SB0614: SUMMARY OF INTRODUCED BILL IN COMMITTEE (Date Completed: 10-21-21)

CONTENT

The bill would add Part 183A (Dietetics and Nutrition) to the Public Health Code to do the following:

-- Establish a licensing process for dietician nutritionists and nutritionists and prescribe the requirements an individual seeking licensure as a dietician nutritionist or nutritionist would have to meet.

-- Prescribe the scope of practice for a dietician nutritionist and a nutritionist.

-- Create the Michigan Board of Dietetics and Nutrition in the Department of Licensing and Regulatory Affairs (LARA), and prescribe its membership.

-- Require LARA in consultation with the Board to prescribe, by rule, continuing education requirements as a condition of license renewal.

-- Allow LARA in consultation with the Board to promulgate rules to supplement the requirements for licensure as a dietician nutritionist.

-- Require LARA in consultation with the Board to promulgate rules on appropriate supervision that were consistent with the range of prevailing professional standards.

-- Prescribe the requirements to qualify as a qualified supervisor for purposes of Part 183A.

-- Allow LARA to issue a license by endorsement to an applicant from another state that, at the time the applicant obtained his or her license from the other state, had licensure requirements substantially equivalent to Part 183A.

The bill also would amend Part 161 (General Provisions) of the Code to prescribe license fees for an individual seeking licensure as a dietician nutritionist or nutritionist under Part 183A.

Definitions

The bill specifies that in addition to the definitions in Part 183A, Article 1 (Preliminary Provisions) of the Code contains general definitions and principles of construction applicable to all articles in the Code and Part 161 contains definitions applicable to Part 183A.

Licensure

Under the bill, except as otherwise, if an individual were seeking a license as a dietitian nutritionist, he or she would have to meet all of the following requirements:

-- Hold a baccalaureate, master's, or doctoral degree from a college or university located in the State or another state that, at the time of graduation, was accredited in good standing by a United States institutional accrediting body for higher education recognized by the US Department of Education, and approved by LARA in consultation with the Board, or hold from a foreign educational institution an academic degree that was validated as equivalent by a credential evaluation agency recognized by the US Department of Education and is approved by LARA in consultation with the Board.

-- Have successfully completed a major course of study in human nutrition, dietetics, foods and nutrition, food systems management, or an equivalent course of study, as approved by LARA in consultation with the Board, fulfilling the didactic requirements of a program in dietetics accredited by the Accreditation Council for Education in Nutrition and Dietetics.

-- Have successfully completed an examination for dietitian nutritionists administered by the Commission on Dietetic Registration.

-- Have successfully completed a planned, documented supervised practice experience in the practice of dietetics and nutrition fulfilling the competency requirements of a program in dietetics that was accredited by the Accreditation Council for Education in Nutrition and Dietetics.

"Practice of dietetics and nutrition" would mean the integration and application of scientific principles derived from the study of food, nutrition, biochemistry, metabolism, nutrigenomics, physiology, food systems and management, and from behavioral and social sciences in achieving and maintaining health throughout the lifespan and in providing nutrition care services, including medical nutrition therapy, for the prevention, management, and treatment of diseases or medical conditions. The term would not include the medical differential diagnosis of the health status of an individual but would include each of the following:

-- Nutrition assessment.

-- Nutrition diagnosis.

-- Nutrition support.

-- Dietary and nutrition counseling and education.

-- Nutrition intervention.

-- Nutrition monitoring and evaluation.

-- Development and administration of nutrition care standards and systems.

"Nutrition diagnosis" would mean identifying and labeling nutritional problems managed and treated by a dietitian nutritionist or nutritionist. The term would not include the medical differential diagnosis of the health status of an individual.

The practice experience described above would have to include at least 1,000 hours under the supervision of a dietitian nutritionist or a registered dietitian nutritionist.

Except as otherwise provided, if the individual were seeking a license as a nutritionist, he or she would have to hold one of the following:

-- A master's degree or doctoral degree from a US regionally accredited institution of higher education approved by LARA in consultation with the Board, or a degree from an educational institution in another country that LARA in consultation with the Board determined was substantially equivalent to the master's or doctoral degree described in this provision, with a major course of study in human nutrition, foods and nutrition, community nutrition, public health nutrition, nutrition education, nutrition, nutrition science, clinical nutrition, applied clinical nutrition, nutrition counseling, nutrition and functional medicine, nutritional biochemistry, nutrition and integrative health, or an equivalent course of study, as approved by LARA in consultation with the Board.

