IMPLEMENTING “BEST PRACTICE”

TOOLS

2011 Indiana Healthcare Leadership Conference on Improving NutritionMarch 31, 2011 in Indianapolis, Indiana.

Brenda Richardson MA, RD, LD, CD

ANDRESOURCESTO IMPROVE NUTRITION

Objectives- Attendees can:

• Identify “Best Practice” for

Nutrition • Know Resources• Implement at the

Facility Level

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•Federal•State•Professional Organizations

•Identify the Team•Team Responsibilites•Staff/Residents/ Families

•Programs•Policies/Procedures• Training/Education• QI Customers•Vendors/Contracts

I. Know what ”Best Practice” Is for LTC

II. Facility Team Management

III. Facility Systems and Processes

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RESOURCES: •Federal• State• Professional Organizations

I. Know what Nutrition ”Best Practice” Is for

LTC

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VISULIZE ACTIVITIES WITH TIMELINES!

Minimum Data Set/RAI

QM/QI/Care Levels

State Food Regulation/Codes

National Pressure Ulcer Advisory Panel

State Operations Manual

American Health Care Association

American Association of Homes

and Services for the Aging

Dietary Managers Association

Am Assoc

Retired Persons

AARPADA AHCAHEALTHDEPT

MDS NPUAP DMA AAHSAQUALITYSOM

ProfessionalOrganizations (ADA, AMDA, NPUAP, CDC, etc.

State and Federal Gov Agencies (CMS, ISDH, Health Dept, AoA, etc)

CONSUMER & Consumer Organizations (AARP, NCOA, etc)

Examples of Resources for Best Practice

American Dietetic Association

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 expert-endorsed research and clinical

practice guidelines/resources”

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• Nursing• Registered Dietitian• Dietary Manager/ Diet Technician Registered• Speech Language Pathologist• Quality Improvement• Medical Director• CNAs• Others (Pharmacist, Occupational Therapist, etc.)

Identify a Nutrition “Oversight” Team

II. Facility Team Management

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• 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.)

Identify Team Responsibilities

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• Memos• In-services• Newsletter• In-Services• Department Head Meetings• Change in Shift Meetings• Care Plan Meetings• Others (Website, etc)

Communication with Staff,

Residents and Families

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III. SystemsAnd Processes

• Key Facility Nutrition Programs• Nutrition Manuals• Menu and Vendor Programs• Customer Satisfaction• Quality Improvement

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III. SystemsAnd 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

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III. SystemsAnd 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)

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III. SystemsAnd 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

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III. SystemsAnd Processes

Manuals:• RAI Manual• Additional References• Client Education Material

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III. SystemsAnd Processes

Menus:SeasonalReflect input from ClientsReviewed and Approved by RD

Vendor/Manufacturer ProgramsMeet requirements, services, resources,

team player.

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III. SystemsAnd 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 ProcessQuality Improvement: - Nutrition Programs, Weights, Heights, QMs, Meal Serice, Dining, etc.

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Revised in 2010

Using a “Best Practice” Clinical Practice Guideline

American Medical Director’s

Association (AMDA) “Altered

Nutritional Status in the Long-Term

Care Setting”

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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)

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STEP 1Perform a

baseline evaluation of the client’s nutritional status.

- Admission Weight

- Height

- BMI

- Eating Preferences

- Baseline testing

- MDS

- MNA© - SF

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RECOGNITION

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

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RECOGNITION

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

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RECOGNITION

STEP 4Confirm

existence of a nutritional problem that requires additional assessment.

- Validate measurements

- Weight change is truly unintentional or unexpected

- Evaluate client willingness to undergo a diagnostic assessment

* If client or family chooses to not intervene then decision and rationale should be clearly documented (see step 13)

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ASSESSMENT

STEP 5If 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)

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ASSESSMENT

STEP 6If food

intake is inadequate, screen for functional impairments.

- Observe while eating

- Evaluate for oral pain

- Observe swallowing ability

- Evaluate adequate feeding assistance

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ASSESSMENT

STEP 7If 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

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ASSESSMENT

STEP 8If 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

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ASSESSMENT

STEP 9If 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

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ASSESSMENT

STEP 10Screen

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

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ASSESSMENT

STEP 11For 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

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ASSESSMENT

STEP 12For 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.

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ASSESSMENT

STEP 13

Identify and document unavoidable 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.

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ASSESSMENT

STEP 14Summarize 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.

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ASSESSMENT

STEP 15Address

each identified risk factor and potential cause of ANS identified in Steps 1-13.

- For each identified risk factor establish a planned intervention

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TREATMENT

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

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TREATMENT

STEP 17Tailor

meals and foods to individual preferences.

- 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

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TREATMENT

STEP 18

Reconsider any dietary restrictions.

- Special diets for diabetes, hypertension, heart failure and hypercholesterolemia have not shown to improve control of or affect symptoms

- Late-stage renal insufficiency is exception- protein restriction may delay onset of diabetes (no protein restriction necessary with dialysis)

- Altered consistencies

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TREATMENT

STEP 19Consider

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.

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TREATMENT

STEP 20Consider

use of appetite stimulants on an individual basis.

- Increase activity/exercise

- Use is controversial

- Consider on individualized basis

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TREATMENT

STEP 21Evaluate

risks and benefits of artificially administered nutrition and hydration by tube feeding.

- May be clinically appropriate in some circumstances:Clear clinical indicationProvides benefit not outweighed by risks

Consistent with known values and preferences of client and family

- Consider risks and benefits

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TREATMENT

STEP 21-continuedEvaluate 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

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TREATMENT

STEP 22

Summarize the results of treatment interventions 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

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TREATMENT

STEP 23Monitor

effectiveness of treatment interventions.

- Weight stabilization is primary endpoint

- Document at least monthly if persists

- Document when resolved

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MONITORING

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

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MONITORING

STEP 25Monitor 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

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MONITORING

STEP 26Monitor

the incidence and prevalence 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

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MONITORING

STEP 27

Monitor the assessment process.

- QI process with mechanism for tracking the assessment process when a client triggers an evaluation for ANS.

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MONITORING

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 YouBrenda Richardson, MA, RD, LD, CD

Email: brendar10@juno.com

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