When supporting major trauma clients after their discharge into the community, how often do you request funding for private dietetic input? How often are these requests approved?

Many clients after a major trauma require physiotherapy, occupational therapy and psychology as standard.  This means that solicitors and insurance companies are used to seeing these types of requests and are very likely to approve them.

The benefit of dietetic input for these clients, however, has been overlooked for many years.  Case managers don’t always think to ask for dietetic input and sometimes when they do, funders don’t approve these requests because they are less familiar with the benefits of dietetic input for these clients.  It’s therefore up to the case manager to make a very compelling case as to how dietetic input can pre-empt and/or resolve certain problems and streamline a client’s rehabilitation.

Why is nutrition important after a major trauma?

An analogy can be helpful to understand this point.  If you think of your body like a house with a live-in renovation team inside, then it makes sense that the food you eat breaks down into the nutrient building blocks that your renovation team needs to repair any damage that occurs inside or outside the house/body (e.g. broken bones, skin damage, etc).  High-quality nutrient building blocks from healthy food allow your renovation team to make the repairs to a high standard.  Conversely, a diet comprised primarily of fast food, takeaway, ready meals, biscuits, and chocolate, will be missing many of the key nutrient building blocks needed to repair the damage after a major trauma or injury.  When nutrient building blocks are missing, the renovation team can’t do their job well and the consequences are a) the repairs don’t happen at all (e.g. nonunion of a bone), b) the repairs take longer than they should (e.g. a slow healing wound) or c) the repairs are done but not to a very high standard (e.g. skin that is paper thin and tears easily).

Top 7 “red flags” when case managers should be requesting dietetic input

• Malnutrition – when the client has a Malnutrition Universal Screening Tool (MUST) score of 2 or higher.

• Upcoming elective surgery – particularly when intermediate or complex surgeries are being planned.

• Gut-related issues – especially if chronic abdominal pain, diarrhoea, vomiting and/or constipation persist in spite of being on medication.

• Diabetes – particularly if the HbA1c is over 55mmol/mol.

• Weight management – any time a client has a BMI over 30kg/m2, and/or who has unintentionally gained 10% or more of their body weight within the last 6 months and/or who has had (or is considering) bariatric surgery.

• Grade 3 or 4 pressure sore or slow healing wound

• Nonunion or slow bone healing

For more information on each of the above “red flags” and for reference articles outlining the benefit of dietetic input for each of the above conditions, please go to our other article “Red flags and evidence for dietetic input.”

11 steps to requesting funds for private dietetic input (for major trauma clients)

For the reasons outlined above, case managers will need to justify the benefits of dietetic input and outline the potential consequences to the client if the funding is not approved.

1.  Flag up any issues with diet, nutrition and weight early on (e.g. in your Immediate Needs Assessment).

Make sure your case management Immediate Needs Assessment screens clients for malnutrition (using the MUST screening tool) and asks questions about weight changes, changes to food intake and changes to taste or smell.  All of these factors may highlight a current or future dietetic problem or need.  Give some thought as to how you can objectively measure and articulate any dietetic needs the client may have (examples below).  Alternatively, contact Specialist Nutrition Rehab if you need help understanding how to screen clients and/or evidence the need for dietetic input.

Some dietetic and weight issues may resolve on their own, which is fine.  However, it’s easier for funders to agree to something which is flagged up early in the process, because it allows them to request and/or allocate the necessary funds early on.  Once interim funding has already been agreed, significant costs which were not anticipated are much more difficult to approve.

2.  State why you feel dietetic input is required and how it is expected to help.

Does this client need to see a dietitian due to one (or more) of the “red flags” mentioned above or is it for some other reason?  Be sure to include supporting evidence like the client’s MUST score, weight records, evidence of nonunion, evidence of slow wound healing or any concerning blood test results (e.g. HbA1c).

3.  State any other variables that make the client high risk.

Major trauma clients usually have multiple health challenges occurring simultaneously.  So while you may be referring a client for nonunion, the client may also be overweight, have chronic abdominal pain, and/or have high blood glucose levels.  All of these factors just support the need for dietetic input, so be sure to list all of them in your request for funding.

4.  State that dietetic input is needed to improve the risks outlined above.

Check out our article on “Red flags and evidence for dietetic input” if you need “evidence” for how dietitians can help, or do a Google search of past Specialist Nutrition Rehab blog articles for the hyperlinks to relevant research articles and NICE guidelines.

