1. RESEARCH
RECHERCHE
Estimation of Human Resource Needs
And Cost of Adding Registered Dietitians
To Primary Care Networks
JULIA WITT, PhD, Melbourne Institute of Applied Economic and Social Research, The University of Melbourne, Melbourne, Australia;
PAULA BRAUER, PhD, RD, Department of Family Relations and Applied Nutrition, University of Guelph, Guelph, ON;
LINDA DIETRICH, MEd, RD, Dietitians of Canada, Toronto, ON;
BRIDGET DAVIDSON, MHSc, RD, Nutrition and Research Consulting, Kitchener, ON
STEERING COMMITTEE
Paula Brauer, PhD, RD, Linda Dietrich, MEd, RD, Bridget Davidson, MHSc, RD, John Krauser,
Primary Health Care Team, Ministry of Health and Long-Term Care, Toronto, ON, Karen Parsons,
Primary Health Care Team, Ministry of Health and Long-Term Care, Kingston, ON
Abstract Résumé
Purpose: Information on human resources and costs is Objectif. Nous avons besoin d’information sur les ressources
needed to plan for the addition of registered dietitian (RD) humaines et les coûts pour planifier l’insertion des services de
services to new models of primary health care (PHC). Estimates diététistes professionnelles (DP) dans les nouveaux modèles de
were developed, based on an analysis of an enhanced RD model soins de santé primaires (SSP). Des estimations ont été établies,
of counselling and health promotion services in three Ontario basées sur une analyse d’un modèle amélioré de services de
Family Health Networks (FHNs). counselling et de promotion de la santé dispensés par des DP
Methods: Both direct and indirect costs were averaged over dans trois réseaux de santé familiale de l’Ontario (RSF).
the three FHNs. Costs and RD activities were tracked through- Méthodes. On a calculé les coûts moyens directs et indirects
out 2005. The FHN staff completed two questionnaires address- dans les trois RSF et relevé les coûts et activités des DP pen-
ing communication, case management, and satisfaction with RD dant toute l’année 2005. Le personnel des RSF a rempli deux
services. questionnaires sur la communication, la gestion des cas et la
Results: Actual and reported case management indicated satisfaction vis-à-vis des services de DP.
that an estimated 1.3% to 2.4% of the 60,000 enrolled patients Résultats. Selon la gestion des cas réels et rapportés, de 1,3 à
may require individual nutrition counselling in a year. If one 2,4 % des 60 000 patients inscrits nécessiteraient un counselling
full-time equivalent (FTE) RD can manage 380 new referrals, nutritionnel individuel en une année. Si un équivalent temps
then one FTE RD is needed per 15,800 to 29,000 patients. The plein (ETP) de DP peut traiter 380 nouveaux patients, on aura
estimated direct costs of adding one FTE RD (including expenses besoin d’un ETP par 15 800 à 29 000 patients. Coût estimé de
and fixed costs) is $78,169 to $80,169, when the RD is an inde- l’ajout d’un ETP de DP (incluant dépenses et coûts fixes) : entre
pendent contractor. 78 169 $ et 80 169 $, lorsque la DP est une entrepreneure
Conclusions: Additional studies are needed to develop better indépendante.
estimates of human resource needs and costs of interdisciplinary Conclusions. Des études supplémentaires sont nécessaires
nutrition services in all PHC settings. These estimates should be pour obtenir de meilleures estimations des besoins en ressources
based on population characteristics and direct and indirect costs humaines et des coûts liés aux services nutritionnels interdisci-
for all models of nutrition services in PHC settings. plinaires dans tous les milieux de SSP. Ces estimations devraient
(Can J Diet Prac Res 2006;67 Suppl:S30-S38) être basées sur les caractéristiques de la population et sur les
coûts directs et indirects relatifs à tous les modèles de services
nutritionnels en milieu de SSP.
(Rev can prat rech diétét 2006;67 Suppl:S30-S38)
INTRODUCTION
Successful integration of registered dietitians (RDs) Primary Health Care Transition Fund demonstration
into primary health care (PHC) organizations will be project, preliminary human resources and cost estimates
achieved by creating feasible, effective services that meet were developed, based on data collected when three RDs
the needs of health care providers and patients, at a price were placed in three Family Health Networks (FHNs).
that the Canadian health care system can afford. When Family Health Networks are an Ontario model of primary
they are considering adding an RD to the team, service care with three or more family physicians (FPs) working
planners need information about the projected direct costs, with other selected health care professionals to provide
including salary and expenses, as well as the indirect costs to PHC services to enrolled patients. They are funded in a
the rest of the organization. Therefore, as part of an Ontario blended funding model that includes capitation payments
S30 Revue canadienne de la pratique et de la recherche en diététique – Supplément, automne 2006

2. RESEARCH
RECHERCHE
(population-based funding of health care services) with study and to soliciting possible participation. Otherwise,
incentives for additional specific preventive health care the RD and her clients developed individualized care plans,
activities. These FPs often work in separate offices. They based on mutually agreed-upon goals. Work for the project
have received support to implement electronic health was completed in March 2006.
