Mid Essex Locality Guidelines For The Use Of Oral Nutritional Supplements For Adults In The Community. Purpose of Guideline 2.

Transcription

1 Guidelines For The Use Of Oral Nutritional Supplements For Adults In The Community CONTENTS PAGE Purpose of Guideline 2 6 step summary 3 Nutrition Screening For Residents In Care Homes 4 Nutrition Screening For People In Their Own Homes 4 First Line Management For All Patients 4 Second Line Management For All Patients 4 Over The Counter (OTC) Nutritional Supplements 4 Prescribed Oral Nutritional Supplements 5 Standard ACBS Indications 5 First Line Prescribable ONS For People InTheir Own Homes 6 Second Line Prescribable ONS For People InTheir Own Homes 6 Appropriate Prescribing Of ONS On Discharge From Hospital 6 Treatment Review 6 References 7 Appendices 8-16 ONS CommunityGUI201706V3.0FINAL Page 1 of 16

2 Purpose of Guideline This document has been produced in order to provide guidance for GPs, Community Nurses, and healthcare staff involved in assessing and monitoring the nutritional status of adult patients in community care homes and in their own homes. Please note that this guideline is not intended for use in paediatric patients. It is a guide for staff to identify those at risk of malnutrition and provides appropriate management plans based on the NICE Guidelines for Nutrition Support in Adults (2006) 1. The NICE Guidelines recommend that all adult patients in the community should be screened for malnutrition or the risk of malnutrition. ONS CommunityGUI201706V3.0FINAL Page 2 of 16

3 6 step Summary to Oral Nutritional Supplements (refer to main guideline for further information) Step 1 Nutrition screening - Identification of nutritional risk Step 2 Nutritional assessment Step 3 Set goals Step 4 Offer food first advice Step 5 Prescribe ONS The following criteria identify those who are malnourished or at nutritional risk (NICE Guidelines (CG32) Nutritional Support in Adults): Malnutrition Universal Screening Tool (MUST) score of 2 or more. (See section 1.1 & 1.2 of main guideline) Body Mass Index (BMI) <18.5kg/m2. Unintentional weight loss >10% in the past 3-6 months. BMI <20kg/m² and an unintentional weight loss >5% in past 3-6 months. Those who have eaten little or nothing for >5 days. Those who have poor absorptive capacity or high nutrient losses. Assess underlying causes of malnutrition and consider availability of adequate diet: Ability to chew and swallowing issues. Impact of medication. Physical symptoms (i.e. vomiting, pain, GI symptoms). Medical prognosis. Environmental and social issues. Psychological issues. Substance/alcohol misuse. Set and document realistic and measurable goals including aim of nutrition support treatment and timescale, e.g.: Target weight or target weight gain, or target BMI. Wound healing. Weight maintenance. 1 st line management -promote and encourage the Food First approach: High calorie, high protein dietary advice, homemade nourishing drinks. Resources: Food First Leaflets (link) and Fabulous Fortified Feasts (link). Over the counter (OTC) supplements can be recommended. (see Appendix 3) Consider referral to dietitians if no improvement after 1 st line management for 4 weeks. Use Community Dietitians referral form for housebound patients. Appendix 4 2 nd line management if no improvement after 4 weeks of the food first approach, prescribed oral nutritional supplements (ONS) can be considered if the patient s condition meets the ACBS criteria. Over the counter (OTC) ONS can be recommended if the patient does not meet the ACBS criteria for prescribed ONS. (Appendix 3) DO NOT prescribe ONS to Mid Essex Care Home residents unless authorised by a Dietitian. 1 st line prescribable ONS POWDER FORM prescribable supplements. Appendix 5 ONLY for patients in their own home without dietetic input OR on dietitian s recommendation for patients in care homes. 2 nd line prescribable ONS READY-TO- DRINK PRODUCTS. Appendix 6 ONLY on initiation/recommendation of dietitian. Step 6 Review and discontinue ONS Step 6: Review and discontinuation of ONS Review regularly to monitor, review against goals and assess continued need for ONS When goals of treatment are met discontinue ONS If patient no longer has clinical need or no longer meets ACBS criteria but wishes to continue ONS, recommend over the counter supplements as in Step 4 Table summarised from Prescqipp bulletin 145 April 2017 (full link in references) ONS CommunityGUI201706V3.0FINAL Page 3 of 16