-- A master's degree or doctoral degree in a field of clinical health care with a major course of study in nutrition with at least three years of clinical nutrition experience, as approved by LARA in consultation with the Board.

"Nutrition counseling" would mean a supportive process, characterized by a collaborative counselor-patient relationship with individuals or groups, to establish food and nutrition priorities, goals, and individualized action plans and general physical activity guidance that acknowledge and foster responsibility for self-care to treat or manage an existing disease or medical condition or to promote health and wellness.

As part of the educational requirements described above, the individual would have to have completed coursework leading to competence in medical nutrition therapy, which included the following content areas:

-- Fifteen semester hours of clinical or life sciences, at least three of which were in human anatomy and physiology or its equivalent, as determined by LARA in consultation with the Board.

-- Fifteen semester hours of nutrition and metabolism, at least six of which were in biochemistry or its equivalent, as determined by LARA in consultation with the Board.

"Medical nutrition therapy" would mean the use of nutrition care services, including any of the following, for the treatment or management of diseases or medical conditions:

-- Interpreting anthropometric, biochemical, clinical, and dietary data in acute and chronic disease states and recommending or ordering nutrient needs based on dietary data, including tube feedings and parenteral nutrition.

-- Food and nutrient counseling, including counseling on food and prescription drug interactions.

-- Developing and managing food service operations for the management or treatment of diseases or medical conditions, including operations with the primary function of nutrition care or recommending, ordering, or providing therapeutic diets.

"Nutrition care services" would mean the provision of any part or all of the following services within a systematic process:

-- Assessing and evaluating the nutritional needs of individuals and groups and determining resources and constraints in the practice setting, including ordering laboratory tests to check and track nutrition status, creating dietary plans and orders, and monitoring the effectiveness thereof.

-- Establishing priorities, goals, and objectives that meet nutritional needs and that are consistent with available resources and constraints.

-- Providing nutrition counseling in health and disease.

-- Developing, implementing, and managing nutrition care systems.

-- Evaluating, making changes in, and maintaining appropriate standards of quality in food and nutrition services.

-- Ordering therapeutic diets.

"Therapeutic diet" would mean a diet intervention prescribed by a physician, or another health professional licensed under Article 15, that provides food or nutrients via oral, enteral, and parenteral routes as part of treatment of a disease or clinical condition to modify, eliminate, decrease, or increase identified micronutrients and macronutrients in the diet, or to provide mechanically altered food when indicated.

If the individual were seeking a license as a nutritionist, he or she also would have to meet both of the following requirements:

-- Have successfully completed the examination from the Board for Certification of Nutrition Specialists or an equivalent examination dealing with all aspects of the practice of dietetics and nutrition that was approved by the Board, or, at the time of application, held a certification as a Certified Nutrition Specialist or "C.N.S." from the Board for Certification of Nutrition Specialists.

-- Have completed a documented, supervised practice experience demonstrating competence in nutrition care services and the provision of medical nutrition therapy of at least 1,000 hours, at least 200 hours of which were in nutrition assessment, at least 200 hours of which were in nutrition intervention, education, counseling, or management, and at least 200 hours of which were in nutrition monitoring and evaluation.

"Nutrition assessment" would mean the ongoing, dynamic, and systematic process of obtaining, verifying, and interpreting biochemical, anthropometric, physical, nutrigenomic, and dietary data to make decisions about the nature and cause of nutrition-related problems and making recommendations, including recommendations on enteral and parenteral nutrition. The collection of data would not, by itself, constitute nutrition assessment.

"Nutrition intervention" would mean purposefully planned action and nutrition counseling that is intended to positively change a nutrition-related behavior, risk factor, environmental condition, or aspect of the health status for an individual.

