Alyssa: Hello everyone, and welcome to the Fresh Focus Podcast. A podcast where we give you bite-sized food and nutrition tips to chew on in between office visits. I’m Alyssa, one of your Marion VA Healthcare System Registered Dietitian Nutritionists. My primary role with the VA is as a Home-Based Primary Care Dietitian. I am joined by Jessica Sneed, a Home-Based Primary Care Occupational Therapist. Hi Jessica, how are you today?

Jessica: Hey Alyssa, I’m doing well! I’m looking forward to talking with you today on this episode of Fresh Focus.

Alyssa: I’m so glad to have you! As I stated before, I am a Registered Dietitian with Home-Based Primary Care or HBPC. As an HBPC dietitian, I visit veterans in their homes, assess their nutritional status, and identify any needs that I can assist with to improve their overall health. There are several things that I assess during visits, including weight, fluid intake, diet recall, lab values, and chewing or swallowing difficulties. I also complete a nutrition-focused physical exam. Which can include a head-to-toe assessment of the patient to help identify any signs of nutrition deficiencies or malnutrition. The unique thing about being a dietitian in HBPC is that I can get a great picture of the veteran’s day-to-day life because I’m visiting them where they spend most of their time…their home! HBPC is also unique because each member of the team works closely together to provide veterans with the very best care. Since I have Jessica to help me out with this episode today, I would love to dig into 4 aspects of veterans’ care that the Dietitians and Rehab Therapists work together on- Fall prevention, Wound prevention, Self-feeding, and Meal preparation. So, Jessica, before we really dig in to those 4 areas, can you first tell us a little about what occupational therapy is?

Jessica: Occupational therapy is a client centered healthcare profession that focuses on promoting health and well-being through engagement in everyday activities. When I say, “everyday activities”, this could mean any activity that an individual completes that is meaningful to them. That could be things like taking care of yourself, managing household tasks, going to work or school, or being able to participate in your favorite hobbies, just to name a few. Let’s say I go to see a veteran and they tell me that their goal is to be able to complete their own grocery shopping, I will help them to identify the barriers that are keeping them from doing that task. It may be that they are having difficulty getting dressed in order to go shopping, maybe they cannot get into their car, or it could be that they do not have the endurance to complete the trip. Whatever the barrier may be, the veteran and I can create a plan to try to help them accomplish their goal.

Alyssa: That really gives us an understanding of what your role is in the veterans’ care team. It is so beneficial to have you as part of the HBPC team- our veterans are lucky to have you! How do you feel that dietitians and OT’s work together?

Jessica: Having a dietitian and therapist on the same team is so beneficial to the veterans we serve and there are several ways in which OT’s can incorporate nutrition into their practice. The veterans we serve may have a variety of physical, cognitive, or social impairments that can affect their ability to adhere to dietary recommendations. As an occupational therapist, I can help a veteran to identify the barriers that are keeping them from adhering to the recommendations that you have made. Once we have identified the barriers, we can begin to make modifications or implement strategies to help them to overcome these barriers. Since we work so closely together, we can collaborate to ensure that all the needs of our veterans are being addressed. For example, I know just recently we were able to work together to help a veteran with some significant mobility issues. He was skipping meals frequently because of weakness and fear of falling when he went into the kitchen to prepare a meal. As the OT I was able to get him a walker and teach him some strength strategies to reduce his fall risks when ambulating. And as the dietitian you were able to provide some education on healthy meals that didn’t require extensive preparation to limit his time in the kitchen. It’s great to see the impact our collaboration has had on him and the rest of the veterans we serve.

Alyssa: I absolutely agree! I find it so beneficial to be able to work together to help veterans and to make sure they get the most well-rounded care. Now that we know a little more of the basics of how the OT’s and Dietitians work together, let’s start looking at those areas that we mentioned earlier, starting with fall prevention. Falls are a significant concern for older adults, often leading to serious injuries and a loss of independence. As the Rehab Therapist, Jessica’s role in fall prevention is obvious, right? But did you know that dietitians can also help older adults stay on their feet and live healthier, safer lives? Dietitians can help prevent falls by promoting bone health. This is done by ensuring that older adults are getting enough calcium and vitamin D from dietary sources like dairy products, leafy greens, and fortified cereals or if needed, from supplements. We can prevent falls by helping older adults maintain their muscle mass and strength because as we age, muscle loss can lead to frailty and increased fall risk. Dietitians can educate veterans on the importance of adequate protein intake to keep their muscles strong. If inadequate, we can provide tips on ways to incorporate more protein-rich foods like lean meats, dairy products, nuts, and beans into their diet. Dietitians can prevent falls by reducing veterans’ risk of dehydration, which can lead to dizziness and confusion. We can tailor hydration plans based on individual fluid needs and provide the education and tips on how to meet their daily goal. Many older adults are on multiple medications. Dietitians can review all of their medications and identify any potential interactions with nutrients from the foods they eat. This can prevent falls because some interactions may lead to impaired balance or coordination. Finally, proper nutrition supports overall health and energy levels. Dietitians ensure that older adults consume a balanced diet and help them to maintain a healthy weight. This can help them stay active and engaged, reducing the risk of falls. Jessica, in addition to fall prevention, OT’s and Dietitians work together on wound prevention. Can you tell us a little more about that aspect of veterans’ care?

