Malnutrition Prevention Programme

SalfordKirstine FarrerSarah Cleverly

The Five Principles

Raising awareness Working together

Identifying malnutrition Personalised care, support and treatment

Monitoring and evaluating

Setting the scene

Who we are

Salford Steering Group Name Job Title Place of work

David Haynes Chief Executive Age UK, Salford

Jean Rollinson Director of Service Development Age UK, Salford

Kirstine Farrer Consultant Dietitian Salford Royal NHS FT

Brenda Blackett Lead Nutrition Nurse Salford Royal NHS FT

Katie Foster/Tony Ward Team Leader, Community Dietetics Salford Royal NHS FT

Sarah Cleverly ICP Project Manager (Care Homes) and Mental Health Lead.

Integrated Care Programme ( Greater Manchester West NHS Foundation Trust)

Stephanie Webb ICP Project Manager (MDGs in the Community)

Integrated Care Programme (Salford Royal NHS FT)

Claire Vaughan Head of Medicines Management Salford CCG

Paul Walsh Integrated Commissioning Manager Salford City Council

Julia Wood AQuA Affiliate

Overview of Salford City

• Total population is 218,000• Eight neighbourhoods• Although there are diverse levels of affluence, Salford is ranked as one of

the most deprived local authority areas in England with life expectancy lower than the England average

• Population of people aged 65 and over is 35,000 • Number of older people is forecast to rise by 28% by 2030• Large Orthodox Jewish community• 14% (nearly 5000) of people aged 65 and over may be at risk of

malnutrition (using BAPEN prevalence tool)

Our approach• Governance

– Integral part of integration agenda in Salford – Monthly reporting to the ICP Alliance Board

• Methodology– Model for Improvement using PDSA cycles

• Workstream Remits & Action Plans

Launch Event - May

Aims• To share the work of the MTF and drum up enthusiasm• To understand the current state and identify gaps• To help shape the priorities for taking the work forward

On the day• Over 80 people in attendance• Presentations – understanding the scale of the problem• Interactive group work – scenario planning• Video – developed for the event: https://www.youtube.com/watch?v=SFIzFMw6iJ8• Pledge Tree

Outcomes• Great evaluation• Learning developed into workstreams• Pledges• Film clip – developed at the event:

https://www.youtube.com/watch?v=Z7tH6Z91mKs&feature=youtu.be

Project Launch Event

Work Stream Remits

1. ICP Standards of Nutritional Care Across Organisations to reflect the NIHCE Quality Standards

2. Nutrition and Dysphagia Education for Staff across Salford ICP3. Raising Awareness 4. Working with Community and Primary Care

SALFORD WORKSTREAM REMIT:ICP Standards of Nutritional Care Across Organisations

Reflect the NIHCE Quality Standards

ContextAs part of the ICP it is important that all organisations are delivering the same standard of care

Pur

pos

e

Objectives• Statement 1: People in care settings are screened for the risk of malnutrition using a validated screening tool• Statement 2: People who are malnourished or at risk of malnutrition have a management care plan that aims to meet their nutritional requirements• Statement 3: All people who are screened for the risk of malnutrition have their screening results and nutrition support goals (if applicable) documented and

communicated in writing• Statement 4: People managing their own artificial nutrition support and/or their carers are trained to manage their nutrition delivery system and monitor their

wellbeing• Statement 5: People receiving nutrition support are offered a review of the indications, route, risk, benefits and goals of nutrition support at planned intervalsAll NIHCE statements to be integrated into ICP (Integrated Care Programme) Standards as part of the Salford Quality Assurance Framework by March 2015 to be considered when commissioning high quality nutrition support services across the City.

Links to MTF workstreams: raising awareness, working together, identifying malnutrition, personalised care. Support and treatment, monitoring and evaluation

Out

puts

ScopeN/A to paediatrics, for adult services only

Deliverables• Robust IT systems in place at Salford Royal FT

(SRFT) to provide data to support measure 1 and 2

• Tangible areas you can hold or point to, e.g.:•current pathway mapped (April)

• proposed pathway/protocol designed (Ongoing)

• robust systems in place for implementation and review/measurement (ongoing)

Success measuresHard Success Measures:• >95% of patients screened using ‘MUST’ on admission to hospital through monthly reporting (BB,

KF, SC)• >95% of patients over 65 years of age who score 2 consecutive high ‘MUST’ scores within 10

days of admission to be seen by dietitan (KF)• All over 75 years to have a BMI recorded as part of the GP contract (FT)• All care and nursing homes to have nutritional standards and KPIs agreed and assessed by April