"Nutrition monitoring and evaluation" would mean identifying patient outcomes relevant to nutrition diagnosis and comparing the outcomes with the patient's previous health status, intervention goals, or reference standards to determine the progress made in achieving desired outcomes of nutrition care and whether planned interventions should be continued or revised.

The supervised practice experience described above would have to be approved by LARA in consultation with the Board and would have to be completed under a qualified supervisor.

For a dietician nutritionist license, LARA in consultation with the Board automatically would have to approve an academic program or an applicant's supervised practice experience if the applicant's supervised practice experience were accredited by the Accreditation Council for Education in Nutrition and Dietetics.

Any supervised practice experience undertaken after one year after the bill's effective date would have to be under the supervision of an individual licensed in the State if the individual were supervising an applicant who was providing medical nutrition therapy to an individual located in Michigan.

An individual who, on the day before the bill's effective date, had the credential conferred by the Commission on Dietetic Registration as a registered dietitian nutritionist, would be eligible for licensure as a dietitian nutritionist. An individual who met the requirements of this provision and who maintained the credential conferred by the Commission on Dietetic Registration or a successor credential conferred by its successor organization would have to first apply for a license within two years after the effective date of the rules promulgated under Part 183A. An individual who obtained a license under this provision would be eligible for renewal of that license if he or she continued to meet the requirements described above.

For a period of one year after the bill's effective date, an individual could be granted a license as a nutritionist if he or she met all of the following requirements:

-- The individual had been employed or self-employed at least half-time to provide nutrition care services for the treatment or management of a diagnosed disease or medical condition for three of the five years immediately preceding the bill's effective date.

-- The individual had been a Michigan resident providing medical nutrition therapy to Michigan residents without supervision for at least six months immediately preceding the bill's effective.

-- The individual presented satisfactory evidence to the Board that he or she had received a baccalaureate or higher academic degree from a US regionally accredited institution of higher education approved by LARA in consultation with the Board, with at least 30 credit hours, or a major course of study, in human nutrition, foods and nutrition, food systems management, nutritional science, nutritional education, community nutrition, public health nutrition, nutrition education, nutrition, nutrition science, clinical nutrition, applied clinical nutrition, nutrition counseling, nutrition and functional medicine, nutritional biochemistry, nutrition and integrative health, or an equivalent course of study leading to competence in medical nutrition therapy, as approved by LARA in consultation with the Board.

A major course of study described above would have to lead to competence in the provision of medical nutrition therapy as approved by LARA in consultation with the Board.

Qualified Supervision

Under the bill, to qualify as a qualified supervisor for purposes of Part 183A, an individual would have to be one of the following:

-- A registered dietitian nutritionist or an individual certified by the Board for Certification of Nutrition Specialists as a certified nutrition specialist.

-- A nutritionist or dietitian nutritionist.

-- An individual licensed or certified in another state as a dietitian, dietitian nutritionist, nutritionist, or other qualified nutrition professional whose scope of practice included the provision of medical nutrition therapy.

-- A health professional licensed or otherwise authorized by another state to provide nutrition care services for the treatment or management of diseases and medical conditions.

If he or she were supervising the provision of nutrition care services that did not constitute medical nutrition therapy, the individual would have to meet one of the following requirements:

-- The requirements described above.

-- Had been regularly employed or self-employed in the field of clinical nutrition for at least three of the five years immediately preceding the commencement of an applicant's practice experience and hold a master's or doctoral degree in a field of clinical health care with a major course of study in nutrition with at least three years of clinical nutrition experience, as approved by LARA in consultation with the Board.

A qualified supervisor could supervise only a clinical activity or nutrition care service for which he or she was qualified and was authorized to perform. A qualified supervisor would have to comply with all of the following:

-- Oversee the activities of, and accept responsibility for, the nutrition care services rendered by a supervisee.

-- Limit the assignment of nutrition care services to those services that were within the training and experience of a supervisee, were customary to the practice of the qualified supervisor, and were within the parameters of the laws and rules of the State and any standards of the facility in which the qualified supervisor practiced.

-- Develop and carry out a program for advancing and optimizing the quality of care provided by a supervisee.

