Please, face the fact that your practice is not walking the talk in nutrition........ Here are a few statements and questions to do a self-assessment of your practice and staff in the area of nutritional awareness:

 50% of the animals coming through the front door of an average companion animal practice have a need for improved nutritional care. Is this number reflected in your medical records?

 Purina states that an animal kept on premium diet and at the preferred body condition score will live 22 months longer. Has this information been shared with every client in your practice?

 Staff (including doctors) who use the premium diets appear to share the nutritional benefits to clients with far higher consistency. Has you practice negotiated a preferred premium diet purchase program for the staff from your primary premium diet vendor?

 Hills tells us that 35-40% of all patients get introduced to premium diets each year in each practice, but less than 7% stay on the diet year around. Are these numbers reflected in your medical records?

 VetCentric showed us that home delivery of nutritional products averages a 8.9 month usage rate, while come in and purchase the next bag at the practice averages only 3.3 months compliance. Are these nutritional feeding rates reflected in your patients?

 Cats need as much dietary help as dogs (50% of the animals coming through the front door). Does your practice have similar support programs for cats versus dogs?

 Pet Parents want to give their pets treats, some times as training rewards, some times as just caring morsels. Does your practice nutritional counseling integrate treat calories when balancing dietary programs?

Your practice may be a very rare one that meets all of the above parameters and has an excellent nutritional counselor system within the staff. If so, be proud and flaunt that level of caring. For the other 95% of the practices out there, start paying attention to the nutritional needs of your patients; 22 more months of life means over $1000 of more income per patient during their life time.

Body Scoring

For years, the veterinary profession has been selling pet food, but only recently have we actually begun the active role of wellness counselors. Most practices try to take sequential weights, but have not developed an easy system to record the assessment of that weight; we call this documentation "body scoring". Hills and Pfizer have offered 5-point systems, and Purina has provided a 9-point system; use the one that excites your doctors and staff. With that role, the veterinary staff member must take an active part in the overall condition of the pet since there are significant numbers of obese and malnourished pets in the general population. As a general rule, every pet's body score should be recorded at each visit following the weight (e.g., 35/5).

Just as with the pain scoring model, the staff member must be trained to make a judgment about the course of action necessary to address the nutritional condition; vendors have more than ample systems, just ensure there is a single standard in your practice so clients do not get confused. According to clinical experts, any patient with a score of below 3 or is probably in need of immediate intervention to prevent death. Likewise, animals with a score of 7 or higher need an immediate response to their condition to prevent life-altering disease or conditions.

Hill's and Pfizer provides aides which recommend a five-point system, which can be used for dogs and cats (if the doctors or staff start using decimals, e.g. 4.5, shift to the nine point system and do not allow decimals).

 Body condition score of 1 = Very thin

 Body condition score of 2 = Underweight

 Body condition score of 3 = Ideal

 Body condition score of 4 = Overweight

 Body condition score of 5 = Obese

The body scoring of the well pet often leads into nutritional scoring of the inpatient animal. There has been some excellent literature from the Veterinary Emergency & Critical Care Society on the importance of nutritional supplementation for ill pets, and like pain scoring, it should be an "all staff" patient advocacy program within the practice. It is critical that every member of the team be accountable for monitoring every inpatient with each feeding - some hospital directors have set the standard that nutritional scoring is performed on each patient at least twice a day while they are in the hospital since recovery is so dependent on the metabolic process.

In-Patient Nutritional Scoring

Just as with the pain scoring model, the clinician must make a professional judgment about the course of action necessary to address the nutritional deficiency. According to clinical experts, any patient with a score of 4 or higher needs an immediate response to their nutritional deficiency. This response may be as simple as hand feeding or low-dose oral glucose for enterocinetic maintenance. In cases where the patient's response is mediated, the placement of a naso-gastric tube may be required for administration of glucose, Clinicare or a/d gruel. If the duration of the treatment is anticipated to be prolonged, the placement of a pharyngostomy or PEG tube may be indicated.