4 NUTRITION SCREENING 1.1 Nutrition Screening For People In Care Homes People in Mid Essex Care Homes should be screened for malnutrition on admission and monthly thereafter using the Malnutrition Universal Screening Tool (MUST) 2. This tool is designed to detect those with low, medium or high risk of malnutrition. The MUST screening tool and action plan for residents in Care Homes is shown in Appendix Nutrition Screening For People In Their Own Homes People in their own homes should be screened for the risk of malnutrition when they are seen in GP clinics or other community outpatient services when there is a clinical concern. The MUST screening tool should also be used for this purpose. The MUST screening tool and action plan for patients in their own homes is shown in Appendix First Line Management For All People The Food First approach should be followed as the first line of management for all people at risk of malnutrition. This includes the process of fortifying foods and fluids with an aim of increasing calories, protein and nutrients. Information and recipes are available in the Food First Leaflets (link) and Fabulous Fortified Feasts (link). (See website Care Homes, people in their own homes and/or their carers should also make either homemade nourishing drinks, such as high calorie milkshakes using full cream milk, ice cream, cream and blended fruits etc. or purchase milkshake powders to make up with full cream milk. Care homes and people in their own homes should also be advised to purchase Over The Counter (OTC) supplements as part of a food first programme. 2.2 Over The Counter (OTC) Nutritional Supplements OTC supplements are available from most supermarkets and some chemists. They can also be advised when patients do not meet the criteria for prescribed ONS. There are two varieties: Ready To Drink from the bottle or tin e.g.: Nurishment Original, Nurishment Extra, Complan Smoothie and Complan Milkshake. Powdered, to mix with milk e.g.: Meritene Energis, Complan, Aymes. Full cream milk is preferable to use. Further details of OTC nutritional supplements can be found in Appendix Second Line Management For All People After following the Food First approach for at least 4 weeks, with no significant improvement, prescribable oral nutritional supplements (ONS) can be considered for people requiring additional energy and protein. A referral to the Community Nutritional Support Dietitians can also be considered. ONS CommunityGUI201706V3.0FINAL Page 4 of 16

5 Referrals will only be accepted on completion of the referral form in Appendix 4 in cases where there has been no improvement despite food fortification and OTC supplement use. A MUST score of 2 or above and evidence of weight loss should also be stated on the referral form. People in any setting should also be encouraged to take as much of their oral foods as possible and not to use supplements as a meal replacement. 3.1 Prescribed Oral Nutritional Supplements (ONS) Since April 2016, prescribed ONS are not to be given in Mid Essex Care Homes unless these have been authorised by a Dietitian. More details are provided in the statement that has been issued by Mid Essex CCG. Link to the prescribing policy statement Standard ACBS indications The Advisory Committee on Borderline Substances (ACBS) recommends that certain food products (e.g. prescribed ONS) should be regarded as drugs for use in the management of specific conditions. For people in Mid Essex who are in their own homes only, ONS should only be prescribed on FP10 if they meet ACBS prescribing criteria (see below) and have been screened using the Malnutrition Universal Screening Tool (MUST) and deemed to be at nutritional risk. One or more of the following ACBS criteria should be present: Intractable malabsorption Pre-operative preparation of undernourished patients Proven inflammatory bowel disease Following total gastrectomy Bowel fistulas Dysphagia Short-bowel syndrome Disease-related malnutrition Disease-related malnutrition encompasses a wide range of conditions that may result in a requirement for nutrition support. Certain supplements may have further indications (e.g. dysphagia or dialysis). Details can be found in the BNF and MIMS. People for whom supplements are a sole source of nutrition should be referred to the Nutrition and Dietetic Department for assessment and on-going support. People with diabetes can be given most supplements. Glucose polymer based supplements should not be used. Please seek advice from a registered dietitian if there is uncertainty on which supplement to use. The supplements should be given in small volumes throughout the day. Blood glucose levels should be carefully monitored and medication adjusted if necessary. People with complex clinical conditions e.g. advanced stages of renal impairment, may require dietetic intervention before commencing on oral nutritional supplements. ONS CommunityGUI201706V3.0FINAL Page 5 of 16

