personalised care plans in care homes 2010-2014 muriel gall team lead dietitian food first team
TRANSCRIPT
Personalised Care Plans in Care Personalised Care Plans in Care Homes 2010-2014Homes 2010-2014
Muriel GallMuriel Gall
Team Lead DietitianTeam Lead Dietitian
Food First TeamFood First Team
HypothesisHypothesis
• A specific dietetic-led service with personalised A specific dietetic-led service with personalised care plans optimises nutritional status of care care plans optimises nutritional status of care home residents and reduces inappropriate home residents and reduces inappropriate prescribing of oral nutritional supplements (ONS)prescribing of oral nutritional supplements (ONS)
Introduction & BackgroundIntroduction & Background
• Two GP practices with 200 care home beds (spend on ONS Two GP practices with 200 care home beds (spend on ONS increasing at ~50% per year) increasing at ~50% per year)
• EvidenceEvidence
– NICE (CG32, 2006) NICE (CG32, 2006) • Nutritional screening eg. MUSTNutritional screening eg. MUST• diet should be optimised in addition to ONS ie. promoting diet should be optimised in addition to ONS ie. promoting
Food FirstFood First
– Audits of prescribing criteria indicates 30–70% inappropriate Audits of prescribing criteria indicates 30–70% inappropriate prescriptions (Gall et al., 2001; Kennelly et al., 2009)prescriptions (Gall et al., 2001; Kennelly et al., 2009)
Development of Service• Evaluation of current practice Evaluation of current practice
– Accuracy of MUSTAccuracy of MUST– Meal and snack observations – serving sizes,Meal and snack observations – serving sizes,
sauces; portion sizes, evidence of food fortification, sauces; portion sizes, evidence of food fortification, toileted prior to meals, sufficient staff to support toileted prior to meals, sufficient staff to support assisted feeding, compliance with ONS – provided assisted feeding, compliance with ONS – provided report to care homereport to care home
– Developed care pathway and provided in-house Developed care pathway and provided in-house trainingtraining
CARE PATHWAYCARE PATHWAY• Training for care home staff on:Training for care home staff on:1)1) MUSTMUST2)2) Food First Approach – 3 principlesFood First Approach – 3 principles
– 2 fortified milky drinks.2 fortified milky drinks.– Fortifying one dish at each meal time.Fortifying one dish at each meal time.– 2 nourishing snacks between meals.2 nourishing snacks between meals.
• Monthly monitoring of weights and MUST. Any resident found to Monthly monitoring of weights and MUST. Any resident found to have a MUST score of 1 or morehave a MUST score of 1 or more
– taken onto dietetic caseload, with a care plan based on the taken onto dietetic caseload, with a care plan based on the food first principles and resident’s preferences, care pathway food first principles and resident’s preferences, care pathway and ONS where appropriateand ONS where appropriate
– Evaluated residents’ nutritional outcomesEvaluated residents’ nutritional outcomes
Equivalent to 4 plain biscuits = 140kcalsEquivalent to 4 plain biscuits = 140kcals
• Fairy cake• Malt loaf (1 slice with butter)• Fruit scone (1/2 scone with butter & jam)• Hot cross bun (1/2 bun with butter & jam) • Sausage roll (medium)• Crisps (standard packet)• Ham sandwich (1 slice, butter & ham)• Icecream (1scoop)• Yoghurt (thick and creamy)• Meringue nest with whipping cream• Cereal bar • Dried fruit (handful, e.g. raisins, sultanas)
Types of food to fortifyTypes of food to fortify
milkmilkcustardcustard
milk puddingsmilk puddingsporridgeporridge
mashed potatoesmashed potatoessoupsoup
sponge puddingsponge puddingicecreamicecream
vegetablesvegetablesgravygravy
Nourishing foods used for fortificationNourishing foods used for fortification
Milk powder 1 heaped tablespoon 50 calories
Whole milk 75mls 50 calories
Margarine 1 heaped teaspoon 75 calories