Body Scoring and Nutritional Scoring, like Pain Scoring, are methods for Internal healthcare communications, not numbers for clients. Clients must hear the words and the explanations. Clients must be able to picture the outcome of neglect, and the rewards of appropriate care, for the animals which they have assumed accountability. Remember the three basic rules of ensuring the client perceives quality veterinary healthcare delivery:

Never Allow Pain
Never Allow Puking
Help the Client Find Ways to Feed Their Animal

Marketing Nutritional Wellness

There is no overhead involved in something which replaces "coffee time." Dr. Catanzaro

For years, we have thought things like: grooming has no net; nutritional sales has minimal net; we are professionals and do not "sell." These types of functions were even "unethical" a couple of decades ago. The times have changed and the companion animal veterinary profession has polarized into two camps: change and capitalize upon the new opportunities - or - maintain what we have always done, and "this, too, shall pass." The latter thought has caused practices to decrease their liquidity.

Before we start, let me state that I am not a believer in sales for sales sake! I believe in sales for wellness sake, and letting the client buy for peace of mind. In providing them options (see Building The Successful Veterinary Practice: a three volume series from Blackwell Publishing), we cause additional stress; we are professionals, it is either needed or not needed, and most Practice Acts restrict us to only needed care. Marketing is a three-alignment process: (1) alerting a client to a pre-existing need of the pet and elevate that to a want, (2) making the client aware that our profession now has some alternatives to meet this need and ensuring the client that our own scope of services can meet that need, and (3) taking a few moments to validate their decision, regardless of which way they choose, and set a time to "make it happen" as the client has accepted. In today's environment, marketing is the ability to believe in what you do and let others know that it is worthwhile, and the entire alignment process is explained in greater detail in the Blackwell Press text, Veterinary Healthcare Services: Options in Delivery, in Chapter 5, Persuasive Marketing.

Nutrition as a Profit Center

As I originally published in Veterinary Forum, March 1989, in an article titled, "How to Market Nutritional Wellness--Use Practice Extenders to Stretch Your Influence," I believe nutrition is a contemporary healthcare concern. Wellness is a popular term for our clients in their own healthcare and nutritional counseling is well accepted for people. Nutritional wellness is a media industry in itself. The phrase Nutritional Wellness brings mental images into our client's mind that makes our marketing efforts easier. The sad thing to note is the Hill's research shows that while most practices have started 35 percent or more of their patients on some form of quality diet, less than 7 percent of the patients stay on for an entire year; we are not doing our job as patient advocates when these many animals are allowed to "fall off" a quality nutritional program.

There are those who have started to sell nutritional products, and there are those who have recently stopped selling maintenance diets because of the "pet food warehouse" competition in their catchment's area(s). Regardless of the decision, there is one important "profit center" concept to understand: your practice overhead is a fixed cost whenever you consider adding any new line item.

For years, we considered square footage and of the apportionment methods to determine profitability of a service or product, but in this mew millennium, that thought pattern is outmoded. In the cost benefit analysis, if the service or product replaces something else, the values of each must be assessed and compared. If the new line item or service only replaces idle time ("coffee time"), there is no overhead expense. You would pay the overhead expenses with or without the new product line or service. Since research has shown most all companion animal practices have a staff "idle time" of about 29% per day, this is the category in which I usually find pet food and nutritional counseling. It is a spare time activity within a practice, not displacing anything else.

Rules of Thumb

In this day of veterinary diversification, marketing of nutritional products has become a concern in many practices. The current rule of thumb is that when the income from pet food exceeds three percent of gross, it should become a separate expense element and be managed as its own profit center. The standard mark-up on pet food makes volume a tracking concern if the lower net is combined into the drug and medical supply account. To see it as a profit center, rather than just a client service, it needs to be tracked separately.