6 3.2 First Line Prescribable ONS For People In Their Own Homes People in their own homes who are prescribed ONS should be initially commenced on one of the POWDER FORM of prescribable supplements shown in Appendix 5. The product with the lowest acquisition cost should be considered. Personal preference and flavour should be taken into consideration in order to help with compliance. The powder shakes are suitable for the majority of individuals and can be prescribed as per ACBS guidelines. Full cream milk should be used to mix with these products, unless it is medically contraindicated, in order to ensure maximum nutrition support. Water could be used as an alternative. These powder shakes should NOT be used as tube feeds. They are NOT to be prescribed for children unless this is under the instruction of a paediatric dietitian. All other supplements other than the powder-form prescribable feeds above should ideally be prescribed only under dietetic supervision. 3.3 Second Line Prescribable ONS For People In Their Own Homes If there are anticipated difficulties in preparing a powder shake for undernourished people in their own homes, one of the recommended second line liquid products could be prescribed. Appendix 6 Second line ONS should only be prescribed once a day initially. These may then be increased to twice daily once tolerance is assessed and only if absolutely necessary. 4.0 Appropriate Prescribing Of ONS On Discharge From Hospital Patients who are discharged from hospital on ONS will not automatically require ONS on prescription once they go home. They may have required ONS whilst acutely unwell or recovering from surgery, but once home and eating normally the need is often negated. Therefore it is recommended that ONS are not prescribed following hospital discharge without first assessing the need for them. If ONS is required, a switch to one of the first line POWDER FORM prescribable products in Appendix 5 should be considered, unless the patient is under dietetic care or second line prescribable ONS Appendix 6 is deemed necessary. 5. Treatment Review To assess the benefit of the prescribed nutritional supplements, individuals should be reviewed within 3-6 months of commencement by the clinician who initiated them. When the aim of starting prescribed supplements is achieved, the supplements should be discontinued. Patients in the final weeks of life are unlikely to benefit from prescription supplements. OTC supplements may be a better option due to palatability. See link to Oral Nutritional Supplements prescribing in Palliative Care prescribing policy statement. ONS CommunityGUI201706V3.0FINAL Page 6 of 16

7 6. References 1. National Institute for Health and Care Excellence (2006) Nutrition Support In Adults CG British Association for Parenteral and Enteral Nutrition (BAPEN) 2012 MUST Tool NHS London Procurement Programme 4. Prescqipp bulletin 145 April 2017 Guidelines for the appropriate prescribing of oral nutritional supplements (ONS) for adults in primary care v2.0. Fabulous Fortified Feasts. 5. British National Formulary Appendices 1. MUST Score Action Plan For Adult Patients In Their Own Home 2. MUST Score Action Plan For Adult Patients In Care Homes 3. Over The Counter (OTC) Nutritional Supplements 4. Referral form to Dietitian 5. First Line Recommended Nutritional Supplements 6. Second Line Recommended Nutritional Supplements ONS CommunityGUI201706V3.0FINAL Page 7 of 16

8 Appendix1 MALNUTRITION UNIVERSAL SCREENING TOOL (MUST) FOR ADULTS IN COMMUNITY CARE HOMES STEP 1 + STEP 2 + STEP 3 BMI Score Weight Loss Score Acute Disease Score BMI kg/m² > < Unplanned weight loss in past 3-6 months <5% % 1 >10% 2 If the patient is acutely ill and there has been or is likely to be no intake for >5 days Score 2 STEP 4 - Overall risk of Malnutrition Add scores together to calculate overall risk of malnutrition Score 0 = Low Risk Score 1 = Medium Risk Score 2 = High Risk STEP 5 - Care Plan MUST Score = 0 Low Risk If BMI>30kg/m² then suggest/offer a healthy eating plan ) Repeat MUST Score monthly in Care Home MUST Score = 1 Medium Risk Observe intake using a food and fluid chart If oral intake is poor, then initiate Food First advice If no improvement, then devise a nutrition care plan If oral intake is improved/adequate, repeat MUST score monthly or more frequently if condition deteriorates MUST Score = 2 or more High Risk TREAT unless detrimental or no benefit expected from nutritional support e.g. terminal phase of illness. Observe intake using food and fluid chart. Initiate Food First advice, including OTC nutritional supplements or a homemade high calorie alternative drink. Monitor weight weekly. Prescribable supplements are no longer available in Mid Essex Care Homes without the involvement of a dietitian. If there is a major clinical concern, and the patient meets ACBS criteria please refer to the Community Nutrition Support Dietitian. ONS CommunityGUI201706V3.0FINAL Page 8 of 16

