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
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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 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!
State and Federal
Gov Agencies
(CMS, ISDH,
Health Dept,
AoA, etc)
SOM
MDS
QUALITY
HEALTH
DEPT
Professional
Organizations
(ADA, AMDA,
NPUAP, CDC, etc.
NPUAP
ADA
CONSUMER &
Consumer
Organizations
(AARP, NCOA,
etc)
DMA
AAHSA
Others: QIOs, Pioneer Network, USDA, CDC, FDA, AMDA, ASPEN, etc.
AHCA
AARP
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”
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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.)
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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.)
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•
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•
•
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)
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III. Systems
And Processes
• Key
Facility Nutrition Programs
• Nutrition Manuals
• Menu and Vendor Programs
• Customer Satisfaction
• Quality Improvement
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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
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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)
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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
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III. Systems
And Processes
Manuals:
• RAI Manual
• Additional References
• Client Education Material
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III. Systems
And Processes
Menus:
Seasonal
Reflect input from Clients
Reviewed and Approved by RD
Vendor/Manufacturer Programs
Meet requirements, services, resources,
team player.
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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.
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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
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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 1
Perform a
baseline
evaluation of the
client’s nutritional
status.
- Admission Weight
- Height
- BMI
- Eating Preferences
- Baseline testing
- MDS
- MNA© - SF
RECOGNITION
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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
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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
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STEP 4
Confirm
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)
ASSESSMENT
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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
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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
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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
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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
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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
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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
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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
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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
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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.
ASSESSMENT
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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
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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
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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
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STEP 17
Tailor 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
TREATMENT
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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
TREATMENT
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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
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STEP 20
Consider use
of appetite
stimulants on
an individual
basis.
- Increase activity/exercise
- Use is controversial
- Consider on individualized
basis
TREATMENT
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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
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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
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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
TREATMENT
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STEP 23
Monitor
effectiveness
of treatment
interventions.
- Weight stabilization is
primary endpoint
- Document at least monthly
if persists
- Document when resolved
MONITORING
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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
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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
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STEP 26
Monitor 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
MONITORING
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STEP 27
Monitor the
assessment
process.
- QI process with mechanism
for tracking the assessment
process when a client triggers
an evaluation for ANS.
MONITORING
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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: brendar10@juno.com
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