IMPLEMENTING BEST PRACTICE TOOLS AND RESOURCES TO IMPROVE

IMPLEMENTING “BEST PRACTICE” TOOLS AND RESOURCES TO IMPROVE NUTRITION 2011 Indiana Healthcare Leadership Conference on Improving Nutrition March 31, 2011 in Indianapolis, Indiana. Brenda Richardson MA, RD, LD, CD

Objectives- Attendees can: • Identify “Best Practice” for Nutrition • Know Resources • Implement at the Facility Level

• Federal • State • Professional Organizations • Identify the Team • Team Responsibilites • Staff/Residents/ Families • Programs • Policies/Procedures • Training/Education • QI �Customers • Vendors/Contracts I. Know what II. Facility III. Facility ”Best Practice” Team Systems and Management Processes Is for LTC 3

RESOURCES: • Federal • State • Professional Organizations I. Know what Nutrition ”Best Practice” Is for LTC 4

Examples of Resources for Best Practice VISULIZE ACTIVITIES WITH TIMELINES! Professional Organizations (ADA, AMDA, NPUAP, CDC, etc. State and Federal Gov Agencies (CMS, ISDH, Health Dept, Ao. A, etc) SOM HEALTH DEPT QUALITY MDS ADA NPUAP CONSUMER & Consumer Organizations (AARP, NCOA, etc) DMA AAHSA AHCA AARP ar n y. M ica l. P n iso tio dv cia r. A ce so As Ul ic et e ur et ss Di re ry s de Co n/ tio la gu ls ve Le Re e ag an od Fo ar I/C AI /R t Se l ua an M s n on c tio rs so cia As Pe so d As Am tire e r Re Ca es m th al Ho He of n n ing ica tio Ag er cia he Am so r t As fo n n es tio ia ic er erv oc ss Am d S s. A an er et Di er te na io Am t Na a St /Q ta ns io at Da er um Op im te in QM M a St Pa l ne Others: QIOs, Pioneer Network, USDA, CDC, FDA, AMDA, ASPEN, etc.

Remember that “whatever nutrition assessment and care planning resources are used, they are expected to be: - current, - evidence-based or expertendorsed research and clinical practice guidelines/resources”

• • II. Facility Team Management Identify a Nutrition “Oversight” Team Nursing Registered Dietitian Dietary Manager/ Diet Technician Registered Speech Language Pathologist Quality Improvement Medical Director CNAs Others (Pharmacist, Occupational Therapist, etc. ) 7

Identify Team Responsibilities • Nursing/ Director of Nursing, Unit Mgrs, CNAs, others • Registered Dietitian (Indiana Certification, Skills and Competencies, Professional Involvement) • Dietary Manager/ Diet Technician Registered • Speech Language Pathologist • Quality Improvement • Medical Director • Others (Pharmacist, Occupational Therapist, etc. ) 8

• • Communication with Staff, Residents and Families Memos In-services Newsletter In-Services Department Head Meetings Change in Shift Meetings Care Plan Meetings Others (Website, etc) 9

III. Systems And Processes • Key Facility Nutrition Programs • Nutrition Manuals • Menu and Vendor Programs • Customer Satisfaction • Quality Improvement 10

III. Systems And Processes • Key Facility Nutrition Programs - Food service program - Dining program - High Risk Nutrition - Weight monitoring program - Hydration program - Skin and wound care program - Nutritional supplement program - Quality Improvement program 11

III. Systems And Processes Manuals: • Policy/Procedure Manuals: • Current, Best Practice, Reflect What your Facility Does, Staff is educated/trained. • Diet Manual: • Current and Best Practice (Indiana Dietetic Association Diet Manual, Company, Others) 12

III. Systems And Processes Manuals: State Operations Manual (SOM) • Requirements in 42 CFR Part 483, Subpart B, • Know The Survey Process, Survey Forms, Appendix P - Survey Protocol for Long Term Care Facilities - Part I and Appendix PP- Guidance to Surveyors for LTC Facilities • Know the Deficiency Criteria and Determination and the Plans of Correction 13

III. Systems And Processes Manuals: • RAI Manual • Additional References • Client Education Material 14

III. Systems And Processes Menus: Seasonal Reflect input from Clients Reviewed and Approved by RD Vendor/Manufacturer Programs Meet requirements, services, resources, team player. 15