The qualified supervisor and the supervisee would have to identify and document each goal for the supervised practice experience, the supervisee's scope of practice, the assignment of clinical tasks as appropriate to the supervisee's level of competence, the supervisee's relationship and access to the qualified supervisor, and an evaluation process for the supervisee's performance.

Additionally, a qualified supervisor, at a minimum, would have to be physically on-site and present where the supervisee was providing nutrition care services or be immediately and continuously available to the supervisee by means of two-way real-time audiovisual technology that allowed for the direct, contemporaneous interaction by sight and sound between the qualified supervisor and the supervisee. If the qualified supervisor assigned a nutrition care service to a supervisee that was to be provided in a setting where the qualified supervisor was not routinely present, the qualified supervisor would have to ensure that the means and methods of supervision were adequate to ensure appropriate patient care, which could include synchronous videoconferencing, chart review, or another method of communication and oversight that was appropriate to the care setting and the education and experience of the supervisee.

Scope of Practice

Beginning one year after the bill's effective date, an individual could not engage in the provision of medical nutrition therapy unless he or she was licensed or otherwise authorized under the Article 15. This provision would not prevent any of the following:

-- A physician or other individual licensed under any other part or any other Act from performing activities that were considered the practice of dietetics and nutrition if those activities were within the individual's scope of practice and the individual did not use the titles protected under the bill.

-- An individual from doing any of the following if the individual did not use the titles protected under the bill: a) furnishing general nonmedical nutrition information; b) providing evaluation, guidance, information, and education on the use of food, food materials, or dietary supplements; or c) providing explanations to individuals or groups about food or food products, including dietary supplements.

-- An individual from providing medical weight control for prediabetes or obesity to individuals under a program of instruction that was approved by one of the following: a) a dietitian nutritionist or nutritionist licensed under Article 15 or licensed by another state that had licensing requirements substantially equivalent to those in Michigan, as determined by LARA in consultation with the Board; b) a registered dietitian or an individual certified by the Board for Certification of Nutrition Specialists as a certified nutrition specialist; c) a health professional licensed under Article 15 whose scope of practice otherwise authorized him or her to provide nutrition care services for the treatment or management of a disease or medical condition and for which the medical weight control was being provided.

-- An individual from providing delegated medical weight control services under a plan of care that was overseen by a health professional licensed under Article 15 whose scope of practice otherwise authorized him or her to provide and delegate nutrition care services for the treatment or management of a disease or medical condition for which medical weight control was being provided.

-- An individual from providing nutrition care services under the appropriate supervision of another health professional licensed under Article 15 whose scope of practice authorized him or her to provide nutrition care services for the treatment or management of a disease or medical condition.

-- An individual from providing general nonmedical nutrition information, guidance, encouragement, individualized nutrition recommendations, behavior change management, coaching, assessments, services for weight management, or nutrition care services that did not constitute medical nutrition therapy, if the individual did not use the titles protected under the bill or otherwise hold himself or herself out as a dietitian nutritionist, as a nutritionist, or as a provider of medical nutrition therapy, or otherwise violated the Code.

-- An individual who was pursuing the educational requirements described in the bill from providing medical nutrition therapy, but only if the individual were providing medical nutrition therapy as part of a course of study; the individual did not engage in the unrestricted practice of medical nutrition therapy; the medical nutrition therapy was provided under the appropriate supervision of a qualified supervisor; and the individual was designated by a title that clearly indicated his or her status as a student, trainee, or supervisee.

-- An individual from fulfilling supervised practice experience requirements to qualify for licensure as a dietitian nutritionist or nutritionist under Part 183A but only if the individual did not engage in the unrestricted practice of medical nutrition therapy; the individual was designated by a title that clearly indicated the individual's status as a student, trainee, or supervisee; and the individual was appropriately supervised by a qualified supervisor who agreed to assume full legal responsibility for the individual's work by verifying, directing, and authorizing the work.

"General nonmedical nutrition information" would mean information on any of the following:

-- Principles of human nutrition and food preparation.

-- Principles of self-care and a healthy relationship with food.

-- The essential nutrients needed by the human body.

-- The recommended amounts of essential nutrients in the human body.

-- The actions of nutrients in the human body.

-- The effects of deficiencies or excesses of nutrients in the human body.

