areas of research, communication, leadership/management skills, cultural care, interprofessional work, basic food and culinary preparation, and sustainability.

Employers indicated that more time might be needed in the preparation of future nutrition and dietetics practitioners to assure application of knowledge and demonstration of skills needed for effective practice.

Stakeholders identified the importance of associate and bachelor’s level prepared graduates for roles in community health, wellness, and management.

Employers identified the need for preparing undergraduates with transferable skills in leadership, business and management, and expressed the need for faculty prepared at the doctoral level.


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regarding their needs with employment of current and future practitioners (9). The table on page 8 shows key themes that emerged from these interviews. Opportunities

The Academy is entering its Second Century and there are many exciting opportunities to advance the profession. Six Second Century opportunity categories have been identified (15). The potential is great for the profession heading into the Second Century and opens the door for further stakeholder collaboration.

Moving the educational preparation of the RDN to the master’s degree level will help elevate the profession among our allied health professional colleagues, whose professions have already elevated entry-level educational standards to either a master’s degree or practice doctorate (16). Advancing the education level should also increase the profession’s ability to effectively advocate for coverage and reimbursement for nutrition services provided by RDNs, and for appropriate positioning of RDNs on the health care team (2).


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The CFP Visioning Report 2017 also looked at the future needs of society and the profession. Highlights from the report are shown below. Credentialed nutrition and dietetics practitioners can help fulfill these changing needs (5).

Society’s Future Needs and Changes

Demographics

Diversity

Generations

Geographic distribution

Financial and political disparities

Education levels

Client/Patient Needs, Preferences and Health Education

Lifestyles

Cultural values

Consumer trends

Health disparities

Health education

Health and nutrition literacy

Personal resources (income) Food and Nutrition Systems and Sustainability

Food industry

Food systems management

Food and nutrition security

Food safety

Food-related environmental sustainability

Agricultural systems

Healthcare

Healthcare reform

Coordinated care

Healthcare delivery systems and models including long-term care and acute care facilities

Alternative medicine/health

Access to primary care

Access to RDNs and NDTRs

Quality care and outcomes

Public Health, Policies and Priorities

Obesity

Nutrition and physical activity across the lifespan

Chronic disease management

Health promotion and wellness

Changing the environment/infrastructure to promote healthy lifestyle

Economics/Market Forces

Economic outlook

General employment trends o Wages o Areas for job growth

Delivery and payment for nutrition services

Public reporting of measureable results for nutrition service

Advances in Medicine, Science and Technology

Genetics, genomics

Behavioral science

Information communication technologies

Mobile connectivity

Electronic health records

Global Context

Nutrition and dietetics practices in other countries

Migration/immigration and global workforce

Global professional collaboration

Trends in population health and agriculture

Profession’s Future Needs and Changes


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Education/Professional Development

Integrated didactic education and supervised practice

Knowledge and continuing competence

Education programs and curriculum

Learning technologies and platforms

Work and Workplaces

Practice roles

Business models

Emerging opportunities

Competitive providers of nutrition and dietetics services

Work and family balance

Salaries and benefits

Workforce Projections

Supply and demand

Mobility and adaptability

Workplace settings and focus areas

Staffing models and ratios

Retention of RDNs, NDTRs and dietetics students/interns

Diversity of the workforce

Practice Requirements

Evidence-based practice

Business and entrepreneurial skills

Technology use

Education, counseling and behavior change

Cultural competency

Interprofessional training and proficiency

Practice efficiency methods

Career Advancement and Leadership

Reward and recognition

Leadership and management

Drive and motivation

Mentoring new practitioners

Advocacy, Credentialing and Licensure

Advocating for the profession

Patterns in credentialing in nutrition and dietetics

Competing and related credentials

Translating Evidence-Based Research into Practice and Policy

Research on effectiveness of nutrition services

Opportunities for practitioner/researcher collaborations

New developments in nutrition and health sciences

Informatics and data analytics

Translating research into policy

Values and Ethics

Evidence-based nutrition

Social responsibility

Personal integrity and professionalism

Figure 2. Ten priority change drivers and their associated trends for the Council on Future Practice’s 2014-2017 Visioning Cycle **In July of 2014, the CFP utilized the scanning framework to identify and prioritize the following five shaded categories for the 2014-2017 visioning cycle.

Before moving on to the next section, please stop and read the following documents to set the stage for the strategic position and capacity section.

Appendix A: CFP’s Visioning Report 2017: A Preferred Path Forward for the Nutrition and Dietetics Profession


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As we head into the Second Century and

look to advance with multiple levels of

practice, there are opportunities to

expand the workforce not only in the

U.S., but also globally. The Workforce

Demand Study noted the demand for

nutrition and dietetics services was

predicted to increase due to health care reform and the expansion of health care services to an

additional 30 million people (4). The report suggested that approximately 75% of the demand

for dietetics services would be met by the year 2020, which would leave 25% as an unmet need.

Credentialed dietetics practitioners’ characteristics in 2010 included an average age of 44 years,

96% were women and about 55% worked in clinical dietetics. The net supply of CDR

credentialed dietetics practitioners was projected to grow by 1.1% annually (3). The

implications report also indicated that the public will have more options for nutritional advice

from the rise in homeopathy and other sources of alternative (natural) medicine. Therefore,

without an adequate supply of credentialed nutrition and dietetics practitioners, the

competitive space for RDNs and NDTRs may be challenged (4). Current discussions within the

national political arena around changes to the Affordable Care Act may impact these previous

projections in ways we cannot yet anticipate. Either way, we know the public has a heightened

interest in nutrition and health.

There is also a shortage of health workers globally, while demand for health services jobs are expected to increase. The workforce provides a clear pathway to improved food, nutrition and overall health for those who benefit from access to nutrition and health services (17). The report from the High-Level Commission on Health Employment and Economic Growth also identified a 9 to 1 return on investment in the health sector workforce (17). Additionally, there is growing global momentum for collaborative solutions in food and nutrition. Last year, the United Nations Sustainable Development Goals (SDGs) were launched, with 17 transformative targets for all countries to work toward (18). Food and nutrition is at the top of the agenda. Goal #2 is to end hunger and all forms of malnutrition. A rapid path to supporting the SDG #2, the Decade of Action on Nutrition, and addressing the need for global health workers is by creating a pathway for RDNs, NDTRs, dietetic interns, and undergraduate dietetics majors to fill the gap. RDNs are the mostly highly trained nutrition practitioners and represent a workforce of 100,000 credentialed nutrition and dietetics practitioners. Yet, they

Question #3: What do we know about the capacity and strategic position of our organization that is relevant to this decision?

Without an adequate supply of credentialed nutrition and dietetics practitioners, the competitive space for registered dietitian nutritionists (RDN) may be challenged (4).


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are underrepresented in careers in global health, resulting in an unfulfilled potential to accelerate progress in improving nutritional status of all people around the world. The Academy has built an organizational infrastructure to help advance the profession. This infrastructure includes:

a highly respected research arm (including the Evidence Analysis Library, Dietetics Practice Based Research Network, ANDHII, position and practice papers, and the electronic Nutrition Care Process Terminology used by 15 countries);

a lifelong learning and professional development arm, which hosts the Academy’s annual scientific Food and Nutrition Conference and Expo, offers over 400 continuing professional education credits per year, and manages nearly 30 specialty dietetics practice groups; and

an advocacy arm, which influences food and nutrition public policy at all levels of government.

The Academy’s infrastructure also includes the credentialing arm of the profession, the Commission on Dietetic Registration, and the accrediting agency for education programs preparing students for careers as RDNs and NDTRs, the Accreditation Council for Education in Nutrition and Dietetics (ACEND), which accredits 575 nutrition and dietetics programs in the U.S. and five international programs. In addition, the Academy’s Foundation is the only charitable organization devoted exclusively to promoting nutrition and dietetics, funding health and nutrition research and improving the health of communities through public nutrition education programs.


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As a part of its Second Century initiative and centennial celebrations, the Academy of Nutrition and Dietetics has established a new vision, mission, principles and strategic direction that will expand the influence and reach of the Academy and the nutrition and dietetics profession.

As the Academy and the Academy Foundation move into the Second Century, a Nutrition Impact Summit was held to focus on increasing collaboration among key stakeholders and identifying opportunities to improve the global health trajectory. The Summit brought together 170 thought leaders, experts, innovators, and strategic thinkers across the food, wellness, and health care sectors to answer the question, "How might we accelerate progress toward good health and well-being for all people through collaboration across food, wellness and health care systems?" (19). A key focus of this summit was on increasing collaboration among key stakeholders and identifying opportunities to improve the global health trajectory.

Academy of Nutrition and Dietetics New Mission, Vision and Principles

New Vision A world where all people thrive through the transformational power of food and nutrition New Mission Accelerate improvements in global health and well-being through food and nutrition New Principles The Academy of Nutrition and Dietetics and our members:

Integrate research, professional development and practice to stimulate innovation and discovery

Collaborate to solve the greatest food and nutrition challenges now and in the future

Focus on system-wide impact across the food, wellness and health care sectors

Have a global impact in eliminating all forms of malnutrition

Amplify the contribution of nutrition practitioners and expand workforce capacity and capability.


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Nutrition Impact Summit Vision

Visual rendering from the Nutrition Impact Summit

The core tenets of this proposed new vision:

Accelerating progress through technology

Revealing evidence through gold- standard research

Empowering consumers through education and creating an environment where the healthy choice is the easy choice

Advocating for stronger policies

Optimizing wellness through health care and customized nutrition solutions

Fueling innovation through investment

Many opportunity areas covered during the Nutrition Impact Summit correspond with items from the 2017 Visioning Report and ACEND rationale document, setting the stage for advancing the profession. RDNs and NDTRs can help meet practice needs across the spectrum in the U.S. and across the globe.


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Implications

Implications Scope of Practice for the Profession of Nutrition and Dietetics The scope of practice for the profession of nutrition and dietetics incorporates education, credentials, practice standards, practice management and advancement, and practice resources (20). Scope of practice in nutrition and dietetics encompasses the range of roles, activities, and regulations within which nutrition and dietetics practitioners perform. For credentialed nutrition and dietetics practitioners, scope of practice is typically established within the practice act and interpreted and controlled by the agency or board that regulates the practice of the profession in a given state (21). The Scope of Practice for the RDN reviews the RDN’s education and training in food and nutrition and summarizes the responsibilities for nutrition-related services. RDNs are integral leaders of interdisciplinary teams in health care, foodservice systems, education, and other practice environments. They provide services in varied settings, including health care, business and industry, communities and public health systems, schools, colleges and universities, the military, government, research, fitness centers, private practice, and communications (22). The Scope of Practice for the NDTR describes the NDTR’s education and training in food and nutrition and outlines their roles in providing services and activities. NDTRs are integral members of the nutrition care and foodservice management teams. NDTRs work in employment settings such as health care, business and industry, communities and public health systems, schools, fitness centers, and research (23). Standards of Practice (SOP) and Standards of Professional Performance (SOPP) Standards of Practice in Nutrition Care are authoritative statements that describe practice and responsibilities for which RDNs and NDTRs are accountable using four separate standards. Each standard demonstrates quality indicators through nutrition assessment, nutrition diagnosis (problem identification), nutrition intervention (planning, implementation) and outcomes monitoring and evaluation (24, 25). The Standards of Professional Performance includes standards for six domains of professionalism: Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources. For RDNs in specialty practice, the SOPs and SOPPs in the 17 focus areas (i.e., diabetes, oncology, sports, pediatrics, etc.) further illustrate quality indicators within competent, proficient and expert levels of practice (26).