Double cream Whipping cream Single cream
1 tablespoon 135 calories 110 calories 30 calories
Cheese Small matchbox (30g) 125 calories
Jam / honey 1 heaped teaspoon 50 calories
Products – 2 per dayProducts – 2 per day
ProductProduct Protein (g)Protein (g) Energy Energy (kcals)(kcals)
AA Aymes / Complan Aymes / Complan Shake Shake 1 sachet made with 200ml full 1 sachet made with 200ml full cream milkcream milk
1616 388388
BB Fortified Milk – 200mlFortified Milk – 200mlFull cream milk, dried milk powder, Full cream milk, dried milk powder, double cream + Nesquickdouble cream + Nesquick
1212 300300
CC Ensure Plus 220mlEnsure Plus 220ml 1414 330330
GOVERNMENT
RECOMMENDED POOR
APPETITE B’fast
Lunch
Dessert
Tea
Calories 2160 960
Acknowledgement: Caroline Walker Trust
Nutritional Care – House 1Nutritional Care – House 1• 10 residents on ONS – 6/10 on dietitians case load10 residents on ONS – 6/10 on dietitians case load
– 5/10 (50%) had lost 1.4 – 6.7kg in previous 4 months5/10 (50%) had lost 1.4 – 6.7kg in previous 4 months– 1/10(10%) wt stable1/10(10%) wt stable– 4/10(40%) gained wt 1.5 - 6.7kg4/10(40%) gained wt 1.5 - 6.7kg– After 6-9 weeks of food first approach:After 6-9 weeks of food first approach:
• 7/10(70%) gained wt (0.5 - 6.2kg)7/10(70%) gained wt (0.5 - 6.2kg)• 3/10 lost wt (0.4 – 1.5kg)3/10 lost wt (0.4 – 1.5kg)
• A further 5 residents were nutritionally at risk A further 5 residents were nutritionally at risk – all wt loss of 2.6 – 9.3kg in previous 1-4 months)all wt loss of 2.6 – 9.3kg in previous 1-4 months)– After 6- 9 weeks of food first approach:After 6- 9 weeks of food first approach:
• 4/5 (80%) had gained weight 0.1 – 3.0kg4/5 (80%) had gained weight 0.1 – 3.0kg• 1/5 (20%) had lost wt 1.5kg1/5 (20%) had lost wt 1.5kg• None started on ONS None started on ONS
• 15 residents on project dietitian’s caseload15 residents on project dietitian’s caseload
Practice 1 - BNF units used April - December2010
020406080
100120140
Apr-1
0
Jun-
10
Aug-1
0
Oct-10
Dec-10
Month
nu
mb
er o
f u
nit
s
Practice 1 BNF7.2
Practice 1 BNFTotal 7.1-7.4
Comparisons of 3rd quarter (Sept-Dec) expenditure on ONS in the highest spending DG&S practices
£0.00£2,000.00£4,000.00£6,000.00£8,000.00
£10,000.00£12,000.00£14,000.00£16,000.00£18,000.00
GP practice
3rd Quarter 08/09
3rd Quarter 09/10
3rd Quarter 10/11
SpendSpend (sterling) (sterling)
0
100000
200000
300000
400000
500000
600000
700000
2007
- 08
2008
- 09
2009
- 10
2010
- 11
2011
- 12
2012
- 13
2013
- 14
Annualspending trend
Units of ONS PrescrUnits of ONS Prescribedibed
0
5000
10000
15000
20000
25000
30000
35000
2009 -2010
2010 -2011
2011 -2012
2012 -2013
2013 -2014
Units annuallyPrescribed
Effects of the service on Patient CareEffects of the service on Patient Care
• Patients receive more regular dietetic Patients receive more regular dietetic assessment of their nutritional status.assessment of their nutritional status.
• More patients are managed by ‘food first’ rather More patients are managed by ‘food first’ rather than supplementsthan supplements
• Advice on appropriate food and fluid fortificationAdvice on appropriate food and fluid fortification• Patient centred and personalised advice on Patient centred and personalised advice on
nutrition with regards to their disease state.nutrition with regards to their disease state.• Support for care home staff, residents, families Support for care home staff, residents, families
and GPs for end of life careand GPs for end of life care
SummarySummary
• A specific dietetic-led service with personalised A specific dietetic-led service with personalised care plans optimises nutritional status of nursing care plans optimises nutritional status of nursing home residents and reduces inappropriate home residents and reduces inappropriate prescribing of oral nutritional supplements (ONS)prescribing of oral nutritional supplements (ONS)