records (EHRs). Family Health Networks have not had RDs
in the past. Questionnaire and data collection form development
All questionnaires and data collection forms were
METHODS adapted from other sources. The physicians’ management
Context: dietitian practice in each FHN form, clinical monitoring forms, and workload measure-
The Steering Committee reasoned that better estimates ment categories were adapted from the Hamilton Health
of average human resource needs and costs would be devel- Service Organization (HSO) Mental Health and Nutrition
oped for planning purposes if geographically diverse FHNs Program instruments (Anne Marie Crustolo, personal
were represented. In April 2004, a request for proposals was communication 6 Feb 2004), to ensure that comparable
sent to all FHNs and primary care data would be collected.
models that met specific criteria,
including five or more physicians,
The RDs collected A change-in-routine questionnaire
was developed to identify any major
diverse locations in urban, rural, and information on costs workflow disruptions that the RD may
northern settings, development of have caused FHN staff (10,11). Each
EHRs already underway, and no pre- and activities over the staff member received a letter explain-
vious RD services. The three FHNs ing the study, the questionnaire, and
(Parry Sound, Kingston, and Strat- entire project. a stamped envelope addressed to the
ford, Ontario) were chosen in May University of Guelph. No identifying
2004 from eight submissions. In July, Dietitians of Canada information was collected. The person responsible for
(DC) hired three experienced RDs as independent administering the survey at each FHN sent an e-mail
contractors to work at each of the sites. The RDs received reminder to staff halfway through the data collection
orientation and training in August, and began working in period.
FHN offices in September 2004 as directed by staff at All questionnaires and data collection forms were pilot
each FHN. The RDs were contracted to work seven hours tested or reviewed by the RDs and the lead physicians. A sur-
a day for three or four days a week, depending on available vey methodologist also reviewed all forms and questionnaires.
project funding. In addition, 14 RDs from a primary health care advocacy
Each FHN organized its RD services differently. In one group reviewed the change-in-routine questionnaire.
FHN with three separate offices, the RD was located in one
office, had to arrange her own appointments, and hired a Overall data collection plan
student to call patients for initial appointments. This RD The three RDs and the project coordinator collected
booked all her own follow-up appointments. In the second information on costs, major time expenditure, and activi-
FHN with 13 offices, the RD had an office in one location, ties, including the number of patients referred over the
and a receptionist or nurse booked the appointments. In entire project. Detailed workload measurement, receptionist
the third FHN of three offices, the RD provided nutrition time, and questionnaires were collected twice for two-week
counselling at each site on given days of the week, and ini- periods in spring and fall 2005, in consultation with the
tially a receptionist booked the nutrition appointments. FHNs. Methods and timing varied somewhat in each FHN.
(Halfway through the project, the RD was required to take Questionnaires are available from the corresponding
over the booking of all initial and follow-up appointments.) author (P.B.).
This RD also did not have an office, and carried all her
resources, including her computer and nutrition patient Assessment of human resources needs
charts, to each site. All FHNs were in the process of imple- Mean number of physicians per one full-time equivalent
menting EHRs over the course of the project, but only one FHN dietitian: This method has been used in the past to estimate
had a fully functioning EHR system by project completion. service needs (12). The number of physicians from all three
The RDs implemented a practice model that was broadly FHNs was used as the basis for calculation, without regard
based on previous role documents (1,2), with a main focus to patient load.
on nutrition counselling and a secondary mandate to develop
health promotion and disease prevention programming. Mean number of new referrals to a full-time equivalent
Elements of “enhanced” practice were implemented (3,4). dietitian: The calendar data on new referrals for January
These included computerized diet record analysis, a coun- to December 2005 were used to calculate new referrals,
selling process using the PRECEDE-PROCEED model (5), defined as new persons referred for nutrition counselling
and assessment of blood pressure, waist circumference, and for a new diagnosis. The patient roster as of December 2005
health-related quality of life (SF-36) (6-9) with a minimum was the denominator. An “episode of care” was defined as
of two client visits (a baseline assessment and three-month a person who was referred to nutrition counselling for a
follow-up). In addition, a portion of each baseline appoint- specific problem, and who continued counselling for
ment was devoted to explaining an RD clinical evaluation the same problem, irrespective of follow-up timing.
Canadian Journal of Dietetic Practice and Research – Supplement, Fall 2006 S31

3. RESEARCH
RECHERCHE
Physician report of referral activity for one week: All activity for two two-week periods during the study, using a
physicians were asked to complete a yes/no checklist that check-off form and estimating the average call as taking two
listed all patients seen in a one-week period by initials, age, minutes.
sex, referral problem, whether they had a contributing Another aspect that was considered in the sensitivity
nutrition issue, and how the case was managed. Manage- analysis was the possible effect of the RD on the work of
ment options were a. provided nutrition/lifestyle counselling, other FHN staff, as reflected in the change-in-routine
b. referred to nurse, c. referred to RD, or d. referred to other questionnaire.
and, if so, whom.