Question #4: What are the ethical and legal implications?

Six Domains of Professionalism

Quality in Practice

Competence and Accountability

Provision of Services

Application of Research

Communication and Application of Knowledge

Utilization and Management of Resources


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Future Considerations

With the education model shifting and implementation of the newly updated education knowledge standards and corresponding competencies, the scopes of practice, standards of practice, and standards of professional performance will be evaluated after workforce uptake and adoption of the three levels of nutrition and dietetics practitioners. The Academy’s Quality Management Committee will review employers’ identified and initiated job position specifications that meet their market demand. The helix graph (see right) will also expand to include the third level of education and parallel pathway as applicable (27).

Competency, Professional Knowledge and Continuing Education According to Principle 14 of the Academy of Nutrition and Dietetics and Commission on Dietetic Registration (CDR) Code of Ethics, “The dietetics practitioner assumes a lifelong responsibility and accountability for personal competence in practice, consistent with accepted professional standards, continually striving to increase professional knowledge and skills and to apply them in practice.” (24) The Essential Practice Competencies are already applicable to all credentialed nutrition and dietetics practitioners. However, continuing education opportunities will need to be geared towards the future types of practitioners, as well as multiple levels of practice (competent, proficient and expert). Credentialed nutrition and dietetics practitioners will need continuing education opportunities that match their practice level and allow for growth across their career to ensure they are abiding by the Code of Ethics.


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Professional Regulations The purpose of states licensing professionals is for public protection by ensuring only qualified individuals are engaged in practices that could impact the health or safety of citizens. Currently 47 states either require dietitians to be licensed, license and regulate the practice of nutrition and dietetics without requiring one be licensed to practice, or regulate the use of dietetics and nutrition-related titles. State dietetics and nutrition licensing boards or state departments of professional regulation or health are responsible for developing and implementing regulations governing professional qualification and practice. Each state defines the legal scope of practice for licensed dietitian nutritionists or licensed dietitians (i.e., what licensees are legally permitted to do) and determines the requisite educational preparation and experience required to be recognized as a licensed practitioner in the state. A non-RDN bachelor’s level practitioner who passes CDR’s examination for registered dietitians is generally eligible for state recognition and oversight as licensed dietitian nutritionists (or similar titles). This means that non-RDN CDR credentialed nutrition and dietetics practitioners with a bachelor’s level education will hold the same legal scope of practice as a licensed RDN unless the states and the federal government are persuaded to adopt the Academy’s recommendations for concomitant amendments to scores of statutes and regulations. The Academy continues to work with our affiliates and numerous interested stakeholders to lay the foundation for changes to state licensure laws to improve the practice of nutrition and dietetics around such issues as therapeutic diet ordering, telehealth, and the minimum academic requirements necessary for licensure. Credentialing by Third Party Payers

There will be continued emphasis on expanding consumer access and coverage for Medical Nutrition Therapy (MNT) and the broad range of services provided by credentialed food and nutrition practitioners, while working to achieve competitive reimbursement for quality nutrition services. Under the fee-for-service payment structure, provider credentialing is tied to professional credentialing requirements (such as those of CDR) and state licensure. For example, Section 1861[42 U.S.C. 1395x] of the Social Security Act defines the qualified provider of Medical Nutrition Therapy services under Medicare Part B as follows: (vv)(1) The term “medical nutrition therapy services” means nutritional diagnostic, therapy, and counseling services for the purpose of disease management which are furnished by a registered dietitian or nutrition professional (as defined in paragraph (2)) pursuant to a referral by a physician (as defined in subsection (r)(1)).

(2) Subject to paragraph (3), the term “registered dietitian or nutrition professional” means an individual who—

(A) holds a baccalaureate or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics, as


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accredited by an appropriate national accreditation organization recognized by the Secretary for this purpose;

(B) has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional; and

(C)(i) is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed; or

(ii) in the case of an individual in a State that does not provide for such licensure or certification, meets such other criteria as the Secretary establishes.

(3) Subparagraphs (A) and (B) of paragraph (2) shall not apply in the case of an individual who, as of the date of the enactment of this subsection, is licensed or certified as a dietitian or nutrition professional by the State in which medical nutrition therapy services are performed.

Without a change in state licensure laws to align the RDN credential with a master’s degree or higher, NDTRs, who in the future will hold a bachelor’s degree, might be deemed to meet the definition of “nutrition professional” for the purposes of Medicare enrollment and the provision of MNT services to Medicare beneficiaries. Similar implications may apply for state Medicaid programs and private payers. It should be noted that this change is not guaranteed and could lead to disastrous and costly unintended consequences as licensure laws and federal statutes and regulations are opened up. It will be important to align laws, regulations, and third party payer credentialing policies with the education and credentialing requirements and scope of practice of the future credentialed nutrition and dietetics practitioners, once they are actually defined.

Conclusion: The dietetics profession is propelling forward with the advancements of education and practice;

and while some changes may take decades to implement, the time to advance practice is now.

The changes will affect every area of the profession. Credentialed nutrition and dietetics

practitioners must be prepared to advance skills and elevate practice to compete in the Second

Century workforce.

The Academy has an opportunity to accelerate improvements in nutrition and health around the world, by building on our strengths and collaborating with

other leaders.


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REFERENCES:

1. Academy of Nutrition and Dietetics Foundation. The Second Century of the Academy

of Nutrition and Dietetics. ANDF Web Site. http://eatrightfoundation.org/why-it-

matters/second-century/. Accessed January 15, 2017.

2. Kicklighter JR, Cluskey M, Hunter AM, Nyland N, Spear B. Council on Future Practice Visioning Report and Consensus Agreement for Moving Forward the Continuum of Dietetics Education, Credentialing and Practice. J Acad Nutr Diet. 2013; 113(12):1710–1732.

3. Academy of Nutrition and Dietetics 2016 Needs Satisfaction Survey. ReadEx Research.

4. Hooker RS, Williams JA, Papneja J, Sen N, Hogan P. Dietetics supply and demand: 2010-2020. J Acad Nutr Diet. 2012; 112(suppl 1):S75-S91.

5. Rhea M, Bettles C. Future changes driving dietetics workforce supply and demand: future scan 2012-2022. J Acad Nutr Diet. 2012; 112(suppl 1):S10-S24.

6. Kicklighter JR, Dorner B, Hunter AM, Kyle M, Pflugh Prescott M, Roberts S, Spear B, Hand RK, Byrne, C. Visioning Report 2017: A Preferred Path Forward for the Nutrition and Dietetics Profession. J Acad Nutr Diet.2017; 117(1):110 – 127.

7. Academy of Nutrition and Dietetics. Archived Mega Issue Backgrounders. Academy of Nutrition and Dietetics Web Site. http://www.eatrightpro.org/resource/leadership/house-of-delegates/mega-issues-and-backgrounders/archived-mega-issue-backgrounders. Accessed January 15, 2017.

8. Accreditation Council for Education in Nutrition and Dietetics. Expanded Standards Committee Background Report (Appendices). ACEND Web Site. http://www.eatrightacend.org/ACEND/content.aspx?id=6442485290. Accessed January 15, 2017.

9. Accreditation Council for Education in Nutrition and Dietetics. Rationale for Future Education Preparation of Nutrition and Dietetics Practitioners. ACEND Web Site. http://www.eatrightacend.org/ACEND/content.aspx?id=6442485290. Published February, 2015. Updated July, 2015. Updated August, 2015. Updated January 2017. Accessed January 15, 2017.

10. Accreditation Council for Education in Nutrition and Dietetics. Monthly Standards Updated, ACEND Web Site. http://www.eatrightacend.org/ACEND/content.aspx?id=6442485290. Accessed January 15, 2017.

11. Commission on Dietetic Registration. New Graduate Degree Eligibility Requirements Effective January 1, 2024. CDR Web Site. https://www.cdrnet.org/new-graduate-degree-eligibility-requirement-effective-january-1-2024. Accessed January 15, 2017.

12. Commission on Dietetic Registration. Essential Practice Competencies for CDR Credentialed Nutrition and Dietetics Practice. CDR Web Site. https://www.cdrnet.org/competencies. Accessed January 15, 2017.

http://eatrightfoundation.org/why-it-matters/second-century/

http://eatrightfoundation.org/why-it-matters/second-century/



http://www.eatrightacend.org/ACEND/content.aspx?id=6442485290



https://www.cdrnet.org/new-graduate-degree-eligibility-requirement-effective-january-1-2024

https://www.cdrnet.org/new-graduate-degree-eligibility-requirement-effective-january-1-2024

https://www.cdrnet.org/competencies


21

13. Rogers D. Report on the American Dietetic Association/Commission on Dietetic Registration 2008 Needs Assessment. J Am Diet Assoc. f2009; 109(7):1283-1293.

14. Nyland N, Lafferty L. Implications of the Dietetics Workforce Demand Study. J Acad Nutr Diet. 2012; 112:(suppl 1):S92-S94.

15. Academy of Nutrition and Dietetics and Academy of Nutrition and Dietetics

Foundation. The Nutrition Impact Summit Briefing Paper: Food, Wellness, Health

Care: Connecting Strengths, Inspiring Innovation, Scaling Up Solutions. September

2016.

16. Skipper A, Lewis NL. A look at the educational preparation of the health diagnosing

and treating professions: Do dietitians measure up? J Am Diet Assoc.2005;

105(3):420-427. 17. Working for Health and Growth Investing in the Health Workforce. High-Level

Commission on Health Employment and Economic Growth.

http://apps.who.int/iris/bitstream/10665/250047/1/9789241511308-eng.pdf?ua=1.

Accessed January 30, 2017.

18. Division for Sustainable Development Knowledge Platform. Division for Sustainable

Development Department of Economic and Social Affairs.

https://sustainabledevelopment.un.org/sdg2. Accessed January 31, 2017.

19. Academy of Nutrition and Dietetics. Nutrition Impact Summit. September 21-23,

2016, 2016, Irving Texas.

20. The Academy Quality Management Committee and Scope of Practice Subcommittee of the Quality Management Committee. Academy of Nutrition and Dietetics: Scope of practice in nutrition and dietetics. J Acad Nutr Diet. 2013; 113 (suppl 2): S11-S16.

21. The Academy Quality Management Committee and Scope of Practice Subcommittee of the Quality Management Committee. Academy Definition of Terms: A List of Terms with Associated Definitions and Key Considerations. J Acad Nutr Diet. 2013; 113 (suppl 2): S9. http://www.eatright.org/scope. Accessed March 3, 2017.

22. Academy of Nutrition and Dietetics Quality Management Committee and Scope of Practice Subcommittee of the Quality Management Committee. Academy of Nutrition and Dietetics: scope of practice for the registered dietitian. J Acad Nutr Diet. 2013; 113(6 suppl 2):S17-S28.