Jessica: Absolutely! We know that compromised nutrition is not only associated with wound development, but it can also delay wound healing. Of course, our goal is always to prevent wounds and OT’s and dietitians both play a key role in wound prevention. As an occupational therapist, I assess for skin breakdown at each visit. Often, I will issue cushions to help with pressure reduction that can occur with prolonged sitting or air mattresses if needed for pressure that could occur while lying in bed. There are a lot of different options for pressure reduction and prevention is key! Proper nutrition, use of appropriate footwear (especially for veterans who are diabetic), frequent repositioning, and remaining active are all important components of prevention. I tell all the veterans that I see, if you have been sitting for an hour, it’s time to get up and move! Even a short walk across the room or throughout the house is so beneficial.

Alyssa: definitely, that is such good advice, of course our goal is to prevent skin breakdown or wound development however if a veteran does have a wound nutrition plays a key role in wound healing. As a dietitian I can provide nutrition education on factors that are critical for healing like optimal hydration adequate protein, blood glucose control in veterans with diabetes and vitamin and mineral supplementation. Nutrition needs change when wounds are present as the dietitian, I want to help make sure those needs are met so Jessica you know one thing I always assess while in veterans’ homes is their ability to feed themselves. Some of our veterans have physical limitations due to current or past medical problems that hinder their ability to feed themselves. I know you are an incredible resource to me when I have a veteran that needs help with self-feeding. Can you share a little bit more about how you may be able to help someone struggling with feeding themselves?

Jessica: Yes, there is so much equipment available to our veterans to help with self-feeding! Often people have difficulty holding onto utensils and something as simple as built-up utensils and a divided plate is all that is needed. I also see quite a few veterans who have tremors that are affecting their ability to feed themselves. In this case, weighted utensils or self-stabilizing/anti tremor utensils are often beneficial. Depending on the specific diagnosis, there is a variety of different equipment that can help with self-feeding. If anyone on the team notices that someone is struggling with self-feeding, they will notify both the dietician and therapist so that we can assess for appropriate equipment recommendations.

Alyssa: Great! Another thing that I tend to see quite often with our HBPC veterans is difficulty with preparing food for themselves. Is that something you have seen as well? And if so, is that something you can assist with?

Jessica: This is very common and is absolutely something that an occupational therapist can address! There is a lot that goes into preparing a meal. Does the veteran have the upper body range of motion needed to reach into the cabinets or do we need to look at making environmental changes? Do they have the balance that is required to reach overhead or into the lower cabinets? They may benefit from some balance training exercises. I see a lot of veterans who just don’t have the endurance to stand long enough to prepare a meal. In this case, we can teach people to how to break down the tasks into smaller steps, completing a little at a time throughout the day. Can some of the meal prep be completed in a seated position to conserve energy? I also recommend making extra so that you have 2-3 meals instead of just one. People who are using a walker often have difficulty in the kitchen because they do not have their hands free to be able to pick up and transport items. There are various types of walker trays available to help with this and you can also “scoot” items across the counter. I also recommend keeping items that are frequently used within reach; the countertop or the lower shelf of the cabinets are the perfect height for this. With a little bit of rearranging, you will find that most of what you use daily will fit in those 2 places. If you are having difficulty preparing or eating your meals, I highly recommend speaking with an occupational therapist.

Alyssa: Wow, what awesome information. Thank you so much for taking the time to join me today. I think what we have discussed will really give listeners a great understanding of what Dietitians and Occupational Therapists do overall, and as part of the Home-Based Primary Care program here at the VA. And to everyone listening, we want to say thank you and hope you have enjoyed this episode of Fresh Focus! Be sure to listen to the next episode in the series where another HBPC Dietitian is joined by an HBPC Social worker to discuss their roles in the program. Thank you everyone and have a great day!