Workload measurement
Calculation of direct costs Detailed workload assessment was carried out for two-
Direct costs are those that are directly incurred by having week periods twice during the project. The RD tracked
the RD in the FHN. They include RDs’ compensation, the work time in 15-minute blocks by checking the appropriate
set-up costs (for example, purchasing weigh scales or food boxes for the activity codes. Additional categories of work
models), and the ongoing costs that the RD requires to time were added in this study for health promotion activities,
operate (for example, telephone training, research, and travel time
charges, paying a booking assistant). Of 1,884 patients between FHN sites during a workday.
Direct costs were calculated from All data were analyzed using either
monthly data submitted to the project reviewed, 17.5% were Microsoft Excel 2002 (Redmond, WA,
coordinator. Direct costs were tracked Microsoft Corporation, 2002) or SPSS
according to the category in which reported to have a 10.0 (SPSS Inc., Chicago, IL, 2000). All
the money was spent. For the purposes aspects of the study were approved by
of calculation, a full-time equivalent contributing nutrition the Research Ethics Board at the
(FTE) position was assumed to equal University of Guelph.
1,950 hours of work per year. problem.
Other direct costs could be RESULTS
incurred if the addition of the RD to the FHN created Only mean values are reported across the three FHNs,
significant additional work for the FHN staff. This would both to protect the identity of individuals and to develop
need to be so significant that it would necessitate hiring estimates for planning purposes.
additional staff. If that were the case, another direct cost
would be the cost of hiring an additional person to work Human resources estimates
at the FHN to help with the extra work created by the The RDs’ paid hours ranged from 0.57 to 0.71 of an FTE,
RD. Whether this might be necessary was assessed by the with an average of 1,306 hours per year or 0.67 FTE. There-
change-in-routine questionnaire. fore, 0.67 x 3 = 2.0 FTE RDs were working with 41 MDs. The
ratio of RDs to MDs was 1:20.5.
Calculation of indirect costs From January to December 2005, 757 referrals were
Indirect costs are not directly billable. For the purposes made, according to a combined roster of 59,926 patients
of this analysis, the major indirect cost considered was the (as of December 2005), for an average referral rate of
cost of communication between the RDs and other providers. 1.26% (range: 1.04% to 1.44%). Therefore, the 757 new
For example, when the RD needed to speak with a physi- referrals translated to 379 referrals per FTE RD.
cian, she was incurring an indirect cost because the time This overall referral rate includes patients who were
that the physician took to talk with her was time taken from referred but did not book an appointment with the RD
other work. Hence, the indirect cost of such interactions (10% of total referrals), as well as patients who booked an
would be the physician’s salary multiplied by the amount appointment but did not show up for the appointment (10%).
of time for the interaction. Of the 757 referrals, the RDs completed baseline interviews
To assess indirect costs, RDs completed a two-week form with 603 patients, or 302 patients per FTE RD per year.
twice during the study. The RDs placed a check mark in Twenty-seven of 41 physicians (66%) completed the
the appropriate column for each interaction, noting with physician management form. Of 1,884 patients reviewed,
whom the interaction took place (e.g., physician, nurse, 17.5% were reported to have a contributing nutrition prob-
receptionist, etc.). The RDs also indicated the average lem. Physicians reported that they discussed the nutrition
amount of time for each interaction, and weekly interac- issues with 12% of all patients and referred 25 patients, or
tion times were calculated from these data. 1.3% of the patients reviewed, to the FHN RD. Another 20
(1.1%) patients were referred to other community services,
Sensitivity analysis such as diabetes education centres.
A major issue in adding an RD to the team was the
potential impact on receptionist workload. As previously Direct costs
mentioned, one RD made her own appointments through- Two sets of direct costs are shown in Tables 1 and 2.
out the study, while receptionists in the other two FHNs Table 1 shows the actual costs to the three FHNs involved
made appointments at least part of the time. Receptionists in the project. Direct costs were based on the mean RD
making appointments for the dietitian were asked to track this contracted rate of $36.81/hour for the actual hours worked,
S32 Revue canadienne de la pratique et de la recherche en diététique – Supplément, automne 2006

4. RESEARCH
RECHERCHE
fees to send data to the University
Table 1 of Guelph, travel costs, meals, and
Actual direct costs for the three Family Health Networks accommodation were project expenses
in the demonstration project removed from the expense calculations
in Table 2.