23. Academy of Nutrition and Dietetics Quality Management Committee and Scope of

Practice Subcommittee of the Quality Management Committee. Academy of

Nutrition and Dietetics: scope of practice for the dietetics technician, registered. J

Acad Nutr Diet. 2013; 113(6 suppl2):S46-S55

24. The Academy Quality Management Committee and Scope of Practice Subcommittee of the Quality Management Committee. Academy of Nutrition and Dietetics: Revised 2012 standards of practice in nutrition care and standards of professional performance for registered dietitians. J Acad Nutr Diet. 2013; 113 (Suppl 2): S29-S45.

25. The Academy Quality Management Committee and Scope of Practice Subcommittee of the Quality Management Committee. Academy of Nutrition and Dietetics: Revised

http://apps.who.int/iris/bitstream/10665/250047/1/9789241511308-eng.pdf?ua=1

https://sustainabledevelopment.un.org/sdg2

http://www.eatright.org/scope


22

2012 standards of practice in nutrition care and standards of professional performance for dietetic technicians, registered. J Acad Nutr Diet. 2013; 113 (Suppl 2): S56-S71.

26. Focus Area Standards of Practice and Standards of Professional Performance for

Registered Dietitian Nutritionists. http://www.eatrightpro.org/sop. Accessed March

3, 2017.

27. Nutrition and Dietetics Career Development Guide. Academy of Nutrition and

Dietetics Web Site. http://www.eatrightpro.org/resource/career/career-

development/career-toolbox/dietetics-career-development-guide. Accessed

February 1, 2017.

28. American Dietetic Association, Commission on Dietetic Registration. Code of ethics

for the profession of dietetics and process for consideration of ethical issues. J Am

Diet Assoc.2009;109(8):1461-1467.

http://www.eatrightpro.org/sop

http://www.eatrightpro.org/resource/career/career-development/career-toolbox/dietetics-career-development-guide

http://www.eatrightpro.org/resource/career/career-development/career-toolbox/dietetics-career-development-guide

Appendix A

FROM THE ACADEMY

2212-2672/Copyright ª 2017 by theAcademy of Nutrition and Dietetics.http://dx.doi.org/10.1016/j.jand.2016.09.027

The Continuing Professional Education (CPE)quiz for this article may be taken at www.eatrightPRO.org. Simply log in with yourAcademy of Nutrition and Dietetics orCommission on Dietetic Registration usernameand password, go to the My Account section ofMy Academy Toolbar, click the “Access Quiz”link, click “Journal Article Quiz” on the nextpage, then click the “Additional Journal CPEquizzes” button to view a list of availablequizzes. Non-members may take CPE quizzes bysending a request to [email protected] is a fee of $45 per article for non-memberJournal CPE. CPE quizzes are valid for 1 yearafter the issue date in which the articles arepublished.

110 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

Visioning Report 2017: A Preferred PathForward for the Nutrition and DieteticsProfession
Jana R. Kicklighter, PhD, RDN, LD, FAND; Becky Dorner, RDN, LD, FAND; Anne Marie Hunter, PhD, RDN, LD, FADA, FAND;Marcy Kyle, RDN, LD, CDE, FAND; Melissa Pflugh Prescott, PhD, RDN; Susan Roberts, MS, RDN, LD, CNSC; Bonnie Spear, PhD, RDN, FAND;Rosa K. Hand, MS, RDN, LD; Cecily Byrne, MS, RDN, LDN
THE COUNCIL ON FUTUREPractice (CFP) was created as apermanent organized bodywithin the Academy of Nutri-

tion and Dietetics (Academy) respon-sible for formalizing an ongoingvisioning process to define futurenutrition and dietetics practice at alllevels, and to identify the educationaland credentialing needs required forfuture practitioners and theirdevelopment.The CFP is an Academy committee

that collaborates with the Accredita-tion Council for Education in Nutritionand Dietetics (ACEND), the Commissionon Dietetic Registration (CDR), and theNutrition and Dietetics Educators andPreceptors to project future practiceneeds for the profession of nutritionand dietetics. Future practice, accredi-tation, credentialing, and educationrepresent the four critical organiza-tional units and segments necessary toproduce new practitioners and assist

experienced practitioners in advancingtheir careers.One of the functions of the CFP is to

ensure the viability and relevance ofthe profession of nutrition and di-etetics by engaging in a visioning pro-cess to identify the preferred future ofthe profession. The Council developeda standardized process and guidelinesfor visioning and futures thinking in2014, based on a workshop conductedfor members of the CFP by futuristMarsha Rhea from Signature i, LLC.1

The current visioning process focuseson a 3-year program of work (2014-2017) and began with the use of ascanning framework comprising 16categories reflective of the society’sand the profession’s future needs andchanges.

METHODOLOGYIn July of 2014, the CFP utilized thescanning framework to identify andprioritize the following five categoriesfor the 2014-2017 visioning cycle (seeFigure 1):

� Translating Evidence-BasedResearch into Practice andPolicy;

� Food and Nutrition Systems andSustainability;

� Workforce Projections;� Education/Professional Develop-

ment; and� Economics/Market Forces.

A Visioning Process Workgroup ofthe CFP was appointed in 2014 to leadthe CFP’s efforts in the Visioning Pro-cess. The seven-member Workgroupincluded both current and past mem-bers of the Council. The Workgroupidentified a preliminary list of changedrivers and trends related to the five

ª 2

prioritized scanning framework cate-gories, based on CDR’s Workforce De-mand Study, Future Changes DrivingDietetics Workforce Supply and De-mand: Future Scan 2012-20222 andACEND’s Expanded Standards Commit-tee Background Report.3 Other Acad-emy units conducting their ownvisioning also shared their referencelists with the Workgroup, includingthe Foundation’s Future of FoodInitiative4 and ACEND’s Rationale forFuture Education Preparation of Nutri-tion and Dietetics Practitioners.3 Theselists were reviewed for pertinent ref-erences. Also, a systematic review ofresources published since 2010 wasconducted by the Academy’s Knowl-edge Center based on the five prioritycategories. Five databases, includingScience Direct, Taylor, Cochrane, Ovid,and Web of Science, were searchedusing general key words and phrases(eg, wellness and health promotion andregistered dietitians; employmenttrends and registered dietitians; trendsin population health and agricultureand registered dietitians) to identifyreferences pertaining to the fiveprioritized scanning framework cate-gories. Additional references wereidentified by reviewing the referencelists of pertinent articles and resourcesresulting from the systematic review.Finally, the Workgroup reviewed re-sources available through the WorldFuture Society and selected severalreferences related to the priority cat-egories for review. All of these com-bined search strategies resulted in atotal of 357 references, both internaland external, to the profession ofnutrition and dietetics. Referencesidentified as pertinent to the fiveprioritized scanning framework cate-gories by the Visioning Process

017 by the Academy of Nutrition and Dietetics.

http://crossmark.crossref.org/dialog/?doi=10.1016/j.jand.2016.09.027&domain=pdf

http://dx.doi.org/10.1016/j.jand.2016.09.027

http://www.eatrightPRO.org

http://www.eatrightPRO.org

mailto:[email protected]

FROM THE ACADEMYAppendix A

Workgroup were reviewed andanalyzed by Workgroup members andanalysts from the Academy’s EvidenceAnalysis Library. Reviewers identifiedwhether each reference supported anyof the preliminary change drivers andtrends and noted any new changedrivers and trends related to the fivepriority categories not previouslyidentified. Of the 357 referencesreviewed, 218 references were used inthe development of the Change Driversand Trends Driving the Profession: APrelude to the Visioning Report 20175

and the recommendations for theVisioning Report 2017.

SURVEY #1: PRIORITYSCANNING FRAMEWORKCATEGORIES AND TRENDSSURVEY OF CFP THINK TANKMEMBERS AND EXTERNALACADEMY ALLIANCEORGANIZATIONSBased on the CFP’s standardized pro-cess and guidelines for visioning andfutures thinking, the Workgroup sur-veyed members of the CFP’s think tank(n¼49) and individuals representingexternal Academy alliance organiza-tions (n¼15) in February 2015 to seektheir input on priority categories andtrends. Individuals identified the top 5categories from the 16 scanningframework categories and relatedtrends they believed would have themost impact on the future of thenutrition and dietetics profession in 10to 15 years. A total of 44 responseswere received (69% response rate). Theresults from this survey provided sup-port and helped validate the five cate-gories previously identified aspriorities by the CFP.According to the World Future Soci-

ety,6 the most common techniquesused in futuring include historicalanalysis, scanning for trends, trendanalysis, brainstorming, visioning, andconsulting others. Furthermore, theWorld Future Society states that mostfuturist methods strive for objectivitybut rely heavily on subjective humanjudgment. As a result of the Work-group’s literature review, input fromCFP think tank members and in-dividuals representing external Acad-emy alliance organizations, and theWorkgroup’s analysis, synthesis, andevaluation of all sources of information,as well as its collective judgment, 10

January 2017 Volume 117 Number 1

priority change drivers and their asso-ciated trends were identified. Becausethere is considerable overlap amongmany of the categories in the scanningframework, several of the changedrivers and trends also overlap andinteract, for example, technology is aseparate change driver, but it also im-pacts the genomics and simulationschange drivers.

SURVEY #2: CHANGE DRIVERSAND TRENDS SURVEYA document including the 10 prioritychange drivers, their associated trends,rationale, and implications, along witha glossary and references, was releasedto Academy members, CDR-credentialed dietetics practitioners,CFP think tank members, and Academyexternal organization liaisons onNovember 12, 2015. An electronicChange Drivers and Trends Surveyasking participants to rate each prioritychange driver and trend on a scale fromstrongly disagree (1) to strongly agree(4) and to select their top five changedrivers (ranking) was conductedthrough December 17, 2015. Partici-pants were also given an opportunityto submit written comments related tothe priority change drivers eitherindividually or as a representative of anAcademy organizational unit.Data on the survey distribution and

response rate and information on sur-vey respondents are provided inTables 1 and 2, respectively; 3.7% ofthose who received and opened the e-mail communication completed thesurvey (n¼1,786). Eighty-five percentof those who completed the surveywere Academy members (n¼1,524).Demographic characteristics of the re-spondents to the Change Drivers andTrends survey were similar to those inthe Academy’s 2015 Compensation andBenefits Survey,7 except there weremore educators and doctoral degreerespondents in the current survey.Based on the scale from 1 to 4,

mean�standard deviation scores forthe 10 priority change drivers rangedfrom a high of 3.68 � 0.53 (stronglyagree) for Food Becomes Medicine inthe Continuum of Health to 2.94 � 0.77(agree) for Population Health andHealth Promotion Become Priorities.Triangulation between two separatedata points, the ratings and rankings,was used to further examine the data.

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Results are shown in Table 3. Based onconsistency among ratings and rank-ings, the top-tier change drivers thatemerged included Food BecomesMedicine in the Continuum of Health,Aging Population Dramatically ImpactsSociety, and Accountability and Out-comes Documentation Become theNorm. However, change drivers in themiddle and bottom tiers were alsoperceived as important by respondents.The lowest mean rating for any changedriver approached 3 (agree) and 8 ofthe 10 change drivers were selected asone of the top 5 change drivers by atleast 40% of the respondents. Data werealso examined based on age and yearsin practice and there was only onemajor difference across these sub-groups. Consumer Awareness of FoodChoice Ramifications Increases was oneof the most frequent change driversranked in the top 5 among those with<9 years of dietetics experience(64.7%) and significantly less frequentamong those with 10 to 29 years and>30 years of experience (55.2% and49.7%, respectively; P<0.001).