5.  State if any consultants or expert witnesses have recommended dietetic input.

Endorsements for dietetic input will give more clout to a case manager’s request.  If other members of the multi-disciplinary team feel dietetic input would be of benefit, encourage them to mention this in their clinic letters or reports!  Case managers may also want to specifically ask consultants whether dietetic input would be of benefit, so that this can be added to the consultant’s clinic letter as well.

6.  State when private dietetic input is needed vs NHS.

Anecdotally, wait times for NHS dietetic input are currently reported as 9-12 months in most areas, so do be sure to enquire about this.  Each region will also have different criteria as to which clients are eligible to see the NHS dietitians – with very malnourished clients (MUST score 3+), very obese clients (BMI over 40kg/m2), clients with gastrointestinal issues or PEG-fed clients generally taking priority.  NHS dietitians may not be able to attend multi-disciplinary team meetings or liaise with other private health professionals on the team, so do be sure to ask about this.  If you feel the NHS may not be able to meet the needs of your client, be clear about this in your funding request for private dietetic input.

7.  State how dietetic input relates to issues/problems linked to the client’s compensable injury.

Did the client have pre-existing problems with weight, managing blood glucose levels or gastrointestinal issues, or are these new problems since the client’s injury?  Will any of their pre-existing problems (e.g. diabetes or coeliac disease) interfere with the client’s rehabilitation now if not addressed? If these pre-existing conditions could interfere, be sure to articulate and acknowledge this in your funding request.  This will help the funding parties understand the challenges which will need to be overcome to help the client progress in their rehab journey.

8.  State what will happen if funding isn’t approved.

What are the consequences if dietetic funding isn’t approved?  For example, will blood glucose levels continue to remain high, putting the client at risk of other complications and delaying the client’s ability to engage in rehabilitation?  Will the client not be eligible for osseointegration or an exoskeleton because their weight is too high?  Will the client continue to be bedbound because of a pressure sore which isn’t healing?

If dietetic input is delayed and problems are not resolved, do you foresee rehab costs escalating?  For example, if HbA1c levels do not come down, the client may face several consequences.  Their surgery might be delayed, or they could require more surgeries or experience additional complications as a result of these surgeries.  They might also have less effective rehab due to frequent hospital visits for chronic UTIs.  Other potential issues include developing new problems, such as diabetic retinopathy or neuropathy and/or being unable to fully engage in physio or psychology due to fatigue.  All of these issues will just prolong a client’s need for rehab as well as the costs associated with this.

9.  State how the client will benefit if dietetic funding IS approved.

For example, a well-nourished client will recover from surgery quicker, have fewer complications and spend less time in hospital.  A client can engage better with physio when they don’t have excruciating abdominal pain.  Faster wound healing means being able to go out into the community quicker and being eligible for hydrotherapy.  A well-nourished client will get more out of their physio and psychology sessions because they can think more clearly and will have more energy.

10.  If the client had a poor diet pre-injury, state why dietetic input is needed now.

Clients with a poor diet pre-injury are at higher risk of nutrient deficiencies post-trauma and are less likely to have the habits, knowledge and skills needed to allow them to make dietary changes on their own.  Additionally, they may not be able to critique the nutrition information they get online and may be at higher risk of following advice that isn’t reliable or evidence-based or that might increase their risk of harm.

11.  Get the timing right.

Dietetic input is predominantly advice-based, which means that aside from getting blood tests done, clients will need enough headspace and motivation to implement any dietary changes which are recommended.  If clients are in the pre-contemplation or contemplation stages of change and/or overrun with expert witness appointments, that may not be the best time to engage the support of a dietitian.  Perhaps the client needs neuropsychology input first, before they feel ready to tackle diet and lifestyle changes.

It is possible to get funding approved for private dietetic input, but case managers need to be skilled in the best way to present this information to funding parties.  Not everyone is knowledgeable about the need for and/or benefit of engaging private dietetic input for major trauma clients (post-hospital discharge), so it’s up to the case manager to articulate this information in a way that everyone can understand and act upon.

If you are a case manager and would like to know if private dietetic input could be of benefit to one or more of your clients, please contact Specialist Nutrition Rehab at 0121 384 7087 or info@specialistnutritionrehab.co.uk.

A huge thank you goes to Margot Widdup, case manager from Unite Professionals, for assisting us with this article!