Compensation (3 RDs over 1 year) $144,276.79
Fixed costs were included in the
Expenses (3 RDs over 1 year) $15,893.28
estimated direct costs to one FHN
Total direct costs over 1 year (including expenses)1 $160,170.07 with one full-time RD only in Table 2,
Total direct costs over 2 years, undiscounted and not in the calculation of the actual
(includes expenses)1 $320,340.14 costs to the three FHNs in Table 1
because the FHNs did not incur these
NPV2 of total direct costs over 2 years, discounted at 5% $297,821.90 costs. For this demonstration project,
1
Expenses include membership fees, educational resources, supplies, printing, telephone, the RDs were expected to supply
postage, couriers, travel, meals, accommodation, conferences, additional help to book their own computers, which would
appointments and analyze food records, gifts, and equipment rental. not be expected if they were hired
2
NPV is the net present value of the income stream, in this case over two years. full time into the FHN. Fixed costs in
RD = registered dietitian Table 2 would have included mostly
set-up costs, such as the cost of a desk,
office chairs, and a computer for the
RD; however, because they were not
Table 2 incurred in the demonstration pro-
Estimated direct costs for one Family Health Network with ject, these fixed costs were estimated.
one full-time registered dietitian The range of fixed costs used was
$2,000 to $4,000 for furniture and a
Compensation $71,779.50 computer. The ranges are indicated
Expenses (including initial fixed costs, over 1 year) 1
$7,389.75 as lower and upper bounds of the
direct costs, and the middle value of
(Range: $6,389.75 to $8,389.75) $3,000 was used in the cost calcula-
Expenses (excluding initial fixed costs, over 1 year)1 $4,389.75 tion. The range reflected the wide
variability in the price of these items,
Total direct costs (including expenses and fixed costs)1 $79,169.25 and allowed for the possibility that
the FHN may already have owned
(Range: $78,169.25 to $80,169.25) some of these items (e.g., office fur-
Total direct costs over 2 years, undiscounted $155,338.50 niture), and would not need to pur-
(Range: $154,338.50 to $156,338.50) chase them. One potential cost not
incorporated into this calculation is
NPV2 of total direct costs over 2 years, discounted at 5% $144,487.04 the possible need to rent extra space
(Range: $143,534.66 to $145,439.42) for the RD. The basic requirement
for an RD would be an office large
1
Expenses exclude those related to the project only but do include membership fees, enough to seat three people comfort-
educational resources, supplies, printing, telephone, conferences, additional help to book
appointments and analyze food records, gifts, and equipment rental. Fixed costs include our ably for consultations.
estimation of the cost of computer equipment and office furniture ($3,000, range: $2,000 to The project was 19 months long
$4,000). and the costs were projected to two
2
NPV is the net present value of the income stream, in this case over two years. years. This was done for two reasons:
first, to be able to show the difference
in net present value (NPV) of costs
plus actual expenses, adjusted to one The actual expenses from the sub- versus undiscounted costs, and second,
year. Table 2 shows the projected costs mitted expense records included to be able to compare this with two
of adding an FTE RD to one FHN, membership fees, educational years of cost projections for adding
excluding project-specific expenses. resources, supplies, printing, tele- an RD to one FHN. Fixed costs,
One FTE RD costs $36.81 multiplied phone, postage, courier, travel, meals, although not very large compared
by 1,950 hours per year for an annual accommodation, conference costs, with other costs, are nonetheless
cost of $71,779.50, plus expenses. For and help doing bookings and analyz- incurred only in the first year. Costs
an RD in a salaried position, vacation ing diet records. Dietitian expenses are discounted at the end of the year,
pay, health benefits, or remuneration over one year were calculated as fol- since salaries and expenses are paid
in lieu of benefits might need to be lows: because data were available for throughout the year, not wholly at
considered. The RD might also nego- a total of 19 months, all categories the beginning. The 5% discount rate
tiate other benefits, such as employer- were summed and adjusted to one is commonly used, and undiscounted
paid continuing education expenses. year (Table 1). Postage and courier costs over the same period were also
Canadian Journal of Dietetic Practice and Research – Supplement, Fall 2006 S33

5. RESEARCH
RECHERCHE
calculated so that these totals reflect
Table 3 the range of using a discount rate
Average indirect costs for one Family Health Network with between zero and 5%.
one full-time registered dietitian
Indirect costs
Minutes of interactions Value of time In the indirect cost computation,
(weekly average) the term “others” refers to the FHN
administrator, other RDs, pharmacy
With physicians 80.00 $66.49
staff, office staff (including nurses,
With nurses 25.00 $9.73 receptionists, and administrative staff),
With nurse practitioners 23.75 $13.93 and sales representatives. Because the
With pharmacists 20.00 $10.80 salaries of this mix of people vary
With receptionists 126.00 $27.17 substantially, the average salary for all
occupations was used.
With others 152.50 $57.72 Table 3 shows the indirect project
costs. The salaries used to calculate
Total indirect costs (weekly) $185.85 the value of time are listed below the
table. The weekly averages of interac-
Total indirect costs per year $9,664.05 tions are based on four weeks of data
Total indirect costs over 2 years, undiscounted $19,328.10 collection: two weeks in March 2005
and two weeks in October 2005.