Twelve pages of typewritten com-ments were submitted in response tothe Change Drivers and Trends Surveyby individuals and Academy organiza-tional groups; these comments werereviewed by the CFP Workgroup. TheWorkgroup determined that most ofthe comments submitted wereaddressed in the change driver docu-ment and utilized these commentswhen drafting the recommendationsfor the Visioning Report.

Based on results from the ChangeDrivers and Trends Survey, input fromthe CFP, and a thorough review of cur-rent Academy organizational unit ini-tiatives, the CFP Visioning ProcessWorkgroup considered implications ofall 10 change drivers, and in early 2016began drafting recommendations forthe Visioning Report.

SURVEY #3: SURVEY OF DRAFTRECOMMENDATIONSThe CFP Visioning Process Workgroupinitially drafted 31 potential recom-mendations and five statements ofsupport of Academy ongoing initia-tives. The statements of support weredeveloped to avoid duplication of cur-rent Academy initiatives. All Academyorganizational units, CFP think tankmembers, and Academy external

EMY OF NUTRITION AND DIETETICS 111

Society’s Future Needs and Changes

Demographics� Diversity� Generations� Geographic distribution� Financial and political disparities� Education levels

Client/Patient Needs, Preferences and Health Education� Lifestyles� Cultural values� Consumer trends� Health disparities� Health education� Health and nutrition literacy� Personal resources (income)

Food and Nutrition Systems and Sustainability� Food industry� Food systems management� Food and nutrition security� Food safety� Food-related environmental sustainability� Agricultural systems

Health care� Health care reform� Coordinated care� Health care delivery systems and models including long-term

care and acute care facilities� Alternative medicine/health� Access to primary care� Access to RDNsa and NDTRsb

� Quality care and outcomes

Public Health, Policies and Priorities� Obesity� Nutrition and physical activity across the lifespan� Chronic disease management� Health promotion and wellness� Changing the environment/infrastructure to

promote healthy lifestyle

Economics/Market Forces� Economic outlook� General employment trends

B WagesB Areas for job growth

� Delivery and payment for nutrition services� Public reporting of measureable results for nutrition services

Advances in Medicine, Science, and Technology� Genetics, genomics� Behavioral science� Information communication technologies� Mobile connectivity� Electronic health records

Global Context� Nutrition and dietetics practices in other countries� Migration/immigration and global workforce� Global professional collaboration� Trends in population health and agriculture


Education/Professional Development� Integrated didactic education and

supervised practice� Knowledge and continuing competence� Education programs and curriculum� Learning technologies and platforms

Work and Workplaces� Practice roles� Business models� Emerging opportunities� Competitive providers of nutrition and dietetics services� Work and family balance� Salaries and benefits

Workforce Projections� Supply and demand� Mobility and adaptability� Workplace settings and focus areas� Staffing models and ratios� Retention of RDNs, NDTRs, and dietetics

students/interns� Diversity of the workforce

Practice Requirements� Evidence-based practice� Business and entrepreneurial skills� Technology use� Education, counseling, and behavior change� Cultural competency� Interprofessional training and proficiency� Practice efficiency methods

(continued on next page)

Figure 1. Scanning framework highlighting the five priority categories identified for the 2014-2017 Visioning Cycle by the Councilon Future Practice.

FROM THE ACADEMY

112 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS January 2017 Volume 117 Number 1

Appendix A


Career Advancement and Leadership� Reward and recognition� Leadership and management� Drive and motivation� Mentoring new practitioners

Advocacy, Credentialing, and Licensure� Advocating for the profession� Patterns in credentialing in nutrition and dietetics� Competing and related credentials

Translating Evidence-Based Research into Practiceand Policy

� Research on effectiveness of nutrition services� Opportunities for practitioner/researcher

collaborations� New developments in nutrition and health

sciences� Informatics and data analytics� Translating research into policy

Values and Ethics� Evidence-based nutrition� Social responsibility� Personal integrity and professionalism

aRDNs¼registered dietitian nutritionists.bNDTRs¼nutrition and dietetics technicians, registered.

Figure 1. (continued) Scanning framework highlighting the five priority categories identified for the 2014-2017 Visioning Cycle bythe Council on Future Practice.


organization liaisons were sent a Sur-vey of Draft Recommendations toobtain their feedback on the value ofthe 31 potential recommendations inmeeting future practice needs of theprofession in spring 2016. Participantswere asked to indicate whether each ofthe 31 recommendations met each ofthe following six criteria by providing ayes or no response:

� increases the value of the regis-tered dietitian nutritionist (RDN)and nutrition and dieteticstechnician, registered (NDTR);

� increases the reach and influ-ence of the RDN and NDTR;

� responds to new practice needsfor the profession of nutritionand dietetics;

� empowers Academy members tobe visionary leaders and in-novators for the profession;

� meets emerging marketplaceneeds; and

� identifies educational or cre-dentialing needs required forfuture practitioners and theirdevelopment.

Participants were also askedwhether the recommendation had thepotential to cause harm or unintendedconsequences to the Academy, its di-visions, members, and the public, and if


so, to explain how and why. The lastsection of the survey gave participantsan opportunity to provide commentsand suggest additional recommenda-tions related to the 10 change drivers.The survey closed on May 31, 2016, andsurvey responses were analyzed usingboth quantitative and qualitativemethods.Forty-one organizational units

responded to the Survey of Draft Rec-ommendations, with an additional 37individuals responding on behalf of anorganizational unit. The 37 individualresponses were then categorized bytheir organizational unit and com-bined with the initial 41 organiza-tional unit responses for a total of 47organizational unit responses. Per-centages representing the number ofpeople or groups that indicated therecommendation met all six criteriawere calculated. Results revealedthat 28 of the 31 recommendationsreached �80% consensus for meetingall six criteria, suggesting support forthe majority of the recommendations.The three remaining recommenda-tions reached a consensus between70% and 74%.The CFP Visioning Process Work-

group reviewed the 318 written com-ments from the Survey of DraftRecommendations, which wereanalyzed and categorized into 18

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themes by Academy staff. Workgroupmembers agreed to decrease thenumber of recommendations to maketheir implementation more feasible.Upon further review of the commentsand themes, six themes were identifiedas a way to help prioritize and poten-tially eliminate recommendations:

� not within the Academy’spurview;

� concerns over financial burdenand return on investment;

� burden outweighs benefit;� recommendation solves a cur-

rent problem not a vision orsolution to a future problem;

� disagree with value of therecommendation; and

� dilution of RDN credential/blur-ring of professional lines.

Those recommendations where>10% of the comments fell under anyone of these six themes were firstevaluated for potential elimination.After additional review of both thequantitative and qualitative data,Workgroup members determined byconsensus which draft recommenda-tions to eliminate, retain, consolidate,and/or modify and edit. This processresulted in 12 recommendations andseven statements of support for Acad-emy ongoing initiatives for the 2017Visioning Report.


Table 1. Response rate to the Council on Future Practice’s Change Drivers andTrends Survey conducted in November 2015 among Academy members andCommission on Dietetic Registration credentialed professionals

E-mailed,n[94,353

Opened e-mailn[47,749

Began survey 3,253 (3.4%) 3,253 (6.8%)

Completed survey 1,786 (1.89%) 1,786 (3.7%)


RESULTS: CHANGE DRIVERS,TRENDS, ANDRECOMMENDATIONS FOR THENUTRITION AND DIETETICSPROFESSIONThe CFP’s 2014-2017 visioning processresulted in 10 priority change drivers,their associated trends (Figure 2) andimplications, 12 priority recommen-dations, and seven statements of sup-port for Academy ongoing initiatives.The recommendations were written toaddress information in the document,Change Drivers and Trends Driving theProfession: A Prelude to the VisioningReport 20175 (available on the Acad-emy of Nutrition and Dietetics websiteat: www.eatrightpro.org/visioning),which was informed by input fromAcademy members, CDR credentialeddietetics practitioners, Academyorganizational units, CFP think tankmembers, and Academy externalorganization liaisons. The recom-mendations are not intended to beall-inclusive, but rather specific, action-able items that can be pursued in thenext 10 to 15 years to advance theprofession of nutrition and dietetics.Each recommendation may addressmultiple change drivers, but is mostclosely aligned with the one changedriver noted in the next section, based

Table 2. Credential and Membership StatuChange Drivers and Trends Survey conductmembers and Commission on Dietetic Reg

Credential Status

Academy M

Member

Credentialed 1,436 (80.4%)

Noncredentialed 66 (3.7%)

Did not indicate whethercredentialed or not

22 (1.2%)

Total 1,524 (85.3%)

114 JOURNAL OF THE ACADEMY OF NUTRIT

on consensus among Workgroupmembers. The change drivers, theirtrends, implications, recommendations,and statements of support are listed inno particular order and are all impor-tant forces impacting the profession ofnutrition and dietetics.

CHANGE DRIVER: AGINGPOPULATION DRAMATICALLYIMPACTS SOCIETY

Exponential Growth of the AgingPopulation Has Dramatic andWide-Ranging Ramifications andEconomic Impacts onGovernment, Businesses,Families, and Health Care andSupport ServicesRationale. Since 2011, when the firstbaby boomers turned 65 years old,approximately 10,000 Americans turn65 each day.8 From 2010 to 2030, thepopulation of those 65 years and olderin the United States will swell from 13%to >20% as life expectancies, especiallyat the older ages, continue to increase.9

These population trends are projectedto escalate the prevalence of chronicdisease10 and functional and cognitivechallenges and create a health care costcrisis.

s of Survey Completers (n¼1,786) ofed in November 2015 among Academyistration credentialed professionals

embership Status

TotalNonmember

236 (13.2%) 1,672 (93.6%)

18 (1.0%) 84 (4.7%)

8 (0.5%) 30 (1.7%)

262 (14.7%) 100%

ION AND DIETETICS

Increasing rates of obesity andchronic diseases among older adultsdramatically impact the health caresystem and the economic burden ofdisease. The risks for preventablechronic diseases and disability in-creases with age.2 Almost 3 out of 4older adults11 and 2 out of 3 Medicarebeneficiaries have multiple chronicconditions.12 Treatment for Americanswith one or more chronic conditionsconsumes 86% of health carespending.13 Disease prevention andhealth maintenance for the agingpopulation are increasingly the focusfor improving quality of life andcontaining costs. Better nutrition andphysical and mental activity can pre-vent many chronic diseases,2 yetmany older adults are food insecure,and 83% do not consume a good-quality diet.14

The ratio of working-age (18 to 64years) people to retirees will decreasedramatically and strain national re-sources.8 Currently, 100 working-agepeople support every 19 people aged65 to 84 years old, but this ratio willchange to 100:30 by 2028; 33 working-age people currently support eachperson older than 85 years comparedwith 13:1 in 2046.9 Businesses andhealth professions will be impacteddramatically as older adults retire oralter their work lives.2 The nutritionand dietetics profession is continuingto age (2015: median age of 49 years;35% were 55 or older;7 2005: medianage of 44 years; 15% were 55 or older),15

and the anticipated attrition rate of 2%to 5% will impact the future supply ofnutrition and dietetics practitioners.2

Implications.