The rule of thumb that prices are often set by our competitors has waned. The new "rule of thumb" is that, "Prices are controlled by the most efficient agency known; the consumer" (Fortune Magazine, 4/5/03). This is especially true when competing in this market, since the pet or feed stores carry similar products and the manufacture's marketing effort is aimed at the product and not the outlet. The emerging pet food warehouses have a volume discount capability seldom matched by a veterinary practice complex. This is a fact and should not be confused with something a practice can change.

The rule of thumb that a veterinarian is worth in excess of $250 per hour in the consultation room, or more than $400 in the surgical suite, makes nutritional counseling by the veterinarian a low-payoff activity, if nutritional counseling replaces professional healthcare. If it replaces coffee time, it is not a comparison issue. The wages a practice usually pays the paraprofessional staff makes their nutritional counseling efforts a higher payoff practice activity.

The last rule of thumb is the medical basis of this discussion. Is nutrition important to health? Does every animal deserve to be on a nutritionally complete and balanced diet? Is digestibility also a concern? How would you prefer a pet owner to receive information concerning nutrition when it must fit into the veterinary healthcare delivery plan? Do you want your practice to control the veterinary healthcare delivery plan? If most of the answers are yes, the rule of thumb is, "Provide it or lose it."

Managing Public Perception

The client must believe in what we tell them. To be professional and believable, we must sincerely and medically endorse whatever we are saying (please refer back to the initial seven positional questions of this appendix). The marketing of pet food without believing in the product usually results in the practice effort becoming a cost center rather than a profit center. The professional training of our staff, and ourselves, include the mental attitude adjustments required to develop nutritional counseling as a needed service as well as a profit center. In one Illinois practice, when the doctors were asked what they fed to their own animals, only two of the six were feeding premium diets. We made a pact; everyone would feed only "practice available" diets for 90 days (even if they had to be sold at cost to the staff). At the end of the 90 days, retail nutritional product sales had increased by 19 percent. The team saw the difference, believed in the products, and has naturally started to share their belief in nutritional quality with the clients.

Discuss with your staff why certain diets are indicated, why IAMS or HILLS or PROPLAN or ROYAL CANIN (Waltham), or whatever you stock, is available in your practice, and why you professionally feel certain animals need specific dietary management. Get the staff to believe in what you believe. More important, at the end of each month, ask each paraprofessional the following three questions:

1.  How many clients were referred to you this month (the Veterinary Nutritional Advisor; by veterinarian, if applicable).

2.  What is the number of active nutritional patients (contacted within the past 30 days) being tracked by each Veterinary Nutritional Advisor as of the end of each month.

3.  How many nutritional patients did you bring in for "return weigh-ins" during the past month (by Veterinary Nutritional Advisor, if applicable).

4.  How many patients were provided sequential laboratory screens of body chemistry levels to ensure the feeding trial is/was effective?

These questions are designed to empower the Veterinary Nutritional Advisor, based on the training completed outside or inside the practice. They are designed to show the practice's confidence in the capability of the staff member to follow "their own clients" and delegate the client counseling to a cost effective level within the practice. The questions utilized are in concert with the values of most paraprofessionals, client service and a caring approach to wellness. They center on factors for which the staff member has complete accountability. If revenue dollars are brought into the equation, excuses are possible (OTC sales, size of purchases, cross sales, etc.). This would be detrimental to measuring personal success.

In cases of tracking client access, the paraprofessional can be proud of the service provided. In healthcare delivery, it has been shown that staff pride is perceived by the client as quality. Caring and belief in the value-based quality received causes the client bonding. The bonding is what causes return trade (and increased liquidity).