NPV1 of total indirect costs over 2 years, discounted at 5% $17,969.44 The final calculations are the total
1
NPV is the net present value of the income stream.
costs to one FHN with one full-time
RD (Table 4). These include direct
Hourly wages are based on the average annual salary of full-time workers (40 hours/week,
52 weeks) for that profession in Ontario in 2000 (Statistics Canada, Earnings of Canadians, and indirect costs.
available at: www.statcan.ca), except for the salary for nurse practitioners, which is based
on the average salary advertised in job ads posted by the Registered Nursing Association of Sensitivity analysis
Ontario (www.rnao.org). The annual salary of general practitioners is $103,731, and hourly The receptionist workload was
wages are $49.87; the annual salary of nurses (assuming they are registered) is $48,564, and
hourly wages are $23.35; the annual salary of nurse practitioners is $73,200, and hourly wages
calculated to assess how many direct
are $35.19; the annual salary of pharmacists is $67,399, and hourly wages are $32.40; the annual patient contacts related to the RD were
salary of receptionists is $26,904, and hourly wages are $12.94; and the annual salary of others in each FHN. The average number
was taken as the average salary of all occupations, $47,232, and hourly wages of $22.71. of phone calls per week for the first
set of data (collected around April
2005) ranged from 11 to 51.5. For
Table 4 the second set of data (collected
around November 2005), the range
Estimated total direct and indirect costs for one Family Health Network with
was 10.5 to 41.5 phone calls per week
one full-time registered dietitian per FHN. An increase in the number
of calls per week was seen in Stratford
Total direct costs per year (including fixed costs) $79,169.25 (from 20 to 25), while Parry Sound
(Range: $78,169.25 to $80,169.25) and Kingston both saw fewer calls
during the second collection period
Total indirect costs per year $9,664.05 (from 51.5 to 41.5 and from 11 to 10.5,
Total costs per year (first year, including fixed costs) $88,833.30 respectively). If each phone call took
two minutes (as was assumed), then
(Range: $87,833.30 to $89,833.30) 51.5 calls per week represented 4.3%
of a receptionist’s time.
Total costs over 2 years, undiscounted $174,666.60
The number of appointments made
(Range: $173,666.60 to $175,666.60) with the RD and the number cancelled
were also recorded. Not much varia-
NPV 1 of total costs over 2 years, discounted at 5% $162,456.48 tion occurred between the two data
(Range: $161,504.09 to $163,408.86) collection periods in the number of
appointments kept (i.e., appointments
1
NPV is the net present value of the income stream. made minus appointments cancelled).
Expenses include membership fees, educational resources, supplies, printing, telephone, con- The range was two to 16 appointments
ferences, hired help, gifts, and equipment rental. Fixed costs include our estimation of the over the two-week data collection
cost of computer equipment and office furniture ($3,000, range: $2,000 to $4,000). Indirect
costs are those calculated in Table 3. period in April 2005, and five to
16 appointments for two weeks in
November 2005. However, the
S34 Revue canadienne de la pratique et de la recherche en diététique – Supplément, automne 2006

6. RESEARCH
RECHERCHE
Table 5
Change-in-routine questionnaire results1
Spring 2005 (n = 47) Fall 2005 (n = 63)
% who agree Median % who agree Median
or strongly agree (range) or strongly agree (range)
General environment for change
1. The nature of my job makes structural 46 3 (2 – 5) 64 4 (1 – 5)
changes easy to accommodate.
2. The climate for change is very supportive and 66 4 (2 – 5) 862 4 (2 – 5)
positive in our FHN.
Attitudes and opinions about addition of the dietitian
3. Information about how the new RD would fit into our 49 3 (2 – 4) 672 4 (1 – 5)
FHN was well communicated.
4. I was well prepared for my role with respect to the RD. 51 4 (1 – 4) 732 4 (1 – 5)
5. Have your duties increased as a result of the addition 33 n/a 22 n/a
of the RD? (Yes/No) reporting change reporting change
5b. I did not have problems fitting the extra work that 38 3 (2 – 4) 802 4 (1 – 5)
I do for the RD into my regular workload. (6/16) (24/30)
6. Having an RD in our FHN has increased my 43 3 (1 – 5) 652 4 (1 – 5)
job satisfaction.