� Demonstration of the value/cost-effectiveness of evidence-basednutrition care in the prevention,treatment, and managementof malnutrition and chronicdisease in older populations isessential.3,10,14

� Training in geriatric nutritionand a variety of geriatric carespecialties to support optimalhealth and improve health out-comes for a diverse aging popu-lation in a variety of settings isneeded.2

� As the ratio of working-agepeople to retirees decreases, theresources of the country may


http://www.eatrightpro.org/visioning

Table 3. Rankings and ratings of the 10 change drivers from the Change Drivers and Trends Survey conducted in November2015 among Academy members and Commission on Dietetic Registration credentialed professionalsa

Change drivers Ranking %bMean ratingc–standarddeviation

Top Tier

Food Becomes Medicine in the Continuum of Health 77.6 3.68�0.53

Aging Population Dramatically Impacts Society 69.9 3.61�0.55

Accountability and Outcomes Documentation Become the Norm 57.4 3.43�0.61

Middle Tier

Population Health and Health Promotion Become Priorities 58.5 2.94�0.77

Consumer Awareness of Food Choice Ramifications Increases 56.6 3.23�0.68

Embracing America’s Diversity 42.6 3.42�0.61

Technological Obsolescence Is Accelerating 40.6 3.49�0.57

Bottom Tier

Creating Collaborative-Ready Health Professionalsd 47.0 3.37�0.61

Tailored Health Care to Fit My Genes 37.7 3.11�0.71

Simulations Stimulate Strong Skills 12.1 3.05�0.65

aChange drivers are presented in descending order of mean ranking.bPercent of respondents selecting the change driver in top 5.cMean ratings based on a scale from 1 (strongly disagree) to 4 (strongly agree).dThis change driver is in the bottom tier because of its low mean rating, even though its ranking percentage is higher than some middle tier change drivers.


shift from education to healthand caregiving to meet the needsof the older adult population.8

� An adequate supply of RDNs andNDTRs is needed to address theimpact of an older workforce andanticipated rate of attrition,including retirement.2

Recommendations.

� The CFP recommends the Acad-emy implement strategies to in-crease workforce capacity forthe nutrition and dietetics pro-fession to address workforceprojections, including the rec-ommendations in the 2011Dietetics Workforce DemandStudy, as well as ongoing work-force projections.

� The CFP recommends the Acad-emy evaluate existing strategies(eg, current online certificate oftraining programs in leadershipand executive management,mentoring programs) to equipAcademy members to fill lead-ership roles in key influentialand visible positions in order toaddress workforce projectionsand positions vacated byretirees.


CHANGE DRIVER: EMBRACINGAMERICA’S DIVERSITY

Increasing Racial and EthnicDiversity of the US PopulationRequires Innovative Solutions toImprove Health Equity, HealthLiteracy, Cultural Competency,and the Diversity of Nutrition andDietetics PractitionersRationale. The racial and ethnicbackground of the US population hasshifted dramatically during the past11/2 decades and continues to undergoa transformation.16 Hispanic and Asianpopulations have experienced the mostsignificant growth, and this trend isexpected to continue through 2060.16-18

By 2044, >50% of the US population isexpected to belong to a minoritygroup.16 Despite the changing US pop-ulation, the percentage of RDNs whoare men, black, Asian, or Hispanicchanged very little from 2002 to 2011,including the most recent registrants(first 5 years).19

Health equity is an increasinglyimportant public health prioritybecause of evolving US racial and ethnicdemographics. Health disparitiescontinue to exist and some have evenwidened among certain populations,

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despite decades of work to eliminatethem.20 Interventions that remove bar-riers to timeliness, emphasize patient-centered care, and promote equitableuse of evidence-based guidelines maypromote health equity gains.21 ThePatient Protection and Affordable CareAct (ACA) aims to advance health equityby reducing health insurance dispar-ities, improving access to providers,promoting increased workforce di-versity and cultural competence, andensuring that limited English profi-ciency individuals receive resources tocommunicate more effectively withhealth care providers.22,23

Under-represented groups are morelikely to access nutrition and otherhealth care services from professionalswho they perceive to be similar tothem.10 Community health workersand other lay educators will continueto be used to reduce health disparitiesand as a solution to the lack of diversityin the health care workforce.

Implications.

� RDNs and NDTRs should beculturally competent to interacteffectively and appropriately inthe workplace with patients/clients, peers, managers, and


Change Drivers Associated Trends

Aging Population DramaticallyImpacts Society

� Increasing rates of obesity and chronic diseases among older adults dramaticallyimpact the health care system and the economic burden of disease.

� Demand for health care services is increasing dramatically although fewer fundsare available to cover the cost.

� Disease prevention and health maintenance for the aging population areincreasingly the focus to improve quality of life and care and contain costs.

� An aging workforce impacts the economy, businesses, families and healthprofessions.

Embracing America’s Diversity � Community health workers and other lay educators will continue to be used toreduce health disparities and as a solution to the lack of diversity in the healthcare workforce.

� As the US population grows more diverse, stark differences between whathealth providers intend to convey in written and oral communications and whatpatients understand may increase and further exacerbate health disparities.

� Health equity is an increasingly important public health priority because ofevolving US racial and ethnic demographics.

Consumer Awareness of FoodChoice Ramifications Increases

� Agricultural challenges and rapidly changing technology present entrepre-neurial opportunities as food companies seek innovative ways to meet con-sumer demand for healthy foods and demonstrate their social responsibility.

� Siloed approaches to agriculture, health, sustainability, and economics are beingabandoned for transdisciplinary solutions to reduce hunger, poverty, disease,and environmental destruction.

� There is a growing interdependence of countries around the world in sustainingthe planet’s national resources.

� Consumers demand increasing levels of food transparency to meet their health,social justice, and environmental stewardship aspirations.

Tailored Health Care to Fit MyGenes

� Advances in research and increased demand for personalized health andnutrition result in increased availability and decreased costs of genetic testing.

� Health professionals increasingly manage patient care using genetic profiles butthe science of genetics must continue to advance to inform practice.

Accountability and OutcomesDocumentation Become the Norm

� Health care evolutions necessitate increased research and quality improvementactivities.

� The application of informatics facilitates and optimizes the retrieval, organiza-tion, storage, and use of data and information for decision-making.

� Practicing RDNsa do not regularly evaluate and conduct research or accessevidence-based resources for guidance in clinical practice.

Population Health and HealthPromotion Become Priorities

� Evidence-based and multifactorial interventions that access levels of influence atthe policy, systems, and environmental level of the social ecological frameworkare essential to address population health priorities.

� Institutions, organizations, and governments are increasingly striving for policychanges that are informed by research, help create a culture of health, and makehealthy choices the easy choices.

� The ACAb paves the way for tremendous growth and unprecedentedopportunities in workplace health promotion and disease preventioninterventions.

� Hospitals redefine their roles in the continuum of health care services andbecome immersed in the daily culture of the communities they serve.

(continued on next page)

Figure 2. Ten priority change drivers and their associated trends for the Council on Future Practice’s 2014-2017 Visioning Cycle.

FROM THE ACADEMY

116 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS January 2017 Volume 117 Number 1

Appendix A

Change Drivers Associated Trends

Creating Collaborative-ReadyHealth Professionals

� Transdisciplinary professionalism is becoming an essential ideology for a 21stcentury health care system.

� IPEc is an increasingly essential strategy for preparing the health care workforcefor a patient-centered, coordinated and effective health care system.

� A resurgence of interest in IPE has occurred with the goal of team-based carebecoming the norm in health care.

� Many difficulties and challenges exist to the successful implementation of IPEbut innovative approaches can help overcome some of the challenges.

Food Becomes Medicine in theContinuum of Health

� Innovations by food and nutrition-related industries are capitalizing onconsumer’s growing passion for nutrition and health.

� Unprecedented opportunities to lead preventive aspects of health arise fromhealth care reform and emerging models of health care.

� Nutrition and MNTd are poised for primetime with the high prevalence ofobesity and its related diseases.

Technological Obsolescence isAccelerating

� Innovative digital technologies personalize, revolutionize, and increase access tohealth care.

� Technological applications, economics and student demands disrupt traditionaleducational institutions.

� Technological advances impact work settings and change how, when, andwhere people work.

� The digital age is transforming next-generation food systems.

Simulations Stimulate Strong Skills � Simulations help address increased complexity of health care, higher patientacuity levels, and patient safety.

� Accountability of care, pay for performance, and financial penalties for providererrors spur interest in simulations.

� The use of simulations increases in response to cost-cutting in higher educationand reduction in the availability of clinical placements for students.

� The desire to improve critical thinking skills of learners drives the developmentand use of simulations.

aRDNs¼registered dietitian nutritionists.bACA¼Patient Protection and Affordable Care Act.cIPE¼interprofessional education.dMNT¼medical nutrition therapy.

Figure 2. (continued) Ten priority change drivers and their associated trends for the Council on Future Practice’s 2014-2017Visioning Cycle.

FROM THE ACADEMY

Ja

Appendix A

subordinates from differentethnic and racial groups.

� New and innovative ways to re-cruit and retain minority andunderrepresented students innutrition and dietetics programsare needed.24,25

� There is a need for increasedlanguage skills among RDNs andNDTRs, with fluency in Spanish,French, and Cantonese beingsought most frequently.19

� The growth of community healthworkers presents an opportunityfor RDNs and NDTRs to superviseand educate these practitioners.

nuary 2017 Volume 117 Number 1

Statement of Support for Aca-demy’s Ongoing Initiatives.

� The CFP supports the Academy’sDiversity Committee in its effortsto increase diversity within theprofession as stated in objective#2 of the Diversity StrategicPlan: Objectives and Tactics2015-2020: Build an effectiveprogram of community outreachto identify and attract studentsfrom groups traditionally under-represented in the nutrition anddietetics profession (includingrace, ethnicity, and sex).

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CHANGE DRIVER: CONSUMERAWARENESS OF FOOD CHOICERAMIFICATIONS INCREASES

The Public Seeks MoreInformation About Their FoodAcross the Entire Supply Chainand Has Increased Awareness ofthe Global Ramifications of TheirFood ChoicesRationale. A growing social move-ment is underway where consumersdesire an increased connection to foodand nature.2,3,26,27 Today’s consumersseek transparency on how, where, and



by whom their food is grown, pro-cessed, packaged, and distributed, andhow revenues from their purchasesare allocated.28,29 Recent studiesindicate public support, includingsupport among racial minority andlower-income groups, for organic,local, nonegenetically modified, andnonprocessed food.30,31 Local foodsales have increased from $5 billionin 2008 to $11.7 billion in 2014,32

and are expected to outpace totalfood and beverage retail sales over thenext 5 years to reach $20 billion in2019.33

Increased public interest in the USfood supply is accompanied by globalconcerns over the world’s growingpopulation, which is slated to reach 9billion by 2050.34,35 Concurrently, therisk of climate change, high amounts offood waste, and high-yield gaps un-derscore the need to produce morefood using the same amount of landand fewer inputs.35-37 Greater urbani-zation,35,38 growing internationaltrade,39 and planet-wide ramificationsof poor environmental stewardshiprequire a global approach to food andagricultural systems.38,40,41

Agriculture is a major contributor togreenhouse gas emissions36,42,43 andwater constraints.36,44 If currentdietary trends hold, they are projectedto create an 80% increase in globalgreenhouse gas emissions and globalland clearing, while simultaneouslycontributing to high rates of chronicdisease.45 Globally, about 70% of thetotal water that is withdrawn fromsurface water and groundwater isused for irrigation,46 and there aregrowing concerns about agriculturalpesticides and herbicides contami-nating the water supply throughleaching, runoff, and spray drift.29,47,48

In response, increasing numbers ofconsumers are likely to adopt sus-tainable diets.49

Implications.

