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Lane Therrell FNP, MSN, RN MSN, RN, NP

Family Nurse Practitioner

Nurse Practitioner, Coach, Writer

Content by Lane Therrell FNP, MSN, RN

  1. Lane Therrell FNP, MSN, RN

    Helping Patients Make Healthier Food Choices

    Sadly, cooking from scratch seems almost to be a lost art. And when the household adult role-model doesn't cook from scratch, how do kids learn? The Home Economics classes that used to be taught in US public schools were a great place for some some basic cooking skills to be introduced, but I think they're a thing of the past. Maybe we should bring Home Ec back, and make it a requirement.
  2. Lane Therrell FNP, MSN, RN

    Helping Patients Make Healthier Food Choices

    Nutrition is a significant part of everyday health for all ages. However, most nurses and healthcare providers don’t get much classroom or clinical instruction on nutrition and managing dietary change during their basic education. (DiMaria-Ghalili et al., 2014). And yet, in spite of our relatively weak academic foundation, we routinely advise our patients to “eat a healthy diet.” Lasting dietary change begins with a patients’ ability to make healthy, or at least healthier, food choices. One of the foundational skills involved in making those healthier choices is reading food labels. But, if nurses and other healthcare providers have not learned these basics, who is teaching our patients this skill? As an NP in primary care, I observed that most of my patients who would benefit from meeting with a dietician or nutritionist did not actually “qualify” for these types of specialist encounters due to insurance limitations. And many of those who qualified failed to make and keep “extra” appointments. So, food label reading remained an untaught, unlearned skill. Do you feel confident enough in your own food-label reading abilities to teach your patients the basics? I had to do some extra studying to get myself there. Here’s how I’m leveraging what I learned. The 3 Most Important Parts of a Food Package I like to set the stage by pointing out 3 distinct parts of a food package—the front of the package, the nutrition facts panel or “label,” and the ingredients list. These three parts contain key pieces of information that work together to help consumers make healthier food choices. Here’s what to look for, understand, and decide for each part of a food package. Front of Package Food manufacturers know the front of the package is the first thing consumers see on a grocery store shelf, so it’s prime marketing real estate. That’s why you’ll want to take a close, thoughtful, look at the front of the package through the eyes of a skeptic. Look for: When you tune in and look carefully at the front of a food package, you’ll likely become aware of things you’ve never noticed before, even if it’s your favorite brand. Look at the names, descriptions, colors, images, designs. Be alert for key marketing words and phrases like reduced sodium, no sugar added, natural, low fat, or gluten free. What do these components suggest about what’s inside the package? And do the words and phrases really mean what you think they do? Understand: The big takeaway is that the front of a food package is designed to sell the product, not to tell you what’s in it. And when you understand that attractive is not the same thing as healthy, you realize that many packaged foods are not as healthy as they may seem at first glance. The appealing colors, images, and words that make a food product look and sound attractive can also create a “health halo,” an intangible feeling of goodwill and good health associated with the product. Food manufacturers keep this idea in mind when they design packaging and advertisements, because marketing studies repeatedly show that when you think a food is healthier, you'll eat more of it. (Egan, 2019). It’s also important to understand that marketing words may carry hidden meanings or implications. For example, the word “reduced,” as in reduced-sodium or reduced-fat, means the product has 25% less fat than the original version. (Egan, 2019). While that’s a step in the right direction, be aware that the total amount, even when reduced, may still be far more than ideal. Furthermore, whenever an ingredient such as gluten is taken out of a food, something else—like extra sugar or salt—is generally added back in its place. These added ingredients may be more unhealthy than the original ingredient that was removed. Decide: The front of the package is your first stop in gathering clues for deciding whether the product supports your health or not. Notice what you’re drawn to, and what you’re looking for: Does what attracts you match up with what you know will support your health goals? Of course, if you aren’t sure what your health goals are stop and get clear about them before you go any further. Nutrition Facts Panel After you’ve looked at the front of the package with a critical eye, continue your quest for information by looking at the nutrition facts (NF) panel, also referred to as the nutrition facts label. This federally regulated piece of information tells you how much of which nutritional component is in the product. The NF panel is your go-to resource for discovering how many calories are in your favorite foods. And it also reveals the percentage of fat, carbohydrates, protein, sodium, vitamins, and minerals that are present. The NF began appearing on food labels in the early 1990s, as required by the Nutrition Labeling and Education Act. (Egan, 2019). Look for: No matter what your dietary goals happen to be, or how they may change, the NF panel can help you make choices that support them.  