-- Foods, herbs, and dietary supplements that are good sources of essential nutrients in the human body.

"Medical weight control" would mean medical nutrition therapy for the purpose of reducing, maintaining, or gaining weight.

"Unrestricted practice of medical nutrition therapy" would mean the application of dietetics and nutrition knowledge and skills by an individual who regulates and is responsible for his or her own practice or treatment procedures.

All of the following apply to a licensee:

-- He or she could accept or transmit orders related to medical nutrition therapy from a referring health professional licensed under Article 15, as established in rules promulgated by LARA in consultation with the Board.

-- He or she would have to provide nutrition care services using systematic, evidence-based problem solving methods of the nutrition care process to crucially think and make decisions to address nutrition-related problems and provide safe, effective, quality nutrition services and medical nutrition therapy for individuals in clinical and community settings.

-- He or she could accept or transmit oral, verbal, delegated, or electronically transmitted orders from a referring health professional licensed under Article 15 consistent with applicable laws and rules and any controlling facility employer protocols established to implement medical nutrition therapy.

-- He or she could order medical laboratory tests related to a nutritional therapeutic treatment as provided by Michigan law.

-- He or she could implement prescription drug dose adjustments for specific disease treatment protocols within the limits of his or her knowledge, skills, judgment, and informed clinical practice guidelines as indicated in a facility, medical staff, or medical director approved protocol and as approved by and under the delegation of a prescriber.

-- In an outpatient setting, he or she could implement prescription drug dose adjustments for specific disease treatment protocols within the limits of his or her knowledge, skills, and judgment and as approved by and under the delegation of a prescriber.

-- He or she could recommend or order vitamin and mineral supplements or the discontinuance of unnecessary vitamins and minerals, within any existing controlling protocols.

-- He or she could not prescribe or initiate drug treatment.

-- He or she could order patient diets, including oral therapeutic diets, in accordance with this provision.

Enteral and parenteral nutrition therapy, which consists of enteral feedings or specialized intravenous solutions and associated nutrition-related services as part of a therapeutic diet, could be ordered by a licensee only if he or she met one of the following requirements:

-- Was a registered dietitian nutritionist.

-- Was a certified nutrition support clinician certified by the National Board of Nutrition Support Certification.

-- Met other requirements established by LARA in consultation with the Board that are consistent with competencies necessary for evaluating, ordering, and administering enteral and parenteral nutrition therapies.

Continuing Education

Under the bill, notwithstanding the requirements of Part 161, LARA in consultation with the Board would have to by rule prescribe continuing education requirements as a condition of license renewal. At a minimum, the Board would have to accept continuing education approved by the Board for Certification of Nutrition Specialists, the Commission on Dietetic Registration, and any other organization approved by the Board. The Department in consultation with the Board could adopt any updates or amendments to the standards described in this provision by rule.

The Department in consultation with the Board would have to promulgate rules requiring each applicant for license renewal to complete as part of the continuing education requirement an appropriate number of hours or courses in pain and symptom management.

The Department, in consultation with the Board, could promulgate rules under to supplement the requirements for licensure as a dietitian nutritionist, including adopting updated standards of the Commission on Dietetic Registration or the Accreditation Council for Education in Nutrition and Dietetics or standards of any successor organizations of the organizations described above.

Licensure by Endorsement

The bill would allow LARA to issue a license by endorsement to an applicant from another

state that, at the time the applicant obtained his or her license from the other state, had licensure requirements substantially equivalent to Part 183A, as determined by the Board.

License Fees

Under the bill, fees for an individual licensed or seeking licensure as a dietician nutritionist or nutritionist would be as follows:

-- Application processing fee, $20.

-- License fee, per year, $75.

-- Temporary license fee, per year, $75.

Rule Promulgation

The bill would require LARA in consultation with the Board to promulgate rules on appropriate supervision that were consistent with the range of prevailing professional standards. The rules would have to comply with all of the following:

-- Provide for adequate, active, and continuing overview of a supervisee's activities to ensure that the supervisee was performing as directed and complying with Article 15 and any rules promulgated under Article 15.

-- Require the personal review of charts, records, and clinical notes of a supervisee on a regular basis.