9 Appendix 2 MALNUTRITION UNIVERSAL SCREENING TOOL (MUST) FOR ADULTS IN THEIR OWN HOMES STEP 1 + STEP 2 + STEP 3 BMI Score Weight Loss Score Acute Disease Score BMI kg/m² > < Unplanned weight loss in past 3-6 months <5% % 1 >10% 2 If the patient is acutely ill and there has been or is likely to be no intake for >5 days Score = 2 STEP 4 - Overall risk of Malnutrition Add scores together to calculate overall risk of malnutrition Score 0 = Low Risk Score 1 = Medium Risk Score 2 or more = High Risk STEP 5 - Care Plan MUST Score = 0 Low Risk If BMI>30kg/m² then suggest a healthy eating plan Repeat MUST Score annually or every 3-6months if there is clinical concern (e.g. neurological degenerative conditions) MUST Score = 1 Medium Risk Observe intake using a food and fluid. If oral intake is poor, then initiate Food First advice. Repeat MUST score monthly for 3 months. If oral intake is adequate and weight is stable, continue screening annually or more frequently as above if condition deteriorates MUST Score = 2 or more High Risk TREAT unless detrimental or no benefit expected from nutritional support e.g. terminal phase of illness. Observe intake using food and fluid chart. Initiate Food First advice, including OTC nutritional supplements or a homemade high calorie alternative drink. Monitor weight weekly. Prescribable supplements are only appropriate if the patient s clinical condition meets the ACBS criteria. If there is a major clinical concern, and it is felt necessary to prescribe an ONS then a referral to the Community Dietitians should be made using the ONS CommunityGUI201706V3.0FINAL department referral form. Page 9 of 16

10 Appendix 3 Over The Counter (OTC Nutritional Supplements) OTC supplements are available to purchase from most supermarkets and some pharmacies. There are two varieties: Ready To Drink from the bottle or tin e.g. Nurishment Original, Nurishment Extra, Complan Smoothie and Complan Milkshake. Powdered, to mix with milk e.g. Meritene Energis, Complan, Aymes. Full cream milk is preferable to use. The prices will vary, depending upon the retailer. DO NOT PRESCRIBE OTC nutritional supplements should be purchased by patients Powdered Products Presentation Nutritional content per sachet mixed with milk Complan Meritene Energis Aymes 1 box of 4 x 55g sachets of one flavour. Or 1 box of 425g original flavour (approx. 7 servings) vanilla,banana,strawberry, chocolate and neutral flavours 15x30g sachets of one flavour Or 1 tub 270g of one flavour (9 servings) vanilla,strawberry and chocolate 4x 38g sachets Strawberry, chocolate, vanilla, banana 387kcal 15.6g protein mixed with 200ml full cream milk 238kcal, 15.7g protein mixed with 200ml of full cream milk 265kcal g protein Made with 200ml full cream milk ONS CommunityGUI201706V3.0FINAL Page 10 of 16

11 DO NOT PRESCRIBE OTC nutritional supplements should be purchased by patients OTC Soups Presentation Nutritional content per sachet mixed with water Meritene Energis Soup Complan soup Aymes 10x 50g sachets, chicken or vegetable flavours, each mixed with 150ml water 1 box of 4x55g sachets, each mixed with 200ml of water Chicken flavour 4x 49 sachets,each mixed with 150ml water Chicken flavour 207 kcal 7g protein, depending on flavour 249kcals 9g protein 207kcal 7.7g protein Ready To Drink OTC Supplements DO NOT PRESCRIBE OTC nutritional supplements should be purchased by patients Product Presentation Nutritional content per unit Nurishment original Nurishment Extra Nurishment Active 400g vanilla, banana, strawberry, chocolate, mango, raspberry, peanut 310ml bottle, vanilla, banana, straw and choc 500ml bottle, Vanilla, strawberry, chocolate kcal 20g protein kcal 12.4g protein 465 kcal 35g protein Complan Smoothie Complan Milkshake 250ml tetrapak Tropical, berry 250ml tetrapak 273 kcal 10g protein 215 kcal, 9g protein ONS CommunityGUI201706V3.0FINAL Page 11 of 16