7. I feel that I can express my concerns about the new RD. 68 4 (2 – 5) 892 4 (2 – 5)
8. I feel that these concerns would be taken seriously. 62 4 (1 – 5) 842 4 (1 – 5)
Overall attitude to addition of the dietitian
9. My overall attitude toward the addition of the RD in 65 4 (2 – 4) 862 4 (1 – 4)
our FHN is 1 = dissatisfied to 4 = satisfied. satisfied satisfied
Percentage who agree or strongly agree on a five-point Likert scale, unless otherwise indicated; median and range
1
p<0.05 Pearson chi-square for the hypothesis that the proportion agreeing and survey administration are independent
2
FHN = family health network; RD = registered dietitian; n/a = not available
number of appointments cancelled was reduced; zero to (Table 5). Evidence of such adjustment was seen by the
14 were cancelled in the first period, and one to nine in the second questionnaire administration.
second period. The change-in-routine questionnaire did not
indicate that taking calls for the RD disrupted a receptionist’s Workload measurement
work, and the time demands (4.3%) were small. Finally, the output for the average workload distribu-
The change-in-routine questionnaire provides additional tion for each RD at three FHNs in two time periods is
insight into the value of adding an RD to a practice. The illustrated in Figure 1.
response rate was 42% (47/111) for the first administration
of the questionnaire, and 56% (63/112) for the second DISCUSSION
administration. Cronbach’s alpha was used to measure the Currently, human resources planning guidelines and
intercorrelation among the items in this ordinal-scale survey; costing estimates for RDs in PHC are based on very limited
it is a coefficient of internal consistency. Cronbach’s alpha information. Estimates developed in this study are prelimi-
was 0.879 for the eight five-level questions for the survey nary, as they depend on information from only three FHNs
conducted in spring 2005; it was 0.824 for the survey con- gathered during a demonstration project. The analysis was
ducted in fall 2005. Both are considered acceptable. for an enhanced RD model of counselling and health pro-
The data for the two administrations were kept separate motion nutrition services for the first year.
to make possible the identification of any adjustments that We expect that these estimates will differ from others
the FHN staff may have made to the presence of the RD elsewhere for several reasons. Community health centres
Canadian Journal of Dietetic Practice and Research – Supplement, Fall 2006 S35

7. RESEARCH
RECHERCHE
Figure 1
Dietitian workload, averaged over the three Family Health Networks
FHN = family health network
in Ontario serve the needs of special or high-risk popula- devoted to research activity. The definition of an “episode
tions, who typically require more intensive and diverse ser- of care” also may have differed between the programs. Such
vices, such as those to promote community development differences could have a significant impact on perceived
(13,14). Estimates developed by private practice dietitians efficiency. Overall, management of 380 new referrals a year
must include the costs of running a completely independent is a realistic estimate of the number of patients that one
business (14). Estimates developed for organizations, such as FTE RD could manage in the first year of practice.
ambulatory care clinics within hospitals, or regional services If 1.3% to 2.4% of patients require individual counselling
such as the Hamilton HSO Mental Health and Nutrition in a year, and a full-time RD sees 380 new referrals a year,
Program (12), will also differ because coordinating and a reasonable first estimate is that an FHN would need one
evaluation functions are typically centralized. FTE RD per 15,800 to 29,000 patients ([380/0.024] to
[380/0.013]) for an interdisciplinary model of nutrition
Human resources planning services.
Referral rate estimates are based on reported case man- As a check of the estimates developed in this analysis, the
agement over one week and actual referrals over one year. Hamilton data were used to estimate the roster that one
They were very similar – about 1.3% of FHN patients. An FTE RD could manage. The demonstration project data
additional 1.1% were referred to other community programs, revealed that the average physician had 59,926/41 = 1,462
according to the case management survey. Availability of or approximately 1,500 patients. The Hamilton HSO Mental
nutrition programs varies substantially in communities, and Health and Nutrition Program reported that six FTE RDs
so 1.3% to 2.4% of patients may be referred for counselling provided services to 80 physicians (excluding administration
within the FHN. and evaluation), a ratio of 1 RD to 13.3 physicians (12). When
To calculate RD services, an estimate of the caseload that this number and the estimate of 1,500 patients per physi-
the RD can manage is needed. The number of patients seen cian are used, one FTE RD could provide services to an
by one FTE RD in this project was 379, which is lower than enrolled population of approximately 20,000 (13.3 x 1,500),
the number reported by the Hamilton HSO Mental Health an estimate that falls within the same range as the estimates
and Nutrition Program, in which one FTE RD sees 710 developed in this project.
referrals per year (12). A number of possible reasons may Numerous factors in addition to other community services
explain these differences. One factor may have been the will affect the actual requirements. Clients’ ages, genders,
time required to set up new services, determine patient health, and psychosocial characteristics, the organization
needs, and establish relationships with colleagues in the of and number of practice sites in the FHN, and the
FHNs and agencies. Another important difference is that this geographic location may all have an impact. In addition,
demonstration project included an RD evaluation compo- physician referral rates may vary significantly, as was found
nent, which could not be separated from assessment and in this study.
counselling in the workload analysis, as it was embedded Despite their limits, this and other population-based
within appointments; in addition, 11% of time was strictly methods for estimating RD needs will, over time, yield
S36 Revue canadienne de la pratique et de la recherche en diététique – Supplément, automne 2006

8. RESEARCH
RECHERCHE
superior estimates to those based on provider ratios, such and similar primary care organizations seems to be a
as RD to physician ratios. Such ratios become increasingly worthwhile investment.
problematic as the interdisciplinary team expands and The results of this study provide some direction to groups
new ways of organizing services develop. planning to add RD services to their FP-based PHC practices.