-- Require the designation of an alternate qualified supervisor to oversee a service provided in the event of and during a qualified supervisor's absence.

-- Require a personal review by a qualified supervisor of a supervisee's practice on a regular basis and regularly scheduled in person, education and review conferences between the qualified supervisor and the supervisee.

As used in this provision, "in person" would include being in the same physical location as another individual and being close enough to hear, communicate, and observe him or her and two-way real-time audiovisual technology that allowed for the direct, contemporaneous interaction by sight and sound between a qualified supervisor and supervisee.

"Appropriate supervision" would mean a specific type, intensity, and frequency of oversight as provided in rules promulgated under the bill.

In promulgating rules under the bill, LARA would have to consider factors that included level of education, experience, and level of responsibility.

Board of Dietetics & Nutrition

The bill would create the Michigan Board of Dietetics and Nutrition in the Department, which would consist of the following voting members, each of whom would have to meet the requirements of Part 161:

-- Four dietitian nutritionists; a member first appointed under this provision would have to be a registered dietitian nutritionist and could not be eligible for certification by the Board for Certification of Nutrition Specialists or the American Clinical Board of Nutrition.

-- Two nutritionists; a member first appointed under this provision would have to be credentialed by the Board for Certification of Nutrition Specialists or as a diplomate of the American Clinical Board of Nutrition by the American Clinical Board of Nutrition and could not be eligible for credentialing as a registered dietitian nutritionist by the Commission on Dietetic Registration.

-- One public member.

The terms of office of individual Board of Dietetics and Nutrition members, except those appointed to fill vacancies, would expire four years after appointment on June 30 of the year in which the term expired.

The chairperson and vice-chairperson of the Board would have to be elected in the manner described in Section 16139 except that the positions would have to rotate as described below. (Section 16139 requires a board or task force to elect annually a chairperson and a vice-chairperson at the first meeting of each calendar year.)

The chairperson would have to rotate annually between one of the following:

-- A member who was credentialed as a registered dietitian nutritionist with the Commission on Dietetic Registration who was not eligible for certification by the Board for Certification of Nutrition Specialists or the American Clinical Board of Nutrition.

-- A member who as credentialed by the Board for Certification of Nutrition Specialists or the American Clinical Board of Nutrition who was not eligible for credentialing as a registered dietitian nutritionist by the Commission on Dietetic Registration.

The vice-chairperson would have to rotate annually between one of the following:

-- If the chairperson were a member who was credentialed as a registered dietician as described above, the vice-chairperson would have to be a member who was credentialed by the Board for Certification of Nutrition Specialists or the American Clinical Board of Nutrition as described above.

-- If the chairperson were a member who was credentialed by the Board for Certification of Nutrition Specialists or the American Clinical Board of Nutrition as described above, the vice-chairperson would have to be a member who was credentialed as a registered dietician as described above.

"Registered dietitian" or "registered dietitian nutritionist" would mean an individual who is credentialed by the Commission on Dietetic Registration as a registered dietitian nutritionist or a registered dietitian.

Title Protection

The Code restricts the use of certain words, titles, and letters only to those people authorized to use them. Beginning one year after the bill's effective date, the following titles also would be restricted to those authorized to use them: "dietitian nutritionist", "nutritionist", "dietitian", "dietician", "nutrition counselor", "nutrition specialist", "L.D.N.", "L.D.", "L.N.", "nutritional therapy consultant", "certified nutrition therapy practitioner", "master nutrition therapist", "licensed dietitian nutritionist", "licensed nutritionist", or any other words, titles, or letters indicating that an individual provided medical nutrition therapy.

Only an individual who was licensed as a nutritionist could use the words "licensed nutritionist" or the letters "L.N." in connection with his or her name. However, a dietitian nutritionist could hold himself or herself out as and use the word "nutritionist" in connection with his or her name. An individual could use any lawfully earned federally trademarked title, and the following individuals could use the following words, titles, or letters:

-- An individual who was registered by the Commission on Dietetic Registration could use "registered dietitian", "registered dietitian nutritionist", "R.D.", or "R.D.N.".

Type	Annual Fee
Application processing fee	$20.00
License fee	$75.00
Temporary license	$75.00