12 Appendix 4.REFERRAL FORM FOR COMMUNITY NUTRITION AND DIETETIC SUPPORT Fax FAO : Community Nutrition Support Dietitians via MERC at Broomfield : ALL SECTIONS OF THIS REFERRAL SHOULD BE COMPLETED, ANY INCOMPLETE REFERRALS WILL BE RETURNED TO THE REFERRING AGENT WITHOUT THE PATIENT BEING SEEN. The community dietitians will only see people referred for nutrition support. They do not accept referrals for weight reduction or diabetes. PLEASE ONLY REFER PEOPLE WITH A MUST SCORE OF 2 AND ABOVE PATIENT INFORMATION PATIENTS NAME. DATE OF BIRTH.. ADDRESS.. POSTCODE... NHS NUMBER. CONTACT NUMBER(S). MEDICAL/SCREENING INFO this must be completed in full or the referral will be rejected MEDICAL INFO / DIAGNOSIS. MEDICATION. REASON FOR REFERRAL.. MUST SCORE AND DATE.. PREVIOUS MUST SCORE (s).... Weight history (including dates). Height.. Has food fortification been started? YES / NO If yes, date started. Is the patient already on supplements? YES / NO If yes, date started & by whom, and please state what supplements ADDITIONAL CLINICALLY RELEVANT DETAILS REFERRER S DETAILS NAME: PROFESSION:.. CONTACT DETAILS: DATE REFERRAL COMPLETED:. PATIENT S GP DETAILS NAME: ADDRESS:. TEL NO: Received in Nutrition & Dietetic Service on Date of appt / visit: By: ONS CommunityGUI201706V3.0FINAL Page 12 of 16

13 First Line Recommended Prescribable ONS Residents in their own homes who require ONS should be initially commenced on one of the POWDER FORM prescribable supplements shown below. The product with the lowest acquisition cost should be considered. The powder shakes are suitable for the majority of individuals and can be prescribed as per ACBS guidelines. The products require mixing with water or milk before being consumed. Full cream milk should be used, unless it is medically contra-indicated, to ensure maximum nutrition support. These powder shakes should NOT be used as tube feeds. They are NOT to be prescribed for children unless this is under the instruction of a paediatric dietitian. All other supplements other than the powder-form prescribable feeds above should ideally be prescribed only under dietetic supervision. All cost prices are subject to change and should be checked in the latest edition of BNF. Nutritional value may vary with flavour, please consult product literature for further details. CAN BE PRESCRIBED but ONLY for patients in their own home without dietetic input OR on dietitian s recommendation for patients in care homes FIRST LINE POWDERED PRESCRIBABLE ONS- Choose ONE of the following: Product Presentation Nutritional Profile Aymes Shake Complan Shake 1 box contains 7 x 57g sachets. To be mixed with 200ml whole milk Available in 5 flavours: vanilla, strawberry, banana, chocolate, neutral. 1 box contains 4 x 57g sachets. To be mixed with 200ml whole milk Available in 5 flavours: original, vanilla, banana, strawberry, chocolate. 388kcal 15.8g protein 387kcal 15.6g protein Ensure Shake 1 box contains 7 x 57g sachets. To be mixed with 200ml whole milk. Available in 4 flavours: vanilla, strawberry, banana, chocolate 397kcal 17.7g protein Foodlink Complete 1 box contains 7x 57g sachets to be mixed with 200ml whole milk. Available in 4 flavours: natural, strawberry, banana, chocolate flavours. 386kcal 18.3 protein Fresubin Powder Extra 1 box contains 7 x 62g sachets to be mixed with 200ml whole milk. Available in 4 flavours: neutral, vanilla, strawberry, chocolate 397 kcal 17.7g protein ONS CommunityGUI201706V3.0FINAL Page 13 of 16