2015 (SC, PW, KF)• SRFT Catering Strategy to be completed by March 2015 Soft Measures:• Survey of all home enteral tube fed patients to be completed by March 2015• Improved patient survey results on hospital food

Res

ourc

es

Team structure and rolesAll key people identified by initials above. BB – Brenda BlackettKF – Kirstine FarrerSC – Sarah CleverlyPW – Paul WalshK Fo – Katie FosterFT – Francine Thorpe

Others to involveReport to Mal Waters via ICP governance framework and monthly Steering Group Meetings

BMI• Salford Royal Foundation Trust

– MUST Tool can now be used electronically at Salford Royal Foundation Trust. The functionality enables automatic calculation of weight loss and BMI

– Data obtained from Salford Royal shows a median 93% of patients screened within 6 hours of admission using MUST

– Catering Strategy underway – locum dietitian appointed and is working on analysis of hospital menus and to ensure Salford Royal meets new EU legislation regulations.

• Salford Care Homes Practice – Assesses Care Home residents BMI on admission to a care

home and at the 6 month review. N=1100.

Progress

0

5

10

15

20

25

30

35

40

45

May10/apr11 May11/apr12 May12/apr13 May13/apr14

Rate

per

100

,000

per

sons

Hospital admissions relating to malnutrition, Salford,May 2010/April 2011 - May 2013/April 2014

Salford Greater Manchester England

0

50

100

150

200

250

300

0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90 plusRa

te p

er 1

00,0

00 p

opul

ation

Age band

Hospital admissions with malnutrition as a diagnosis by age band, Salford and Greater Manchester

Apr10/May11 to Apr13/May14 (4 year pooled) Salford Greater Manchester

Residential and Nursing Care Homes and Home Care Provider StandardsNICE standards in relation to nutrition have been included in the

development of the Salford Quality Assurance Framework – go live date to be confirmed

Progress

Residential and Nursing Care Homes and Home Care Provider ContractsLocal provider contracts have been revised to include Key Performance

Indicators about nutrition

Progress

SALFORD WORKSTREAM REMIT:Nutrition and Dysphagia Education for Staff across Salford ICP

ContextAs part of the ICP it is important that all organisations are delivering the same standard of care

Pur

pos

e Objectives1) E-learning package on malnutrition and dysphagia to be completed by March 2015 and hosted by SRFT and City Council learning portals which are accessible

for providers in all sectors2) Prepare a paper by August 2014 and present at ADNS meeting (Lead Nurses, Matrons and Assistant Director of Nursing) and clinical effectiveness by October

2014 the need to have Hydrations and Nutritional training mandatory for all SRFT staff, including nurses, medical staff, mealtime volunteers, cadets, and healthcare assistants etc

3) Establish if SRFT electronic patient record can calculate ‘MUST’ automatically for nursing staff by August 20144) Work collaboratively with ICP to produce a Salford patient focused (“Sally Ford” simple diet information sheet that patients, health workers and volunteers across

the city can access

Links to MTF workstreams: raising awareness, working together, identifying malnutrition, personalised care. Support and treatment

Out

puts

ScopeTraining available to all staff via e-learning package across the cityPoints 2 and 3 only pertinent to SRFT staff Diet information sheet available to download as a PDF file from AgeUK Salford website, SCCG website, Salford council website and SRFT website

Deliverables• Funding agreed by Salford CCG for e-learning via innovation fund,

draft of the package should be available by September 2014 (K Fo and Laura O’Shea SALT manager SRFT)

• Once developed organise publicity campaign/comms strategy (K Fo)

4) Leaflet• To meet with patient groups to ensure simple, clear advice is provided

in leaflet (July)• To draft leaflet (Aug) and complete (Sept)• Add to websites (Oct)• Full launch (by November)

Success measures• Publicity campaign/comms developed once e-learning package ready to go

live

• In SRFT all nursing and HCA staff to have mandatory training on dysphagia and nutrition within a year of it becoming mandatory

• All medical staff to have completed NG competency training within a year of it becoming mandatory

• Leaflet downloaded and being used

Risks – lack of knowledge of resource and engagement by staff

Res

ourc

es

Team structure and rolesK Fo – Katie Foster – Team Leader, Community DieteticsSC – Sarah Cleverly – Project Manager, ICPBB – Brenda Blackett – Lead Nutrition Nurse, SRFTKF – Kirstine Farrer, Consultant dietitianLeaflet:Colette McLaughlin (Appropriate Prescribing Dietitian)Katie Foster (Team Leader – Community Dietetics)AgeUK Salford TeamStephanie Webb and Bernadette Alder – MDG workstream

Others to involveReport to Mal Waters via ICP governance framework and monthly

Steering Group Meetings

Diet sheets developed for acute and community settings written by older adults, dietitians and speech and language therapists

Mandatory TrainingPaper written to outline the need for malnutrition and hydration to become mandatory for health

care assistants and nursing staff at Salford Royal FT.Meeting currently being arranged.