� Future-focused dietary in-terventions will encompass waysto improve the health of theplanet, including food wastereduction and consumption offoods that minimize greenhousegas emissions and promote wa-ter conservation.44,50,51

� RDNs and NDTRs need educationon food systems production


practices and policies and shouldplay a key role in educating thepublic about the relationshipsamong diet, environment, andpublic health.52

� Food-sector jobs across all partsof the supply chain will increase,creating opportunities for foodbusiness entrepreneurs to utilizetheir education and leadershipskills to create high-payingjobs.53

� To capitalize on jobs created bythe local food movement, RDNsand NDTRs need to understandagricultural systems and howdiet choices influence localeconomies.

Statement of Support for Aca-demy’s Ongoing Initiatives.

� The CFP supports the Aca-demy’s Second Century initia-tive, including the NutritionImpact Summit, and opportu-nity areas on increasing foodresilience through the integra-tion of nutrition expertise withlocal and global agriculturalpractices and food systems,and on building capacity byexpanding training in foodsystems throughout the con-tinuum of education for NDTRsand RDNs.

CHANGE DRIVER: TAILOREDHEALTH CARE TO FIT MY GENES

Continuing Research andAdvances in Genetics andNutritional Genomics, with TheirAbility to Predict, Prevent, and/orDelay Illnesses and ChronicDiseases, Will Become theMainstay of Health Care in theFutureRationale. Genetics research con-tinues to accelerate, resulting inexponential advances in medicine andmedical knowledge.8 Ray Kurzweil,54 atechnology specialist, predicts that thefuture holds the promise of routinelyadding genes that are protective anddisabling genes that promote diseasesand aging. Genetic testing for diseasesfor which tests are not currentlyavailable will become more readilyavailable, making predictive, preven-tive, early detection, and personalized

ION AND DIETETICS

interventions, including personalizednutrition and lifestyle interventions,possible.2 Consumers want to learnabout their individual risks forfuture illnesses to promote theirhealth and prevent disease. Con-sumers look to Direct to Consumergenetic testing, which has becomeincreasingly available, as a means ofpredicting risk of disease.55 RDNs canassume an increasingly important rolein the emerging health care systemthat focuses on a genetic predisposi-tion model of health and disease,56

disease prevention, and integrativehealth care,3 with the possibility ofreceiving reimbursement for lifestyleand nutrition interventions andcounseling.2

Implications.

� Medicine is moving towardtailoring treatments to individ-ual genetic, environmental, andbehavioral characteristics toimprove patient responses. Ad-vances in nutritional genomicsoffer the promise of personal-ized nutrition and unprece-dented opportunities for theRDN, including reimbursementfor nutrition and lifestyleinterventions.

� The emerging genetic predispo-sition model of health and dis-ease can position the RDN as amajor force in health care.56

Designing nutrition in-terventions that incorporate apatient’s/client’s genetic profile isa task appropriate for specialistsand advanced practice RDNs.57

� RDNs working in the area ofnutritional genomics withininterprofessional teams willneed the scientific knowledgeand technical skills to interpretgenetic testing and to providepersonalized nutrition advicethat prevents or modifiesdisease risk. Specialized andadvanced knowledge and skillsare needed for RDNs to work inthe area of nutritional geno-mics.2,56-58

� RDNs function within andcollaborate with interprofes-sional teams59 to interpret ge-netic testing results and developpersonalized nutrition careplans.58 RDNs may assume



primary management of patientswhen food and nutrition are theprimary intervention.60

Recommendation and Statementsof Support for Academy’s OngoingInitiatives. The change driver on ge-netics and nutritional genomics isaddressed in the following recom-mendation and two statements ofsupport for the Academy’s ongoinginitiatives by use of the terminologyemerging areas of practice and 10change drivers:

� The CFP recommends the Centerfor Lifelong Learning collaboratewith Dietetic Practice Groupsand Member Interest Groups tocreate additional professionaldevelopment opportunitiesrelated to the 10 change driversfrom Change Drivers and TrendsDriving the Profession: A Preludeto the Visioning Report 20175 anddevelop additional online certif-icate of training programs, whichinclude integrated researchmodules, in emerging areas ofpractice to update and advancenutrition and dietetics-relatedknowledge and skills.

� The CFP supports ACEND inincorporating emerging areas ofpractice into standards andcompetencies of the curricula fornutrition and dietetics educationprograms.

� The CFP supports CDR in incor-porating competencies related toemerging areas of practice intothe Essential Practice Compe-tencies for the CDR’s Creden-tialed Nutrition and DieteticsPractitioners.

CHANGE DRIVER:ACCOUNTABILITY ANDOUTCOMES DOCUMENTATIONBECOME THE NORM

Increased Emphasis on Evidence-Based Practice andAccountability for DocumentingBeneficial and Cost-EffectiveOutcomes Become the Norm inHealth CareRationale. Health care costs in theUnited States have been rising in partdue to the aging of the population andprevalence of chronic disease.61,62


According to the Institute of Medicine,there is a “need for evidence aboutwhat works best for whom in order toinform decisions that lead to safe, effi-cient, effective, and affordable care.”63

The Institute of Medicine has set agoal that by “.2020, 90% of clinicaldecisions will be supported by accu-rate, timely, and up-to-date clinicalinformation and will reflect the bestevidence.”63

In addition, current and emerginghealth care delivery models are drivingthe demand for utilization of researchas the basis for policy development.63-67

The ACA aims to rein in health carecosts and improve quality of care andoutcomes through accountable careorganizations, Patient-Centered Medi-cal Homes, value-based purchasing,Centers for Medicare and MedicaidServices financial penalties for hospitalswith high readmission rates and nopayment for “never events,” such ashospital-acquired pressure ulcers.68

Practicing RDNs do not regularlyevaluate and conduct research oraccess evidence-based resources forguidance in clinical practice.69,70

Approximately 50% of RDNs consultevidence-based resources and readprofessional journals less than once amonth.69 Perceived barriers to researchinclude lack of confidence, expertise,skills, time, funding, and administrativesupport.70 RDNs are more likely toengage in research activities when theyare knowledgeable about evidence-based practice, possess a higher levelof education, have taken a researchcourse, and frequently read researcharticles.70

Implications.

� Organizations increasingly relyon data and outcomes to drivedecisions about priorities,including how and where theirlimited resources are utilized.

� RDNs require the necessary skillsto read, interpret, and applyresearch in their practice set-tings; conduct outcomesresearch; and utilize informaticsto enhance their ability to showpositive outcomes. Outcomesresearch is especially vital for thesurvival and advancement of thenutrition and dietetics profession

JOURNAL OF THE ACAD

and should be routinely con-ducted by RDNs.70

� RDNs must promote theirunique role in the identification,promotion, and documentationof how nutrition interventionsare cost-effective, lead to costreductions/savings, and improveoutcomes (clinical and patient-centered) to facilitate adoptionof effective interventions intoinstitutional and/or public pol-icies.71-74

� RDNs must be adept at identi-fying, treating, and documentingmalnutrition to ensure positivepatient outcomes and reim-bursement for health care facil-ities to cover the costs of caringfor malnourished patients.

� Organizations and RDNs withdata and outcomes to supporttheir interventions and validatetheir professional contributionsare more likely to receive reim-bursement and other funding inthe current and future environ-ment of limited health caredollars.

Recommendations and Statementof Support for Academy’s OngoingInitiatives.

� The CFP recommends theAcademy identify strategies toincrease the number of doctoral-prepared RDN educators andpractitioners to create a cultureof research and evidence-basedpractice within the professionand address the 2024 graduatedegree requirement for entry-level RDNs.

� The CFP recommends CDRrequire all credentialed dieteticspractitioners to obtaincontinuing professional devel-opment in evaluation and docu-mentation of nutrition andfiscally responsible outcomestailored to their area of practiceto demonstrate the value of theprofession.

� The CFP supports the Academy’scontinuing efforts with the USDepartment of Health and Hu-man Services’ Health Resourcesand Services Administration toinclude RDNs as essential healthproviders within the Bureaus of



Health Workforce and PrimaryHealth Care.

CHANGE DRIVER: POPULATIONHEALTH AND HEALTHPROMOTION BECOMEPRIORITIES

Health Care in the United StatesIncreasingly Focuses onPopulation Health to ImproveEffectiveness and Reach and Slowthe Growth of Health Care CostsRationale. Transformative change toimprove the health of populations andreduce health care costs is underway inthe United States.75 Forces convergingto bring a national focus to populationhealth include the ACA, aging of the USpopulation, and surge in nutrition-related chronic conditions.75,76 TheACA promotes population health by itsfocus on better care, better health, andlower costs.10,75 A culture change isrevolutionizing institutions as theymove beyond wellness programs toengage people at every level of theirorganizations in shifting their focustoward health promotion and diseaseprevention and creating a culture ofhealth as part of their daily practices.77

Hospitals are playing a central role increating a culture of health75,77 and arenatural leaders for workplace andcommunity-wide health promotioninterventions due to their mission,reach, and influence; hospitals canadopt model policies and practices thatpromote the health of both their em-ployees and patrons.77 Even the insti-tutional kitchen is now at the forefrontof an institution’s wellness mission.78

Some hospitals serve between severalthousand and up to 1 million meals peryear to employees, patients, and visi-tors, with each meal representing anopportunity to promote a healthychoice.77 People spend time in schools,workplaces, food outlets, neighbor-hoods, and communities, which are allimportant targets for policy-, systems-,and environmental-level interventionsas part of a social ecological, compre-hensive population healthapproach.10,79

Implications.

� More RDNs and NDTRs mustposition themselves for new andexpanded practice roles toaddress policy-, systems-, and


environmental-level interven-tions based on the socialecological model.10

� The profession should adjusttraining models to reflectemerging areas of practice inhealth promotion in communitysettings where people live, work,and play.80,81

� RDNs need skills to track effectsand evaluate policy change ini-tiatives designed to address theunderlying causes of environ-ments that foster poor dietaryintake.77,82

� Sustained engagement in advo-cacy and public policy is essen-tial to champion RDNs asqualified providers of populationhealth interventions.83,84

� Nutrition is a key component ofworkplace health promotion;RDNs and NDTRs have uniquequalifications to practice in thesesettings.10,85,86

Recommendation.

� The CFP recommends the Centerfor Lifelong Learning and theCommittee for Public Health/Community Nutrition provideprofessional development op-portunities for current nutritionand dietetics practitioners to in-crease their understanding andapplication of public healthprinciples and population healthto promote behavior change,extend their reach, and influencepolicy for the optimal health ofcommunities.

