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What’s Missing from Your Plate? Nutrition Services Integration in Primary Care

Monday, April 10, 2017   (0 Comments)
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By Michele Guerrero, RD, Primary Care Nutrition Services Supervisor, Yakima Valley Farm Workers Clinic


Behavior change is hard. It’s a long and arduous process with lots of bumps in the road. Add in the barriers that many of our patients face – food insecurity, mental health conditions, homelessness, unemployment, addiction, ACEs – and it can seem downright impossible.

We know that most of the chronic health conditions that impact our patients and communities are related to lifestyle, especially eating patterns and physical activity. How can we support our patients and communities in making realistic, lasting, and impactful change? At Yakima Valley Farm Workers Clinic (YVFWC), we believe providing integrated Nutrition Services to our patients is one solution.

Registered Dietitians (RDs) are health professionals trained in evidence-based medical nutrition therapy and counseling. Despite the multitude of nutrition-related chronic conditions treated in primary care, RDs have not traditionally been included in this setting. Nutrition counseling often falls to other health professionals, although their training and experience in medical nutrition therapy and counseling may be limited. By integrating RDs, patients receive specialized and in-depth care while allowing primary care providers to focus on what they do best. At YVFWC, RDs are integrated side-by-side with primary care and behavioral health providers for ease of access.

“We are lucky to have Registered Dietitians available for our patients. Our office is able to provide a service at every visit that so many others would have to wait for through a referral process. Our RDs have been an excellent addition to our healthcare team. Without their expertise, our patients would be missing a very large piece of the healthcare pie!” says Natalie Miller, PA-C Clinic Medical Director at Rosewood Family Health Center in Portland, OR.


Josie Riggall MPH, RD teaches a group of patients with diabetes the plate method

YVFWC’s Nutrition Services Model of Care


YVFWC’s Nutrition Services model emphasizes same-day access to services and making contact with patients as part of their regular primary care provider clinic visit, in what is called a “warm hand-off” appointment.

Modeled after innovative behavioral health models of primary care integration, the nutrition warm hand-off minimizes obstacles to care and creates a more seamless flow. Brief 15-minute visits are conducted for acute nutrition concerns as well as chronic disease management and prevention immediately after the primary care provider visit. The RD uses motivational interviewing to provide patient-centered care that focuses on realistic, patient-determined goals rather than following a prescribed nutrition intervention. 

RD availability for warm hand-offs, which has the added benefit of increasing access for patients, is made possible by minimizing prescheduled appointments and keeping visits brief. With 75 percent of nutrition visits occurring on the same day as the primary care provider appointment, most patients--many of whom struggle with transportation barriers--have their immediate needs met at one time in one location. Furthermore, by combining related patient visits into one appointment, the problem of high “no-show” rates has been greatly reduced. 

In addition to providing medical nutrition therapy and chronic disease management support, RDs focus on disease prevention and addressing social determinants of health by working with the interdisciplinary team and collaborating with community partners. YVFWC has also worked to employ many multilingual RDs to provide services in the patient’s preferred language.

The YVFWC Primary Care Nutrition Services team


Organizational Contributions

The Nutrition Services team not only provides a valuable service for our patients but also contributes to key organizational measures. Each primary care Registered Dietitian led their respective clinic in designing workflows around and completing self-management counseling for Patient Centered Medical Home accreditation. 

The RDs contribute to a variety of other care metrics, such as decreasing Hemoglobin A1c values in patients with diabetes and providing nutrition and physical activity counseling to pediatric patients.

Through the course of implementing this innovative model and demand created for Nutrition Services, YVFWC has tripled staffing to 18 Registered Dietitians. 

“Integrating RDs into our primary care clinics was one of the greatest decisions that our organization made. Our patients have come to rely on utilizing their services as part of their standard of care when they visit our clinics,” says Erin Moller, Clinic Director at Salud Medical Center in Woodburn, OR. ”Additionally, I don’t think our medical providers could imagine ever going back to a model where RDs aren’t involved in the everyday care that is provided.” 

Mayra Nunez RD, CD, Rocío Peterson MS, RD, CD, and Dianely Acevedo RD, CD at a community health fair

YVFWC is a national leader in Nutrition Services integration. Registered Dietitians in primary care settings are difficult to find, making YVFWC’s program unique among health centers. The Primary Care Nutrition Services program is not only helping YVFWC meet critical care measures but is supporting patients and communities in making lasting behavioral change.



Michele Guerrero, RD, is the Regional Primary Care Nutrition Services Supervisor for ten Oregon and Washington clinics that are part of Yakima Valley Farm Workers Clinic’s network of care.

Yakima Valley Farm Workers Clinic is a nonprofit 501(c)(3) organization that provides comprehensive medical, dental, and social services for more than 141,000 people throughout the Pacific Northwest. Yakima Valley Farm Workers Clinic employs 1,390 full-time staff and more than 600 part-time staff, medical residents, dental residents, students and volunteers. Facilities: 19 medical clinics, 10 dental clinics, 57 programs. Locations: Washington State clinics are located in Grandview, Prosser, Pasco, Spokane, Sunnyside, Toppenish, Yakima, Walla Walla and Wapato. In Oregon, clinics are located in Hermiston, Portland, Salem and Woodburn. Visit: www.yvfwc.com.



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