Each client has specific hot buttons, those things that really spark an interest or keep their attention. The client relations specialist (receptionist), the outpatient nurse (technician), and the veterinarian need to become a team in writing those key personal elements in some specific area of the medical record. This allows more effective communication with the client since analogies can be drawn. The marathon runner will usually understand the need for stamina, the nurse will understand the need for a balanced nutritional program, or a parent will generally understand the need for an owner to provide a nutritionally complete diet for animals under their care. Inversely, the overweight client will generally not respond favorably to statements about a fat pet, but may respond to a comment about the need for higher fiber and extended life spans, or the client which likes to feed table scraps and rebels when we recommend stopping will often respond to the wellness need when we point out that the nutritional consultation can balance the diet to a point where a few specific table scraps are okay during the transition to a better life style and fitness state for the pet.

The public perception of nutritional wellness is formed by many factors, most of which are out of the veterinarian's control. The local media intensity of human nutritional center advertising programs will pre-sensitize the client. The family standards for balanced or complete diets will affect the perception of importance of diet for the pet. The amount of junk food consumed in the client's daily life-style will affect the importance of a controlled diet in their pet's life. The veterinary practice staff cannot affect these environmental factors to any significant degree.

Making it Happen in Your Practice

The total patient advocacy program of your practice style will allow nutritional counseling to be seen as a farce or as a sincere concern. How you approach the healthcare needs of the pet from the first visit will often set the stage for nutritional counseling. Client education in the areas of vaccinations, internal and external parasite screens, pre-anesthesia laboratory testing, documented physical examinations, dental hygiene exams, and similar routine healthcare concerns make the use of nutritional counseling seem normal.

The veterinarian must set the stage for the need, but does not have to conduct the nutritional counseling. A well trained outpatient nurse technician or client relations specialist can act as the nutritional advisor as an extension of the veterinarians within the practice. Veterinary extenders are needed in every practice. Those are the people or things that allow the veterinarians to stay in the consultation room or surgical suite and earn the high income that they were trained to earn.

The phrase, "Fluffy seems a little heavy. Let's get you with our nutritional counselor and see if we can work out a system that will help with this challenge", infers a depth of expertise within the practice. It also infers that the veterinarian trusts the judgment of the staff member, which requires standards be discussed and understood before the first internal referral occurs to one of our veterinary extenders. It also establishes that veterinary extender as a care provider and makes that person responsible for a portion of the healthcare follow-up, that portion which pertains to nutritional wellness.

One consultation room can often be set up for routine use by the trained staff, with certificates of training and other credentials hanging for the clients to read. The display of these "glory walls" should not be restricted to only the veterinarians on staff. This lends an important credibility and recognition to our support staff. To a veterinary extender who serves as a nutritional counselor, the scale is an important instrument, and should reflect a professional approach to monitoring weight loss or gain. Holding animals while standing on a bathroom scale is not the image we want. An appropriate floor scale could be considered as a veterinary extender since it saves manpower time.

The routine follow-up weighing of animals on nutritional programs is expected and can easily be programmed for a veterinary extender to monitor, to include the recall reminders if the pet fails to appear for monitoring. The fact that the nutritional counselor monitors the weigh-ins does not require that the recall be done by that trained person. Any member of the staff can be trained to make "Doctor and I" recalls. For example, after the appropriate phone introduction is made, say, "The doctor and I have noted that we didn't get to weigh Fluffy this month. Is everything okay with you and Fluffy?" This form of client and patient advocacy by the veterinary extenders will be perceived by most clients as professional caring, making the next practice visit that much more pleasant.

To balance the marketing of nutritional products with the sincere caring that is expected in quality practices, some cases will not need pet food. There are certain breeds that can eat any commercial diet and maintain good health, while others gain weight or may become deficient in some portion of their nutritional requirements. A well trained nutritional counselor will know when to supplement, when to change feeds, or when to use the "grain of common sense" and just try to delete a portion of the table scraps from the diet.

It has been said that "Service is adding people to the product." Profit is adding any net income to some action, void, or habit which had none. Marketing nutritional wellness fits these definitions exceptionally well, especially when we consider using the internally trained veterinary extender as our practice methodology to make it happen.