Progress

E-learning Package

Progress

50 minute lesson plus assessment (30 questions, 80% right to pass)

SALFORD WORKSTREAM REMIT:Raising Awareness

ContextNecessary to have consistent messages about malnutrition across staff groups and the community

Pur

pos

e ObjectivesSupport and promote a minimum of 30 local community services To help older people to recognise the causes of poorer eating; direct people to appropriate information, advice or professional services and/or by providing social meals or access to themProvide a supported shopping service to 40 people To prompt discussions, information sharing and to test out models which can help reconnect people with an interest in food and address some underlying practical and social reasons why people under-eat

Links to MTF workstreams: raising awareness, working together, identifying malnutrition, personalised care. Support and treatment, monitoring and evaluation

Out

puts

ScopeCommunity services will include day centres, social and lunch clubs, supermarkets, cafes and other settings or amenities where groups of older people naturally visit or meet. This target does not include statutory health and registered care settings which will be targeted separately.Shopping services will include older people, carers and families; staff and volunteers of the above services. Patients, professionals and volunteers in NHS and registered care settings are excluded.

DeliverablesCommunity Services• Agree content and volume of Salford information ‘pack’,

including any referral pathways (by July)• Produce pack and schedule for community service

presentations and distribution (by August)• Undertaken presentations and distribution as per ScheduleSupported shopping service• Agree model for testing supported shopping service (by

August)• Confirm target group to test the model (by July)• Secure support of supermarkets to deliver supported

shopping service (by August)• Secure (identify and / or recruit) volunteers and service

testers (by Sept)• Secure suitable transport and book supported shopping

service (by Sept)• Review learning and plan future trips accordingly (by Oct)

Success measuresCommunity Services• 50% of identified Community Services have received and are

displaying and using the materials supplied (Dec 14)• 100% of identified Community Services have received and are

displaying and using the materials supplied (March 15)Supported Shopping Service• 15 volunteers and 20 older people have been confirmed to test the

shopping service (by Oct 14)• One shopping trip undertaken (by Nov 14)• Second shopping trip (by Feb 14)Risks• Availability and cost of accessible transport may cause barriers to

encouraging the target group to participate• Supermarkets may impose conditions which create complexities or

add cost• Attracting, recruiting and sustaining necessary levels of trained

volunteers may create delays

Res

ourc

es

Others to involveReport to Steering Group

Input from Jean Rollinson, Katie Foster, Stephanie Webb

TrainingTraining for Community Services managers will be built into the information and presentation pack

Training for volunteers will include:• Age UK Salford’s induction• Information session on the

objectives of the supported shopping service

• Practical information on the supermarket and needs of identified shoppers

Team Structure & Roles

Shopping Trip

Progress

• First shopping trip took place in November – six people in attendance

• Preparation included:• Targeting appropriate older people to attend• Discussions with ASDA regarding preparation for the day• Pull up poster purchased to have on show at the event

to encourage others to find out more• Leaflets available • Development of Top Tips Booklet which includes:

• floor plan of ASDA in Swinton• information on what to look out for in each aisle

• Attendees rewarded with a cup of tea and biscuit for participating

• Staff on hand to support (community dietitians, dietetic assistants, Age UK etc)

• Film clip developed:http://communityreporter.net/videos/malnutrition-task-force-trip-asda

Little Pot of Health Innovation Fund Progress

• Representatives from Communities Together (an income generating community anchor organisation) and a group of older people attended the launch event in May.

• Successful application to the CCG Little Pot of Health Innovation Fund by Inspiring Communities Together.

• Funding will be used to raise awareness of ‘simple messages’ about malnutrition in the form of post cards and fridge magnets. These will be designed to complement the design of the posters created for use in GP practices.

• The postcards will have simple messages on one side and on the reverse there will be an invitation and voucher for people to come to Age UK Salford’s Critchley House and Café where they can have a free drink and cake and collect their free fridge magnet.