The study addresses a gap in the literature on human
Costing analysis resources planning for RD services. Additional studies are
Direct costs of adding an FTE RD (including expenses now needed to improve this estimate by basing calculations
and fixed costs) were calculated assuming the RD was an on a wider range of PHC organizations, on a longer time
independent contractor. However, if the RD were salaried, frame, and on diverse populations; in addition, effective-
vacation pay and other benefits might have to be consid- ness must be linked to resources. While direct costs of ser-
ered. The largest component of direct costs was the RD’s vices are commonly estimated, receptionist and clerical
salary (approximately 80%); expenses contributed the rest. costs often are not included and should be. Information
Indirect costs of adding an RD to an FHN were incurred on the indirect costs of communication and coordination
in this project ($9,664.05 per year [Table 3]). The commu- for RD services has also been lacking. Published informa-
nication documented in this study is an integral feature of tion on both direct and indirect costs for all models of
interdisciplinary practice, however, and the significance of nutrition services in PHC settings is needed to improve
these costs is uncertain. Such indirect costs are significant if the estimates developed in this study.
the opportunity cost truly is time spent working that is not
made up in regular office hours. For example, the indirect Acknowledgements
cost that the RD incurs for physician contact is problematic The authors gratefully acknowledge Theresa Schneider,
if those 80 minutes per week are preventing the physician Deborah Northmore, and Eva West, the RDs who partici-
from continuing to see patients or to work at the same rate pated in this study, for their commitment to professional
as before the RD came into the FHN. The change-in-routine accountability. Their dedication in completing the forms
questionnaire results did not indicate that the RD had pre- and questionnaires under the constraints of “real world”
vented other FHN members from continuing to work at the practice was critical to successful completion of the cost-
same pace, but data by professional designation were not ing analysis. The staff at each of the three Family Health
collected (Table 5). Networks must also be acknowledged, as this costing analy-
One limitation of the costing analysis is the inability to sis would not have been possible otherwise. The commit-
compare the cost estimates with the costs that would be ment of each lead physician – Dr. Murray Overington,
saved by having an RD available to patients who need one, Kingston FHN, Dr. Mark Wilkinson, Stratford FHN, and
or with the advantages of having direct communication Dr. Richard Woodhouse, Parry Sound FHN – was especially
between the RD and the other people involved in a patient’s appreciated, as they were instrumental in ensuring successful
care. The indirect cost savings of having an RD in an FHN completion of the project. Dr. John Dorland of Queen’s
are diverse and would include travel time saved by patients, University advised on the key aspects of the costing analysis.
the convenience of being able to make an RD appointment Anne Marie Crustolo and Dr. Nicholas Kates of the Hamilton
at the FHN, and improved chronic disease management Mental Health and Nutrition Program kindly shared their
through improved communication between the physician clinical tracking and workload measurement tools so that
and the RD. Indirect cost savings were not assessed. Further comparable data could be generated. Two undergraduate
study of the indirect costs and savings of communication students in the applied human nutrition program at the
in interdisciplinary practice is needed. University of Guelph, Catherine Shea and Susan Tran, ensured
accurate and timely data entry. Dr. Mary Thompson of the
RELEVANCE TO PRACTICE Survey Research Centre at the University of Waterloo reviewed
The advantages of having RDs in PHC settings, especially the questionnaires. Stacey Curry Gunn of Flow Public
for disease prevention and chronic disease management, Relations & Marketing, Guelph, ON, provided editorial assis-
are not easily calculated at this point. This is mostly because tance. Funded by the Ontario Primary Health Care Transition
the advantages are long-term health benefits to patients. Fund, 2004-2006. This report does not represent the official
Diet treatment is integral to the management of diabetes, policy of the funding partners, the Ontario Ministry of Health
hypertension, and dyslipidemia, but effectiveness in obesity and Long-Term Care, or other organizations.
treatment remains problematic (4). Chronic diseases are a
large burden on the Canadian health care system, however, References
and reducing their incidence or severity would provide 1. Community Dietitians in Health Centres Network. Community
substantial benefits to the system. For example, the annual dietitians – trusted food and nutrition experts. Toronto: Dietitians
cost of obesity in Canada has been estimated to be between of Canada; 2004 [cited 2006 1 March]. Available from:
$1.8 billion (1997) (15) and $2.1 billion (1999) (16). Indi- http://www.dietitians.ca/pdf/CDHC_role_paper_March2004.pdf.
rect costs could be as high as $3.7 billion (2001) (17). Given 2. Dietitians of Canada. The role of the registered dietitian in primary
the potential long-term health benefits (4), and the positive health care: a national perspective. Toronto: Dietitians of Canada;
response to having RDs at the demonstration sites, the 2001 [cited 2006 1 March]. Available from: http:/ /www.dietitians.ca.
addition of an RD to the interdisciplinary team in FHNs
Canadian Journal of Dietetic Practice and Research – Supplement, Fall 2006 S37

9. RESEARCH
RECHERCHE
3. American Dietetic Association. Evidence-based guides for practice. 10. Performance management – Goddard Supervisor Evaluation Survey.