CHANGE DRIVER: CREATINGCOLLABORATIVE-READYHEALTH PROFESSIONALS

Transdisciplinary Professionalismand Interprofessional EducationAre the Cornerstones of Patient-/Client-Centered Care to HelpSolve Problems, Improve Safetyand Quality, and Drive InnovationRationale. The Institute of Medicinepublished three seminal publicationsbeginning in 1999 that focused onhealth care quality, patient safety, andtheir relationship to health professionseducation.87-89 These publications,along with the Institute for HealthcareImprovement’s 2008 “triple aim” ofbetter care, better health, and lower

ION AND DIETETICS

costs,90 provided a major impetus andurgency for rethinking team-basedcare and interprofessional relation-ships, and restructuring health pro-fessions education.91 The ACA reflectsthe triple aim and is responsible for theresurgence of interprofessional educa-tion (IPE).89 IPE and collaborativepractice are keys to transitioning afragmented health system to onecapable of improved health out-comes.92 IPE informs a pedagogy andcurricula redesign for preparing a newhealth care workforce capable of opti-mizing health system performance in acollaborative-ready, shared decision-making model.93 All health pro-fessions should integrate IPE into theircurricula to prepare practitioners forinterprofessional practice with theknowledge and skills to be effective21st-century members of the healthcare team. Professions that remainuninformed, outdated, and static are atrisk of being left behind. IPE offersRDNs a significant advantage insecuring a place at the “health caretable.”

IPE goals are to deliver patient-centered care that is safe, timely, effi-cient, effective, and equitable.94 IPEhelps develop the knowledge, skills,and attitudes for a reformed, “collabo-ration-ready” health workforce.92,93

“Interprofessional health care teamsunderstand how to optimize the skillsof their members, share case manage-ment, and provide better health ser-vices to patients . . ..”92 For health careprofessionals to work interprofession-ally, they must be educatedinterprofessionally.92

Implications.

� Nutrition and dietetics practi-tioners need sufficient IPE liter-acy and leadership skills to joinand lead teams where nutritionplays an important role.2

� Dietetics educators shouldembrace innovative ways toincorporate IPE into their pro-grams (eg, simulations and web-based resources, health fairs, andstudent-run clinics).95

� Engaging in IPE is an opportunityto actively promote a broaderunderstanding and appreciationof the RDNs’ role and how itdiffers from someone providinggeneral nutrition advice; RDNs



need to be “at the table” now tobe recognized and included asan essential interprofessionalhealth team member, particu-larly as one payment for servicescontinues to be the direction offuture reimbursement.65

� Well-designed studies to deter-mine how IPE affects patients,populations, and health systemoutcomes are needed.95,96

Recommendation and Statementof Support for Academy’s OngoingInitiatives.

� The CFP recommends the Acad-emy continue to increase itsvisibility and influence in na-tional efforts related to inter-professional education andpractice and enhance innovativecontinuing professional devel-opment in this area in collabo-ration with other health careprofessionals to promote andadvance the role of RDNs asessential health care providers.

� The CFP supports the Aca-demy’s, Nutrition and DieteticsEducators and Preceptors,’ andACEND’s advocacy work for in-clusion of nutrition and dieteticspractitioners in interprofes-sional education and practice,including ACEND’s 2017 Stan-dards for interprofessionalpractice as a core componentof nutrition and dietetics edu-cation programs.

CHANGE DRIVER: FOODBECOMES MEDICINE IN THECONTINUUM OF HEALTH

Nutrition and Medical NutritionTherapy Become Even MoreCritical in Current and FutureEmerging Health Care Models forTheir Pivotal Roles in Wellness,Health Promotion, DiseasePrevention, and DiseaseManagementRationale. The public’s explosion ofinterest in nutrition and wellness istransforming food retailers who arepositioning themselves as health caredestinations.97 As health care is dis-rupted and transitions from the medi-cal model to one of prevention andwellness, nutrition is poised to takecenter stage in health-promotion


and disease-prevention programs incommunity-based settings.10,82,86

Forces that are converging to positionnutrition and medical nutrition ther-apy as indispensable to health andwell-being include the prevalence ofobesity and its comorbidities, espe-cially among younger adults; the largehuman and financial burdens and costsof diseases associated with obesity andan aging population; and the recentrevelation that poor diet is the biggestcontributor to early death globally.98

Lifestyle risk-factor modification andweight management are essentialcomponents of health promotion anddisease prevention programs in work-sites, schools, community clinics,health clubs, social service programs,and other community settings.10

A transformation in health care isunderway, with primary care leadingthe way, and the concepts of preven-tion, wellness, and public healthgrowing in popularity.86 There areunprecedented opportunities to leadpreventive aspects of health due tohealth care reform and emergingmodels of health care. The emergingpatient-centered medical homemodel of care includes acute andchronic care and preventive nutrition-related services, but few RDNs are in-tegrated into and valued members ofthe Patient-Centered Medical Hometeam.67

Consumers are actively using foodsas medicine to address their healthconcerns and medical conditions.83

Food and nutrition-related industriesare capitalizing on consumers’ growingpassion for nutrition and health andare overhauling products to cater toconsumers’ desires for safe and healthyfoods.80 Food retailers are increasinglyinvesting in health and wellness; 70%of those surveyed perceive health andwellness programs as a significantgrowth opportunity and envisionpharmacists and RDNs as taking thelead.97 Supermarket RDNs areincreasing in numbers and can impactpublic health by reaching millions ofshoppers.99

Implications.

� Food-sector jobs may increase infood and nutrition-related in-dustries to support the public’sinterest in nutrition and health-ier lifestyles and meet the ACA

JOURNAL OF THE ACAD

mandates for nutrition labelingon restaurant menus and vend-ing machines.2,10

� RDNs must be proactive in pro-moting nutrition and positioningthemselves as an essential andvalued part of Patient-CenteredMedical Homes and otheremerging models of health care.

� Increased encroachment andcompetition in the areas ofwellness, health promotion, anddisease prevention may occurdue to explosion in the numberof nutrition-related credentialsand lack of regulatorystandards.100

� Adjustments in educationalmodels and credentials to reflectemerging areas of practice, suchas wellness and health promo-tion, may be necessary to remaincompetitive in the changinghealth care environment.80

Recommendations and Statementsof Support for Academy’s OngoingInitiatives.

� The CFP recommends the Centerfor Lifelong Learning collaboratewith Dietetic Practice Groupsand Member Interest Groups tocreate additional professionaldevelopment opportunitiesrelated to the 10 change driversfrom Change Drivers and TrendsDriving the Profession: A Preludeto the Visioning Report 20175 anddevelop additional online certif-icate of training programs, whichinclude integrated researchmodules, in emerging areas ofpractice to update and advancenutrition and dietetics-relatedknowledge and skills.

� The CFP recommends the Acad-emy promote collaborationamong Dietetic Practice Groupsand commit additional resourcesto position RDNs and other CDRcredentialed practitioners,consistent with their scope ofpractice, as local and globalleaders in the prevention, reduc-tion, assessment, and manage-ment of malnutrition across allpractice settings by increasingtraining in nutrition riskscreening, including nutrition-focused physical examinations,and by influencing public policy,



regulatory agencies, and otherhealth care practitioners.

� The CFP recommends the Acad-emy develop a standing group ofmember experts to advise theAcademy on controversial topicsin an evidence-based and timelymanner to increase the visibilityand credibility of the Academyand promote the role of theRDN and NDTR.

� The CFP recommends the Acad-emy take the lead in collabo-rating with other organizationsand groups on the developmentof standards and qualificationsfor individuals working in well-ness and health promotion/disease prevention programs toensure delivery of evidence-based nutrition services byRDNs and NDTRs to betteraddress nutrition-related healthdisparities.

� The CFP supports ACEND inincorporating emerging areas ofpractice into standards andcompetencies of the curricula fornutrition and dietetics educationprograms.

� The CFP supports CDR in incor-porating competencies related toemerging areas of practice intothe Essential Practice Compe-tencies for the CDR’s Creden-tialed Nutrition and DieteticsPractitioners.

� The CFP supports the Academyin its Second Century initiativeto foster a culture of innovationthroughout the Academy andprofession commencing with theSeptember 2016 NutritionImpact Summit and forthcominginnovations projects and utilizeinnovative communications toincrease member engagement inthe Academy’s mission andvision.

CHANGE DRIVER:TECHNOLOGICALOBSOLESCENCE ISACCELERATING

Advances in Technologies AreHaving Dramatic Impacts onHealth Care, Education,Employment, and Food SystemsRationale. Technology is transformingthe way we learn, work, and live. Our


lives now revolve around access toworlds of information, instantcommunication, and online shop-ping.101 The “perfect storm” has arrivedin health care as digital technologiesand online platforms emerge.102 Pa-tients can get a secure video doctorconsultation via their smartphones for$30 to $40.103

Innovative digital technologiespersonalize, revolutionize, and increaseaccess to health care. Telehealth en-ables society to address health careworkforce shortages in rural Americaas never before.104 Telemedicine in-terventions are as good as or betterthan traditional approaches to care.105

A teledietetics model is more cost-effective than a face-to-face model forlong-term weight reduction.106

Health and fitness apps are the fast-est growing category of digital tech-nologies, with an estimated worth of$4 billion in 2014, likely to increase to$26 billion by 2017.107 Nutrition apps,mostly geared to weight loss, supportadherence to diet monitoring.108 Futuremedicalized smartphones103 anddoctor-designed, patient-customizedmobile apps102 can potentiallydecrease the use of doctors and healthcare costs, reduce the need for expen-sive clinical trials,109 speed up care, andincrease patients’ control over theirown care.103

Consumers will become “CEOs oftheir own health” in the future, asbiometric sensors monitor their healthstatus and provide warnings to stopdisease before it happens.110,111 Asdigital citizens, we should value andappreciate the many benefits of tech-nological innovations, but we mustalso understand the many implica-tions and unanticipated consequencesto shape the technological future wedesire.101

Implications.

� RDNs should shift to higher-levelskills and services that cannot beautomated or programmed intoexpert systems.2

� RDNs and NDTRs can becomeleaders in mobile app develop-ment and research, focusing ontheir ability to produce dietarybehavior change.108,112

� RDNs and NDTRs who candevelop technological in-novations will be in demand.2

ION AND DIETETICS

� Digital literacy should be a partof the official curriculum to pre-pare all health care professionalsfor digital health caretechnologies.102

� Barriers to utilizing teledieteticsneed to be addressed in orderfor RDNs to embrace tech-nology.104,112,113

Recommendation.

� The CFP recommends the Acad-emy initiate pilots and generateoutcomes data on the provisionof nutrition services using tech-nology (eg, telehealth or tele-nutrition) and develop aframework (eg, overcoming bar-riers, “how to”s, reimbursement,etc) for practitioners utilizingthis method of delivering nutri-tion services.