Little Pot of Health Innovation Fund Progress

The aim is to:

• keep count of the number of postcards taken for the GP practices

• keep count of people presenting a voucher at Critchley House and taking a Fridge Magnet ( in return for a very simple question about their understanding of the issues around malnutrition)

• try and test out the use of Flo as a way of keeping people regularly updated with key messages about nutrition via text alerts on their mobile phones

Raising awareness

Progress

Use of Twitter @AgeUK Salford

The Salford Together Nutrition Armband

Salford Royal NHS Foundation Trust 2014 ©

SALFORD WORKSTREAM REMIT:Community and Primary Care

ContextIncrease awareness and educate GP practices

Share information on nutrition with patients attending their GP practice

Pur

pos

e Objectives• To work in collaboration with 10 nominated GP practices re: sip feed prescribing and in conjunction with AgeUK and ICP to develop displays for the practices• Devise ONS pathway in conjunction with CCG medicines management• Dietetic team to write information for GPs on food fortification• GP contract BMI for >75 years to allow us to define prevalence of malnutrition in Salford• To increase awareness and educate GPs on Salford’s Managing Malnutrition in Community Policy

Links to MTF workstreams: raising awareness, working together, identifying malnutrition, personalised care. Support and treatment, monitoring and evaluation

Out

puts

ScopeWorking in collaboration with 10 GP practices, MDTs within the ICPs, Medicines Management, Dietetics and AgeUK

Deliverables• ONS pathway developed and ratified March 2014Patient Information Displays• Agree draft content of information displays (sept 14)• Produce information/laminate posters (Sept 14)• Launch first display and audit (Oct 14)• Information displayed in all GP surgeries (Jan15)GP Staff Education• Meet with 10 GP practices to educate on Salford’s Malnutrition

Policy (Sept14)• Audit current sip feed prescribing practice (Sept 14)• Re-audit 5 GP sip feed prescribing practice (Mar 15)

Success measuresHard Success Measures:• 100% of the 10 nominated GP practices & MDG practices in ICP to have displays • Audit patient information display to ensure its effectiveness• ONS pathway agreed and ratified• Improvement in GP awareness of malnutrition by re-auditing compliance with Salford Malnutrition Policy• Increase BMI recording

Soft Measures: • Content of display to be agreed• Information to be written and agreed pertaining to food fortification for GP info

Risks:• Lack of engagement by GPs• Staff changes

Res

ourc

es

Others to involveReport to Steering Group

Team structure and roles

Stephanie Webb – Project Management from ICPClaire Vaughan – Medicines Management from CCGKatie Foster – Team Leader – Community DieteticsJean Rollins – AgeUK SalfordKirstine Farrer – Consultant dietitian SRFTFrancine Thorpe – Head of Quality and Innovation, CCG

Patient displaysColette McLaughlin (appropriate prescribing dietitian)Katie Foster – Team Leader – Community DieteticsStudent dietitians – TBCAgeUK SalfordStephanie Webb and Bernadette Alder – MDG workstreamAuditing GPs:Colette McLaughlin – appropriate Prescribing dietitianKatie Foster – Team Leader – Community DieteticsClaire Vaughan – Head of Medicines Management

Patient Information Displays

Progress

• 10 practices identified as part of their high sip feed prescribing

• Content of displays • Draft content developed and

evaluated by the dietetic assistants with the practices

• Posters and Leaflets previously outlined will be included

• Floor plans and isle information for both ASDA and Morrisons

• 3 practices have displays to date.

GP Staff Education

Progress

• Initially working with the practices within the Multi Disciplinary Groups within Swinton and Eccles - 10 GP practices originally identified but now widening this remit. A further 10 practices outside of Swinton and Eccles who are high prescribers of sip feed have been identified.

• Community dietitians to work with these practices

BMI Recording

• In-depth analysis of recording of BMI has been undertaken by Public Health. Public Health attending the January Steering Group to discuss implications.

• The Multi Disciplinary Groups in Swinton and Eccles are now routinely recording a person’s BMI as part of the Shared Care Record.

Challenges and Achievements

Our Challenges and Achievements

Challenges• Developing a cohesive group – definitely

overcome this challenge!

• Working across boundaries

• Governance/accountability

• Conflicting priorities

Achievements• Group has developed and firm relationships are

now formed which ensures the sharing of knowledge, skills and sense of humour!

• The Salford Task Force membership represents all sectors of health, mental health, CCG, and third sector - Age UK, and includes a variety of professional backgrounds including Dietician, Occupational Therapist, Nutrition Nurse Specialist, Project management, Pharmacist, and a Commissioning Manager.

• Governance - The Task Force is accountable to the Salford Integrated Care Programme Alliance Board, and provides update reports monthly, so is now getting the messages heard.

• Conflicting priorities will be an issue for all but this work is now embedded

Next Steps

Next Steps

• Sustainability – meeting dedicated to this in January• Local Celebration event in March – Nutrition and Hydration Week

Any Questions?