Chicago: American Dietetic Association; 2002 [cited 2006 1 March]. NASA’s Goddard Space Flight Center Office of Human Capital
Available from: http://www.knowledgeline.com/adaprotocols1/ . Management; 2005 [cited 2006 16 March]. Available from:
4. Ciliska D, Thomas H, Catallo C, et al. The effectiveness of nutrition http://ohcm.gsfc.nasa.gov/home.htm.
interventions for prevention and treatment of chronic disease 11. Day M. Step by step guide to employee satisfaction surveys.
in primary care settings: a systematic literature review. Toronto: SearchWarp.com. 18-10-2005 [cited 2006 16 March]. Available from:
Dietitians of Canada; 2006 [cited 2006 20 June]. Available from: http://searchwarp.com/swa21348.htm.
http://www.dietitians.ca/public/content/resource_centre/ 12. Crustolo AM, Kates N, Ackerman S, Schamehorn S. Integrating
index.asp. nutrition services into primary care experience in Hamilton, Ont.
5. Green LW. What can we generalize from research on patient Can Fam Physician 2005;51:1647-53.
education and clinical health promotion to physician counseling on 13. Davidson B, Dietrich L, Brauer P. Key informant interviews: dietitian
diet? Eur J Clin Nutr 1999;53(Suppl 2):S9-18. services in current programs 2005. Toronto: Dietitians of Canada; 2006
6. Ware JE Jr, Sherbourne DC. The MOS 36-item short-form health [cited 2006 20 June]. Available from: http://www.dietitians.ca/
survey (SF-36): l. Conceptual framework and item selection. Med Care public/content/resource_centre/index.asp.
1992;30:473-83. 14. Davison K, Mor A, Charlebois H. What are entrepreneurial dietitians
7. Ware JE Jr, Snow KK, Kosinski M, Gandek B. SF-36 Health Survey charging? The Consulting Dietitians Network National Fee Survey.
manual and interpretation guide. Boston: The Health Institute, Can J Diet Prac Res 2004;65:186-90.
New England Medical Centre; 1993. 15. Birmingham CL, Muller JL, Palepu A, Spinelli JJ, Anis AH. The cost of
8. Ware JE Jr, Kosinski M, Keller SD. SF-36 physical and mental health obesity in Canada. CMAJ 1999;160:483-8.
summary scales: a user’s manual. Boston: The Health Institute, 16. Katzmarzyk PT, Gledhill N, Shephard RJ. The economic burden of
New England Medical Centre; 1994. physical inactivity in Canada. CMAJ 2000;163:1435-40.
9. Ware JE Jr, Kosinski M, Bayliss MS, McHorney CA, Rogers WH, Raczek A. 17. Katzmarzyk PT, Janssen I. The economic costs associated with physical
Comparison methods for the scoring and statistical analysis of the inactivity and obesity in Canada: an update. Can J Appl Physiol
SF-36 health profile and summary measures: summary of results from 2004;29:90-115.
the medical outcomes study. Med Care 1995;33:AS264-79.
INVEST IN YOURSELF – DC CAN HELP
REGIONAL EVENTS DIETETICS @ WORK
Dietitians of Canada offers regional workshops A practical, online professional support service
tailored to the interests of dietitians and other featuring courses that present new science in
health professionals. professional practice terms – all from the
COMING SOON convenience of your office or home.
Food Allergies: What’s new in clinical, community, DIETARY SUPPLEMENTS
school and food service applications • Lesson 1 – Vitamin/Mineral Supplements
• Thunder Bay – September 13, 2006 • Lesson 2 – Herbal Supplements – is our most
• Saskatoon – September 15, 2006 recent online offering.
• Winnipeg – September 16, 2006 • Lesson 3 – Sports Supplements – will be
Atlantic Fall Conference 2006: Back to and Beyond available in early 2007. Authors: Susie Langley
the Basics – September 29-30, 2006, Moncton and Kelly Anne Erdman
CSO Regional Conference: Explore the Diversity of DIETARY REFERENCE INTAKES
Practice -- November 10, 2006, Toronto Have you completed the first 6 lessons of the DRI
course? If not, you will want to get caught up and
Making Adult Education Work in Health Care – be ready when Lessons 7 and 8 of the Dietary
November 14, 2006, Winnipeg Reference Intakes course debut in early 2007.
Author: Dr. Susan Barr
For details on how to register, visit the DC web site Visit www.dieteticsatwork.com for registration and
at www.dietitians.ca/public/content/resource_ pricing details.
centre/pd_events.asp
S38 Revue canadienne de la pratique et de la recherche en diététique – Supplément, automne 2006