Paying attention to the serving size, calories, percent daily value, added sugars and other nutrients listed on the NF panel will help you decide how consuming the product will affect your goals. The FDA updated the appearance and requirements of the NF panel in 2016 to better assist consumers in making healthy food choices. The revised NF panel emphasizes total calories, makes serving size information more prominent, shows added sugars, and should be official on all US packaging by 2021 (Egan, 2019). Compare the original and new NF panels for more details. (Side-by-Bide Comparison: Original Label versus New Label, 2019). Understand: The numbers on the NF panel are most helpful to you when your personal intake goals are clear. Are you cutting calories? Reducing sodium? Reducing sugar? The NF panel shows you the extent to which consuming an individual product can help support your efforts to meet your goals. And when you look at the NF panel for everything you consume, it can help you see your real-time and cumulative food intake in the context of your overall dietary goals. In fact, the NF can be used to help you see and track your “food numbers” in much the same way you may already be tracking other health numbers, like blood sugar and blood pressure. The key here is learning to notice the numbers associated with food. It’s not so much about the numbers themselves as it is about the trends over time. The bottom line is: The NF panel cannot help you if you don’t have clear goals and sincere commitment to meeting them. Decide: Use the numbers from the NF to help you decide how the product supports or detracts from your daily intake goals. Ask yourself: Does this food support my health goals? How will choosing this food now influence my other food choices throughout the rest of the day? Use the numbers to help you decide whether to consume the food inside the package you’re looking at or make a different choice. What are the options are available to you? Knowing the array of options available to you is a major step in making healthier choices. If you determine the product does not support your health goals, will you choose to consume this food anyway? Or will you look for a different, more supportive, option? Or might you choose to do something else, like schedule extra exercise to offset any over consumption of a specific nutrient? Ultimately, what action will you take? Ingredients List Finally, take a look at the ingredients list. Ingredients lists are printed in descending order by quantity. (Bjarnadottir, 2019). the item listed first on the list is the most prevalent ingredient. Don’t let the ingredients confuse you. Instead, use the list as a way to spark your curiosity about what’s in your food, and start conversations with your health professionals and your family. Look for: When looking at the ingredients list, pay special attention to the number of items listed, the order in which they are listed, and any specific ingredients of interest. In general, shorter ingredients lists indicate a product has undergone minimal processing. Look for shorter lists and ingredients you recognize. Be alert for allergens like dairy derivatives (whey protein), nuts, and shellfish. Avoid products listing sugar as a first ingredient. Pay attention to the order of items listed. Be alert for ingredients you cannot pronounce or are unfamiliar with, as these may indicate the presence of toxic chemicals and dyes, hidden sugars, non-nutritive fillers etc. Compare the nutrients list to the nutrition facts panel to see how the two correspond. Let the comparison and your conclusions guide you to discover the best ways to support your health. Understand: Because ingredients are listed in descending order, the product contains the most of the first thing on the list. This helps you put the product’s nutritional value in perspective, in light of your health goals.  For example, if one of your health goals is to reduce the amount of sugar in your diet, and you’re deciding whether to eat a certain product, but the first ingredient listed sugar, you may decide to choose a different product. The ingredients list also relates back to the front of the package. If something has been taken out, the ingredients list is where you can find out what has been added back instead. Decide: Ultimately, what’s in the package ends up in your body. Cross reference the ingredients list with the front of the package and the nutrition facts panel. Ask yourself: Does this item contain ingredients that I wish to consume? What is the most prevalent ingredient in the product? Does this ingredient support your health goals? Is this product is as advertised, or is the marketing misleading? Will you decide to consume this product? Do you feel confident and satisfied about your choice? Additional Tips Here are some additional helpful tips for teaching your patients how to make healthier food choices: Keep examples of food packaging in your clinic, exam room, or office so you can provide quick hands-on demonstrations with real products the patient is familiar with. Encourage patients to get familiar with food labels at home where they have time to practice reading them, coming up with additional questions, and figuring things out. Challenge patients to evaluate the packaged foods already in their home pantry to see whether they support their health goals or not. If not, offer support for small improvements such as looking for a low sodium version of a favorite brand, or trying a different brand with less sugar. Advise patients to take their reading glasses with them to the grocery store. Encourage patients to plan enough time in the store to read labels and make their healthiest decisions before they put items in the cart. The bottom line is, your patients can’t eat a healthy diet if they don’t have the tools for making healthy choices in the first place. Learning how to read labels on packaged foods is a good first step toward making choices and decisions that support health goals. If you learn how, you can teach your patients whenever you have the chance. And you’ll be able to back up your instructions to “eat a healthy diet” with practical advice. Question for Discussion How can you use information about food packaging to help your patients manage dietary change?
  3. Lane Therrell FNP, MSN, RN