III. Systems And Processes Customer Satisfaction - Resident Council, Newsletters, Surveys - Be present during all meals and get input. - Provide follow-up and responsiveness. Culture Change: - Eden Alternative, Pioneer Network, Advancing Excellence in NH Campaign, CMS Survey & Certification Process Quality Improvement: - Nutrition Programs, Weights, Heights, QMs, Meal Serice, Dining, etc. 16

Using a “Best Practice” Clinical Practice Guideline American Medical Director’s Association (AMDA) “Altered Nutritional Status in the Long-Term Care Setting” Revised in 2010 17

Altered Nutritional Status (ANS): Unintended and unexpected change in weight that is likely to indicate an undesired alteration in intake or utilization of nutrients. CPG Guidelines (27 steps): RECOGNITION – Steps 1 - 3 ASSESSMENT – Steps 4 - 14 TREATMENT – Steps 15 - 22 MONITORING – Steps 23 - 27

Definition of Altered Nutritional Status (ANS): Unintended and unexpected change in weight that is likely to indicate an undesired alteration in intake or utilization of nutrients. Note: Differentiate Protein-Energy Undernutrition (PEU), Cachexia, and Sarcopenia from Altered Nutritional Status (ANS). (Although these may present as ANS) 19

STEP 1 Perform a baseline evaluation of the client’s nutritional status. - Admission Weight - Height - BMI - Eating Preferences - Baseline testing - MDS - MNA© - SF RECOGNITION 20

STEP 2 Identify Risk Factors. - History of recent weight loss - Functional disability - Pressure Ulcer - Terminal Illness - Depression - Medication - Therapeutic Diets - Nausea/Vomiting/ Diarrhea - Fluid Retention/Edema - Underlying Infections RECOGNITION 21

STEP 3: Observe routinely for changes in weight or food intake that may indicate ANS. - Wt changes: ≥ 5% in 1 month, 7% in 3 months, 10% in 6 months - Decline in food/fluids (not to exceed 7 days) - BMI approaching underweight - Persistent, unexpected, and unintended weight loss for 3 consecutive months - Pressure Ulcer - Abnormal Labs - Uncontrolled disease processes RECOGNITION 22

- Validate measurements STEP 4 - Weight change is truly Confirm existence of a unintentional or unexpected - Evaluate client willingness to nutritional undergo a diagnostic assessment problem that * If client or family chooses to not requires intervene then decision and additional rationale should be clearly assessment. documented (see step 13) ASSESSMENT 23

STEP 5 If there is weight loss: Establish that the client is eating the food received. - Anorexia (Go to step 6) - Weight loss despite normal intake (Go to step 9) - Hyperphagia (Go to step 9) ASSESSMENT 24

STEP 6 If food intake is inadequate, screen for functional impairments. - Observe while eating - Evaluate for oral pain - Observe swallowing ability - Evaluate adequate feeding assistance ASSESSMENT 25

STEP 7 If food intake is inadequate, screen for social and environmental factors, dietary restrictions, and food preferences. - Reassess food preferences - Review necessity for dietary restrictions - Evaluate environment where meal is served: homelike, noise, odor, lighting, eating alone - Evaluate time of meals and portion sizes ASSESSMENT 26

STEP 8 If food intake is inadequate, screen for medical conditions associated with anorexia or dehydration. - Consider fluid electrolyte imbalance - Changes in mood or behavior - Review all meds - Presence of infections - Gastrointestinal pathology and motility disorders - Order chest x-ray and labs if indicated ASSESSMENT 27

STEP 9 If there is weight loss despite normal intake, screen for a malabsorption syndrome and for conditions that increase nutritional needs. - Inadequate caloric intake - Increased metabolic need - Malabsorption ASSESSMENT 28

STEP 10 Screen clients who gain weight for conditions related to fluid retention. - 1 -2 L of fluid (2 -5 pounds in weight) can infiltrate lower extremity tissues before edema is evident ↓ fx - Advanced organ system disease - Aggressive IV therapy ASSESSMENT 29

STEP 11 For clients who lose weight: Evaluate whether a continued search for the cause of weight loss is appropriate. - Repeat client hx and physical exam in light of recent wt change - Order additional labs and radiologic studies on the basis of any new findings in the “second-look” hx and physical exam ASSESSMENT 30

STEP 12 For clients who gain weight: Evaluate whether a continued search for the cause of weight gain is appropriate. - Determine if related to fluid retention - Determine if gain has negatively affected fx, quality of life, or management of comorbid conditions. ASSESSMENT 31