CHANGE DRIVER: SIMULATIONSSTIMULATE STRONG SKILLS

Use of Simulation as anInstructional Methodology andthe Amount of Research Focusedon Simulations in Health CareEducation Has BecomeIncreasingly Popular in the LastFew DecadesRationale. By simulating actual worksettings,114 simulations play a vital rolein training before employment, as wellas updating skills of current practicingprofessionals.115 When compared withclinical experience, research has shownsimilar or improved learner attainmentof knowledge and skills from simula-tion.116 The use of simulations in di-etetics education will continue toexpand because they are effectivepedagogical tools, consistent withcompetency-based education, and havethe potential for cross-discipline com-petency development.117

Simulations help address increasedcomplexity of health care, higherpatient-acuity levels and patient safety.Consistency in students’ simulated ex-periences can enhance the quality ofpatient care.116,118,119 Learners canmake mistakes in simulated scenarios,learn from their mistakes, and rehearseclinical behaviors in a low-risk envi-ronment, thus decreasing harm to pa-tients.115-117,119,120 Simulations thatpromote team settings, where pro-fessionals learn from, with, and about



each other can improve patient safetyand outcomes.115,117,119 Learners canpractice with complex situations in asafe, simulated environment beforeexperiencing similar cases in realpractice, which results in increasedlearner skills, confidence, and potentialfor employment.114,116,118-120 Simula-tions used for continuing professionaleducation help maintain high stan-dards of care that regulatory bodies,professions, and the public demandbetter than traditional educationstrategies.115

GlossaryAccountable Care Organization: A model of

coordinated, high-quality care to their patientsAdvanced practice: The practitioner demons

teristics that include leadership and vision and dCultural competence: The ability of health

language preferences, and health practices ofaddition, competency includes communicating

Culture of health: The result of what happentoward health promotion as part of the daily pr

Interprofessional education: “. . . occurs wheffective collaboration and improve health outc

Medical nutrition therapy: An evidence-baseintervention/plan of care, and nutrition monitorindelay, or management of diseases and/or condi

Nutritional genomics: A broad term encompreveal phenotypic outcomes, including disease

Nutrition informatics: The effective retrievalnutrition-related problem solving and decisiontechnology.121

Patient-Centered Medical Home: A model ohealth care: comprehensive care; patient-center

Social ecological framework: A conceptualiindividual level includes people’s knowledge, skorganization level includes changes in organizatcommunity environments; and policy and systemand political actions.10

Sustainable diets: Diets with low environmesecurity and healthy lives for present and future

Telehealth: “. . . the use of electronic informatand professional health-related education, pubspecialized equipment, for such purposes as hvention/plan of care, and non-interactive (or pmethods of distance communications, for comm

Telemedicine: “. . . applicable to physicians anvia electronic information and telecommunicatreatment of medical conditions, to support c

Telenutrition: “. . . involves the interactive utelecommunications technologies to implementof care, and nutrition monitoring and evaluationapplicable.”121

Transdisciplinary professionalism: An approplines/professions, working in concert, are worth

Value based purchasing: “. . . a financial plaVisioning: A process in which a group describ

what could be, visualizes what excellence lookswants to “look” to insiders and outsiders and sothe perfect position for an organization or profe

World Future Society: A chartered nonprofit epeople interested in how social and technologicfuture, including forecasts, recommendations, amore years ahead.6


A severe shortage of supervisedpractice sites for clinical placementsfor students remains a challengefor dietetics education programs thatare under pressure to recruit andmaintain preceptors.119 By decreasingthe amount of time learners mustspend in facilities and relieving someof the pressure on supervised prac-tice sites, simulations can optimizescarce clinical education resources.119

Simulations can also address theunequal quality of various prac-tice sites and the inconsistent

health care in which groups of physicians, health cboth inside and outside of the hospital.68

trates a high level of skills, knowledge, and behavemonstrates effectiveness in planning, evaluating,organizations and practitioners to recognize thediverse populations, and to apply that knowledgein a way that is linguistically and culturally approps when an organization moves beyond wellness practice of the organization and engages people aten students from two or more professions learn aomes.”92

d application of the Nutrition Care Process (nutritiog and evaluation). The provision of medical nutritiotions.121

assing several fields, all of which involve how nutrierisk.58

, organization, storage, and optimum use of informaking. Informatics is supported by the use

f the organization of primary care that delivers ted care; coordinated care; accessible services; andzation of intervention targets and levels of influenills, and attitudes; the interpersonal level includesional policies, practices, and environments; the cos levels include changes in policies and social struc

ntal impacts that are economically fair and affordgenerations.49

ion and telecommunications technologies to suppolic health, and health administration. Telehealthealth promotion, disease prevention, diagnosis, coassive) communications, over the Internet, video-cunication of broad-based nutrition information.”12

d other practitioners, and is the use of medical infotions technologies to improve patients’ healthlinical care, or to provide health services or aidse, by a Registered Dietitian or Registered Dietitianthe Nutrition Care Process (nutrition assessment, nu) with patients or clients at a remote location, with

ach to creating and carrying out a shared socialy of the trust of patients and the public.124

n that links provider payment to improved performes the future it wants; visioning creates a picture oflike, and shows the best scenario for the time; it ilme say the vision is what you would describe if yossion.1

ducational and scientific organization founded in 1al developments are changing the future; serves asnd alternative scenarios, that help people anticipa

JOURNAL OF THE ACAD

experiences students obtain duringclinical placements.119

Implications.

� Simulations should be graduallyimplemented and integratedinto existing curricular struc-tures with deliberation andadequate evaluation to ensureprogram quality; research andevaluation should focus onthe optimal method and fre-quency of exposure, quality of

are providers, and hospitals align to provide

iors. The individual exhibits a set of charac-and communicating targeted outcomes.121

cultural beliefs, values, attitudes, traditions,to produce a positive health outcome. In

riate.122

ograms and undergoes “a fundamental shiftevery level.”77

bout, from, and with each other to enable

n assessment, nutrition diagnosis, nutritionn therapy typically results in the prevention,

nts and genes interact and are expressed to

mation, data, and knowledge for food andof information standards, processes, and

he following five core functions of primaryquality and safety.123

ce on behavior and behavior change: thesocial and peer influences; the institutional/mmunity level includes neighborhoods andtures and systems through policy advocacy

able and contribute to food and nutrition

rt long-distance clinical health care, patientwill include both the use of interactive,nsultation, therapy, and/or nutrition inter-onferencing, e-mail or fax lines, and other1

rmation exchanged from one site to anotherstatus, to engage in the diagnosis andhealth care personnel at distant sites.”121

Nutritionist, of electronic information andtrition diagnosis, nutrition intervention/planin the provisions of their state licensure as

contract that ensures multiple health disci-

ance by the health care provider.”68

the desired future status, affirms the best oflustrates how an organization or professionu had an overnight epiphany that illustrates

966 in Washington, DC; it is an association ofa neutral clearinghouse for ideas about thete what might happen in the next 5, 10, or



assessment tools, and impact onindividual learners and patientcare.119

� Simulations in dietetics educa-tion have the potential todecrease the number ofrequired hours in actual prac-tice settings (eg, clinical, man-agement, community), improvepreparation for supervisedpractice and improve criticalthinking skills, but simulationscannot and should not be usedto replace supervised practiceexperiences.117,119,120

� Simulations designed for use indietetics education programscould also be used to re- trainand update the skills of experi-enced RDNs and NDTRs.115

� Collaboration should be encour-aged among dietetics educatorsand with other health profes-sional education programsexperienced in simulations, withrespect to the development ofsimulation topics, design ofsimulations based on best edu-cation practices, and simulationevaluation data.114,117,119

Recommendation.

� The CFP recommends ACEND,Nutrition and Dietetics Educa-tors and Preceptors, and CDRwork collaboratively to establishminimum standards and recom-mendations for evaluations ofsimulations for use with di-etetics education programs andwith current credentialed prac-titioners for continuing profes-sional development and create,maintain, and promote a simu-lations bank featuring simula-tions that meet the standardsand are specific to differentlevels, areas of practice, andscopes of practice.

CONCLUSIONSThe Visioning Report of 2017 reflectsthe CFP’s work over the past 3 years,informed by input from Academymembers, CDR-credentialed dieteticspractitioners, Academy organizationalunits, CFP think tank members, andAcademy external organization liai-sons. The Visioning Report 2017 ispresented with support from the


members of the 2015-2016 and 2016-2017 CFP, Board of Directors ExecutiveCommittee, and House of DelegatesLeadership Team.Visioning is a continuous process and

includes a 3-year cycle of activities inwhich the CFP, with input from multi-ple stakeholders, defines a preferredfuture for the nutrition and dieteticsprofession. The outcomes of the 2014-2017 visioning process will help toinform the Academy and its organiza-tional units for moving the professionforward in the next 10 to 15 years. Theprofession will continue to evolve,impacted by an ever-changing world,and credentialed dietetics practitionersmust anticipate and be prepared forchanges in practice, education, andcredentialing. Although the future isunknown and we live in a time ofexponential change, the CFP and otherAcademy stakeholders must be proac-tive and visionary, and collectivelyshape the desired future of the pro-fession of nutrition and dietetics.

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AUTHOR INFORMATIONJ. R. Kicklighter is an associate professor emeritus, Department of Nutrition, Georgia State University, Atlanta. B. Dorner is president, Becky Dorner& Associates, Inc, and president, Nutrition Consulting Services, Inc, Dunedin, FL. A. M. Hunter is an associate professor, Department of BiomedicalSciences, Missouri State University, Springfield. M. Kyle is a diabetes and nutrition care coordinator, Pen Bay Medical Center, Rockport, ME. M.Pflugh Prescott is a postdoctoral fellow, Department of Food Science and Human Nutrition, Colorado State University, Fort Collins. S. Roberts isarea director of clinical nutrition and dietetics internship director, Baylor University Medical Center/Aramark Healthcare Nutrition Services, Dallas,TX. B. Spear is professor of pediatrics emerita, University of Alabama at Birmingham. R. K. Hand is director, Dietetics Practice Based ResearchNetwork, Academy of Nutrition and Dietetics, Chicago, IL. C. Byrne is former director, Academy of Nutrition and Dietetics, Chicago, IL.

Address correspondence to: Jana R. Kicklighter, PhD, RDN, LD, FAND, 6221 Traymore Trace Smyrna, GA 30082. E-mail: [email protected]

Address requests for reprints to: Marsha Schofield, Academy of Nutrition and Dietetics, 120 S Riverside Plaza, Suite 2000, Chicago, IL 60606.

STATEMENT OF POTENTIAL CONFLICT OF INTERESTNo potential conflict of interest was reported by the authors.

FUNDING/SUPPORTThere is no funding to disclose.

ACKNOWLEDGEMENTSThe authors would like to acknowledge the support and input of the members of the 2014-2015, 2015-2016, and 2016-2017 Council on FuturePractice, the Board of Directors Executive Committee, and the House of Delegates Leadership Team related to the development of the 2017Visioning Report. Also, the assistance and ongoing support of the following Academy staff was invaluable: Marsha Schofield, MS, RDN, LD, FAND,senior director, Governance, and Harold Holler, RDN, LDN, former vice president, Governance and Practice.








http://www.futuristspeaker.com

http://www.futuristspeaker.com

http://diamandis.com/blog/ripe-for-disruption-part-3

http://diamandis.com/blog/ripe-for-disruption-part-3

http://www.diamandis.com/blog/ripe-for-disruption-part-1

http://www.diamandis.com/blog/ripe-for-disruption-part-1

























https://net.educause.edu/ir/library/pdf/ERB1003.pdf

https://net.educause.edu/ir/library/pdf/ERB1003.pdf















http://www.eatrightpro.org/resources/practice/quality-management/scope-of-practice



http://health.gov/communication/literacy/quickguide/factsbasic.htm



https://www.pcmh.ahrq.gov/page/defining-pcmh

https://www.pcmh.ahrq.gov/page/defining-pcmh






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