    Helping Patients Make Healthier Food Choices

    I wish with all my soul that the medical and nursing professions would take nutrition education more seriously and devote more time to it in the classroom and during clinical rotations. Alas, that's not the case right now. Meanwhile, I don't pretend to emulate experts, but I am committed to serving my patients' needs in the best way I know how. I've found that my patients appreciate transparency and candor, which means admitting that even the so-called "experts" in any area will often have differing opinions.
  4. Lane Therrell FNP, MSN, RN

    Helping Patients Make Healthier Food Choices

    Referrals to dieticians are ideal, I agree, but they have been ever-so-problematic in my experience. First is the infinite frustration when you know your patient would benefit from the consult, but their insurance won't cover it, and they can't afford it out of pocket. Beyond that, I can't even begin to count how many times I've referred a patient for an insurance-covered dietician consult and the patient failed to keep the appointment. You can lead a horse to water, but you can't make 'em drink.
  5. Lane Therrell FNP, MSN, RN

    Helping Patients Make Healthier Food Choices

    You touch upon multiple important points here: eagerness to assign blame, spread of misinformation, lack of funding for sound nutritional research, prevalence of chemicals in the environment, and lifestyle factors. The big takeaway for me in your comment is that we all need to remember that there's rarely only one causal factor for anything, so "blaming" carbs, sugar, etc. is not helpful for anything except click-bait. That being said, one of the most valuable patient education topics we can address whenever we get the chance is how to be a savvy consumer of health information.
  6. Lane Therrell FNP, MSN, RN

    Helping Patients Make Healthier Food Choices

    Good for you for remembering your charting system has built-in educational handouts and using them! And the feedback about the "big words" from your patient was super-useful. Is there a way you can share your experience with others in your organization so other nurses are reminded of the availability of the educational handouts in EPIC, and that the "big words" in the handouts might need to be explained? You bring up an important point about rushed discharges. It's been my experience that all the patient can think about at discharge is getting the heck outta there, so why would we expect them to retain anything important we say during that time period? No doubt this contributes to the frequency of hospital readmissions... but that's a different topic. It sounds like you're doing everything you can in your bedside environment to maximize patient education. Keep up the great work!
  7. Lane Therrell FNP, MSN, RN

    Billing for Time Spent on Survivorship Care Plans?

    Does anyone in this group know which CPT codes are appropriate to use when spending time working on survivorship care plans? And... if there are no billing codes specific to this activity, why not? I'm worried that cancer survivors aren't getting what they need in primary care over time, but if there's no financial incentive for providers to spend time addressing this essential component of care, it will continue to be overlooked. Thanks in advance for any and all wisdom from oncology specialists.
  8. Lane Therrell FNP, MSN, RN

    Billing for Time Spent on Survivorship Care Plans?

    Thank you so much for this response. Your patients are indeed lucky to have you! I have noticed, too, that the oncologists are not as engaged as I wish they could be in survivorship concerns. Unfortunately, the "encouragement to share (survivorship plans) with their PCP" rarely happens, and even more rarely do the PCP's give survivorship plans any attention if and when they are shared. Patients are lucky if they bring in a survivorship care plan and their PCP makes the effort to scan it into their chart. And then it sits there, never to be noticed again. Yet we all know (or SHOULD know), the consequences of cancer treatment are lifelong. And the idealist in me says we shouldn't all have to be Oncology nurses to receive the right attention and treatments. I recently worked with a private health coaching client who survived a rare facial-nerve neuroma "successfully" treated with radiation 15 years ago. I use quotation marks around the word successfully because her sequelae-related symptoms (incuding partial facial paralysis and vagus nerve involvement) are worsening with age. She recently destroyed the documents relating to her treatment in an effort to clean up her home. In this case, the patient did not have a survivorship plan, nor did she understand the value of maintaining her own records to share with future providers. No one had ever taken the time to help her understand the potential long-term sequelae of her treatment or how to engage in self-management or self-advocacy.
  9. Lane Therrell FNP, MSN, RN

    How Technology Use Can Impact Our Health

    Balancing technology use will continue to grow as an important topic at the forefront of preventive health. My favorite way to balance tech-time is to plan for genuinely unplugged time in nature. "Genuinely unplugged" includes leaving cell phone and fitness tracker behind. When I do decide to take my cell phone along on a hike for safety, I carry it tucked away so I can enjoy the sensory input of my surroundings without being distracted by constantly taking selfies for social proof. Long hikes on marked trails are easily measured in miles covered-- no device necessary.
  10. Lane Therrell FNP, MSN, RN

    Billing for Time Spent on Survivorship Care Plans?