14 SIP FEED WITH HIGH PROTEIN MILKSHAKE STYLE1.5kcal/ml Second Line Recommended Prescribable ONS If there are anticipated difficulties in preparing a powder shake for undernourished people in their own homes, one of the recommended second line liquid products are available. If one of these ONS products is deemed to be immediately necessary, a referral should also be made to the Dietitians at the time of prescribing. Second line ONS should only be prescribed once a day initially. These may then be increased to twice daily once tolerance is assessed and only if absolutely necessary. There are some other nutritional supplements which should only be initiated by dietitians. They may be prescribed for some patients by the dietitian in addition to other ONS when first and second line products are not deemed suitable. These patients should be under constant dietetic review. The types of nutritional products that may also be prescribed by the dietitian include: modular supplements which are not fully nutritionally balanced, e.g. high fat liquid emulsions, specialist protein products for renal patients, pre-thickened nutritional supplements. SECOND LINE PRESCRIBABLE ONS: READY-TO- DRINK PRODUCTS choose ONE of the following. TO BE PRESCRIBED ONLY ON DIETITIAN S RECOMMENDATION Type Product Presentation Nutritional Profile AYMES Complete 200ml bottle. Available in 4 flavours: vanilla, chocolate, banana, strawberry. 300kcal 12g protein 200ml bottle 300kcal Fresubin Energy Ensure Plus Fortisip Fresubin 2kcal Drink Fresubin 2kcal Fibre Available in 8 flavours: banana, blackcurrant, cappuccino, chocolate, lemon, strawberry, tropical fruits, vanilla. 220ml bottle. Milkshake, Yogurt or Savoury Style. Available in 10 flavours: banana, chocolate, coffee, fruits of the forest, neutral, orange, peach, raspberry, strawberry, vanilla. Savoury available in chicken and mushroom flavours. Yogurt available in strawberry and peach flavours 200ml bottle. Available in 9 flavours: caramel, banana chocolate, neutral, orange, strawberry, tropical fruit, vanilla Sip feed with high protein in a 200ml bottle Available in 6 flavours: vanilla, fruits of the forest, apricot-peach, cappuccino, toffee, neutral Sip feed with high protein and fibre. Available in 6 flavours: vanilla, lemon, cappuccino, chocolate, apricot-peach, neutral. 11.2g protein 330kcal 13.8g protein 14g protein in savoury flavour 300kcal 12g protein 400kcal 20g protein 400kcal 20g protein ONS CommunityGUI201706V3.0FINAL Page 14 of 16

15 JUICE BASED DRINK MILKSHAKE STYLE COMPACT Type Product Unit Nutritional Profile 300kcal Ensure Compact Altraplen Compact Fortisip Compact 125ml bottle for patients requiring a small volume feed. Available in vanilla, banana and strawberry flavours 125ml low volume drink. Available in vanilla, strawberry, banana, hazelnut chocolate flavours. 125ml low volume bottle. Available in vanilla, apricot, banana, chocolate, forest fruits, mocha, strawberry flavours. 12g protein 300kcal 12g protein 300kcal 12g protein Fresubin 2 Kcal Mini 125ml low volume bottle.available in 4 flavours: vanilla, apricot peach, fruits of the forest, chocolate 250kcal 12.5g protein 200ml bottle 300kcal Fresubin Jucy Drink Available in 5 flavours:apple, orange, pineapple, blackcurrant and cherry. 8g protein Ensure Plus Juce 220ml bottle Available in 6 flavours: apple, fruit punch, lemon and lime, orange, peach, strawberry 330kcal 10.6g protein Fortijuce 200ml bottle Available in 7 flavours: apple, blackcurrant, forest fruits, lemon, orange, strawberry, tropical 300kcal 8g protein ONS CommunityGUI201706V3.0FINAL Page 15 of 16

16 Title Document reference Author Consulted with Guidelines for the use of Oral Nutritional Supplements in the Community OralNutritionalSupplementsCommunityGUI201703v2.1DRAFT Updated by Millie Olu, Advanced Clinical Specialist Dietitian Natalie Prior, Senior Pharmacist, Mid-Essex CCG Pauline J Bird, Clinical Manager, Nutrition & Dietetic Service Paula Wilkinson, Chief Pharmacist, Mid Essex CCG Lisa Oakey, Deputy Manager, Nutrition and Dietetic Dept, Reference: NICE Guidance Nutrition Support for Adults February 2006 Prescqipp bulletin 145 April 2017 Guidelines for the appropriate prescribing of oral nutritional supplements (ONS) for adults in primary care ons-guidelines Approved by Mid-Essex Area Prescribing Committee Date approved July 2017 Next review date July 2019 Previous version Guidelines for Nutrition screening and prescribing oral nutrition in the community December 2010 January 2015 Key Changes Document Management added. Updated MUST tool for patients in their own homes and in care homes. Updated the Nutrition and Dietetic Department referral form. Updated choices of over the counter products. Formulary choices on oral nutritional supplements amended recommendations. Change in policy ONS prescribed to nursing/care home patients only on dietetic approval. Removed prices of ONS 6 step summary added ONS CommunityGUI201706V3.0FINAL Page 16 of 16