STEP 13 Identify and document unavoidabl e ANS. Unavoidable when 1 or more applies: - No remediable cause for the change in weight - Although cause is identified, client has not responded to therapeutic interventions (steps 15 -20) - Further interventions may harm with no reasonable expectation of benefit. ASSESSMENT 32

STEP 14 Summarize the results of the assessment of the client’s ANS. - Document ANS - Describe all conditions contributing to ANS - Project prognosis and likely clinical course - Update care plan to indicate all palliative care interventions with concurrent document to evaluate effectiveness. ASSESSMENT 33

STEP 15 Address each identified risk factor and potential cause of ANS identified in Steps 1 -13. - For each identified risk factor establish a planned intervention TREATMENT 34

STEP 16: Address factors that may affect the eating environment in the LTC facility. - Pleasant and conducive for dining - Foods attractive and palatable - Consider having more than one meal setting - Flexibility in staffing where clients need assistance - Use non-nursing staff and volunteers to assist set-up and socialization - Happy hour before meals - Use smell to stimulate appetite TREATMENT 35

STEP 17 Tailor meals and foods to individual preference s. - Individualize meal plan - Promote flexibility in meal times - Allow eating at client pace - Invite family to bring client’s favorite foods in - Honor resident preferences- ethnic, regional and personal - Appropriate consistency - Provide adaptive devices - Provide Finger Foods for those that cannot use utensils TREATMENT 36

- Special diets for diabetes, hypertension, heart failure and STEP 18 hypercholesterolemia have not Reconsider shown to improve control of or any dietary affect symptoms restrictions. - Late-stage renal insufficiency is exception- protein restriction may delay onset of diabetes (no protein restriction necessary with dialysis) - Altered consistencies TREATMENT 37

STEP 19 Consider ways to supplement the client’s diet. - Increase nutrient density of foods - Offer snacks - Consider giving a multivitamin and mineral supplement - Distribute liquid nutritional supplements during medication pass. TREATMENT 38

STEP 20 Consider use of appetite stimulants on an individual basis. - Increase activity/exercise - Use is controversial - Consider on individualized basis TREATMENT 39

STEP 21 Evaluate risks and benefits of artificially administered nutrition and hydration by tube feeding. - May be clinically appropriate in some circumstances: § Clear clinical indication § Provides benefit not outweighed by risks § Consistent with known values and preferences of client and family - Consider risks and benefits TREATMENT 40

STEP 21 continued Evaluate risks and benefits of artificially administered nutrition and hydration by tube feeding. - Consider risks and benefits complicated by misconceptions: § Loved one will “starve” to death § Will reduce comfort and promote suffering - Actually may cause diarrhea, abdominal pain, local complications and increase risk of aspiration TREATMENT 41

STEP 22 Summarize the results of treatment interventio ns on the client’s ANS. Document: -Treatment plan and compliance -Complications or side effects of interventions -Trends in wt loss or gain -Strategy for monitoring response and adjustments -Prognosis and likely clinical course TREATMENT 42

STEP 23 Monitor effectivenes s of treatment intervention s. - Weight stabilization is primary endpoint - Document at least monthly if persists - Document when resolved MONITORING 43

STEP 24 Monitor all clients regularly to identify ANS as early as possible. - Admission- weigh weekly for first 4 weeks. If weight is stable weight monthly thereafter - Monitor per ANS criteria - MDS monitoring tool - Review advance directives annually and when clinical status changes - Monitor lab values as needed MONITORING 44

STEP 25 Monitor to ensure that each ANS risk factor identified in the admission evaluation is addressed. - Have mechanism for tracking risk factors identified in admission evaluation - Link to a planned intervention - Monitor care plan and effectiveness of the intervention MONITORING 45

STEP 26 Monitor the incidence and prevalenc e of ANS in the facility. - Significant weight changes - Decline in food intake over several days (not to exceed 7 days) - BMI approaching underweight range - Unexpected and unintentional wt loss persists for 3 consecutive months - Abnormal labs MONITORING 46

STEP 27 Monitor the assessmen t process. - QI process with mechanism for tracking the assessment process when a client triggers an evaluation for ANS. MONITORING 47

It is imperative that health care providers are aware of nutritional issues and that optimal achievable nutritional status is maintained to ensure the health, well-being, and quality of life for our aging population. Thank You Brenda Richardson, MA, RD, LD, CD Email: brendar 10@juno. com 48