    Thank you so much for pointing me toward these resources. From where I sit in primary care, I see that the needs of cancer survivors are ongoing over time, and highly variable. This means survivorship care plans would ideally be updated and revisited over time, as the patient ages and progresses through life. Instead, it seems that survivorship care plans are all too often considered to be one-off documents created as a paperwork formality in the immediate aftermath of acute treatment. And patients don't fully appreciate their value, either. I would truly love to see a shift toward better care for survivors.
  11. Lane Therrell FNP, MSN, RN

    Any Telehealth Billing Experts in Informatics?

    Does informatics specialty education include specific information about billing for telehealth? I have some very specific questions about billing for remote patient monitoring and chronic care management services, and I'm just not sure who to ask, or what types of specialists would have the information I'm looking for. Any guidance that gets me pointed in the right direction is appreciated.
  12. Lane Therrell FNP, MSN, RN

    4 Reasons Nurses Need Mentors

    One of big ideas I took away from being mentored was that textbook cases are great, and things often work differently in the real world. This can be a challenging concept for students and new nurses to wrap their heads around. Now that I'm the mentor, I enjoy helping new nurses navigate the gray areas between academics and real-world practicality.
  13. Lane Therrell FNP, MSN, RN

    What Advice Would You Give to Future Nurses?

    Thanks for keeping it real, Nancy. This is oh so very true.
  14. Lane Therrell FNP, MSN, RN

    What Advice Would You Give to Future Nurses?

    Well said. It's true that my nursing licenses, credentials, and experiences have opened doors for me in writing, business, and academia that would have remained closed to me otherwise. If you have any doubts about whether you'll fit into a traditional nursing job description long term, think outside the box by asking, "What else can I do with a nursing license and credentials?"
  15. Lane Therrell FNP, MSN, RN

    What Advice Would You Give to Future Nurses?

    This is the best advice EVER.
  16. Lane Therrell FNP, MSN, RN

    What Advice Would You Give to Future Nurses?

    Communication skills top my list of must-haves for aspiring nurses. Specifically face-to-face and on-the-phone interpersonal communication skills. In our time crunched, tech driven, digitally connected world it's tempting to assume we already know everything we need to know about communication, but my experience shows the otherwise. The nurses who are able to to communicate genuinely and authentically with patients are the ones who make the most impact and enjoy their careers the most.
  17. Lane Therrell FNP, MSN, RN

    How Does Your Clinic Handle No-Shows?

    Do you make reminder calls before the appointment? Do you have a cancellation policy? If so, do you enforce it? Beyond any administrative policies your clinic may or may not have in place, do you routinely make it your business to find out why your patients aren’t showing up for appointments? Despite the high estimated cost of no-shows, many clinics do not follow up adequately with patients who fail to keep appointments. Busy clinics may make reminder phone calls before appointments, or send letters after a certain number of missed appointments. Some may even discharge the patient after a certain number of no-shows, a policy that is more of a lose-lose than a win-win, in my opinion. And of course, clinicians themselves may secretly breathe a sigh of relief when a patient fails to show up for a scheduled appointment (Woohoo! Extra time to chart!). Asking is Patient-Centered The point is that much of the clinical mindset and the academic research on patient no-shows is decidedly NOT patient-centered. And yet it should be. Ultimately, the resolution to no-shows requires a different action by the patient. But when was the last time you actually asked a patient to tell you, in their own words, in a face-to-face conversation, why they didn’t come to the appointment? You’ll never know the truth unless you ask. Academic literature abounds with statistics and estimates on how costly no-shows are to the clinic, hospital, or medical system. Some papers even frame no-shows as a detriment to patient safety, citing delayed testing and missed screenings as factors that negatively impact human health. And yet, if we used our no-show data to start conversations with patients, we might uncover useful information that could help us deliver care that is truly patient centered. What Patients Say My own thinking on this topic began to expand when I started making it a point to ask my patients why they didn’t show up. I learned a lot about my patients’ home and life situations that kept them from keeping their appointments on time, or at all. These same circumstances were contributing to their health outcomes. And ultimately increasing the cost of care. Here are some reasons my patients have offered for not keeping their scheduled appointments. No doubt these statements will trigger some memories for you about patients you’ve seen. “I couldn’t get my dad down the stairs, out of the house, and into the car to bring him in.” “I couldn’t get a babysitter.” “I forgot.” “I got drunk and couldn’t drive myself in.” “I started feeling better, so I didn’t think I needed to come.” “I really hate coming here.” “My time is too important to waste hanging out in the waiting room with a bunch of sick people.” “I wasn’t feeling bad, so I didn’t think it was important.” “I know the clinic’s busy, so I didn’t call ‘cause I didn’t want to be a bother.” “I couldn’t get a ride.” “I didn’t have enough money for a bus ticket.” “I was afraid to hear the news you were going to give me.” “I didn’t know you wanted me to let you know I wasn’t coming.” “I had to pick up my kids from school, I left my phone at home, and then we got stuck in traffic.” These statements roughly echo the findings of a small study that revealed 3 main reasons patients don’t keep appointments: 1) emotions; 2) a perception of being disrespected by the healthcare system; 3) a failure to understand the appointment scheduling process. This particular study didn’t pick up on transportation and mobility issues, or chronic stress and time management, which have been recurring themes for my patients at the various clinics I’ve worked at over the years. Improving the Quality of Care All of these reasons, no matter how they are categorized, represent deeply significant life and health problems for patients. Some are more easily resolvable than others. But they all provide us with information we can use to provide better quality care. All we have to do is take the time to ask, listen, and dig a little deeper. Whatever the reasons our patients offer, the process of making and keeping healthcare appointments for healthcare involves multiple factors. No-shows should be examined closely from the patient’s perspective. If we can’t see the problem from the patient’s perspective, we can’t hope to help people access the care they need. It’s not our job to resolve every individual’s personal problems, but by asking our patients directly why they fail to keep their appointments, we get to know our patients better. This insight can become part of bigger solutions over time. Meanwhile, this simple act of communication is one way we can build trust and rapport, and keep our care truly patient-centered. We need to know why our patients aren’t keeping their appointments. The information helps shape the care we deliver. And it affects the health outcomes our patients can expect to achieve. By asking the right questions, we’re improving the quality of care. Questions for Discussion How does your clinic handle no-shows? Is the system your clinic is using effective? Do you ask your patients why they don’t keep appointments? What are some of the reasons you’ve heard from patients about why they failed to keep an appointment? Sources and Resources No-shows in appointment scheduling – a systematic literature review Prevalence, predictors and economic consequences of no-shows Why We Don’t Come: Patient Perceptions on No-Shows
  18. Lane Therrell FNP, MSN, RN

    How Does Your Clinic Handle No-Shows?

    I like your clinic's rationale for its 48-hour notice. That is helpful for those on the waiting list as well as for the originally scheduled patient. I'm wondering if a 72-hour notice or longer might be even better? I suppose it may depend on how far in advance appointments are scheduled.
  19. Lane Therrell FNP, MSN, RN

    How Does Your Clinic Handle No-Shows?

    I live in the country, too, and often find myself caught behind slow-moving farm equipment on winding roads with little opportunity to pass. Ideally, a good clinic attendance policy will account for this kind of thing. Meanwhile, I'm glad you and your husband finally found the right place and he was able to be seen. Whew! What a hassle.
  20. Lane Therrell FNP, MSN, RN

    How Does Your Clinic Handle No-Shows?

    This is a great innovative solution, based on the needs of your local patient population. Hats off to your FQHC for being flexible and willing to at least try it out. I once worked at a community clinic that set up "night clinic" hours to accommodate the needs of working families, and it was very effective. We can definitely use more of these types of solutions.
  21. Lane Therrell FNP, MSN, RN

    How Does Your Clinic Handle No-Shows?

    You did the right thing. And I certainly hope your new dental provider is more attentive to detail and proper billing.
  22. Lane Therrell FNP, MSN, RN

    How Does Your Clinic Handle No-Shows?

    This is a great example of how a failure to be patient-centered is bad for business ... and by extension, bad for health. Your comment is also an excellent reminder of why we need to preserve the freedom to choose our providers, and vote with our feet when they don't meet our needs.
  23. Lane Therrell FNP, MSN, RN

    Trump's 'religious conscience'

    Absolutely. It's timeless wisdom. And so incredibly simple. Unfortunately it seems that sense is no longer common in most of the world today.
  24. Lane Therrell FNP, MSN, RN

    Trump's 'religious conscience'

    Yes. It can be this simple: If everyone, no matter what religion or professional training they have chosen, treated others the way they want to be treated the world would be a healthier, happier place.
  25. Lane Therrell FNP, MSN, RN

    Trump's 'religious conscience'

    Thank you for providing a concrete example of a rational solution that apparently meets everyone's needs.
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