Medicines Optimisation Team Standard Operating Procedure Audit: Oral Nutritional Supplements for Adults

Transcription

1 Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group East Staffordshire Clinical Commissioning Group Medicines Optimisation Team Standard Operating Procedure Audit: Oral Nutritional Supplements for Adults Aim To identify all adult patients prescribed oral nutritional supplements (ONS), including sip-feeds, and review to determine whether prescribing is appropriate, evidence based and cost-effective, in line with local and national guidance. Patients will be switched to more cost effective alternative, where there is no difference in terms of clinical effect and patient factors and there is a significant cost differential. Prescribing of Oral nutritional supplements (ONS) will be stopped if not indicated to continue. Rationale Oral nutritional supplements (ONS) represent a significant cost to the NHS so ensuring that they are only used where clinically appropriate and when food first strategies have been sufficiently employed first, will help to ensure that limited NHS resources are used in the best way possible. Furthermore, ONS are only considered suitable for prescribing for medicinal purposes for patients who meet the ACBS (Advisory Committee on Borderline Substances) criteria. Patients must meet at least one of the ACBS criteria below to be eligible for prescribed ONS: Short bowel syndrome. Intractable malabsorption. Pre-operative preparation of patients who are undernourished. Proven inflammatory bowel disease. Following total gastrectomy. Dysphagia. Bowel fistulae. Disease related malnutrition. In addition, some supplements and food products are prescribable for those receiving continuous ambulatory peritoneal dialysis (CAPD) and haemodialysis, or are specifically prescribable for individual conditions. These products would normally be requested by a dietitian and should not be routinely started in primary care. The initial aim will to be review and discontinue inappropriate prescribing of ONS. Where it is not appropriate to stop prescribing, patients will be reviewed to formulary products. One of the main switches will be from ready made products to powdered products which need reconstitution with whole milk where suitable. Advantages of a powder based ONS: They tend to taste better. This is based on local Dietetic taste tests. They can be easily added to meals and as such promotes a Food First Policy. They are half the price of ready-made milkshakes They can be prescribed as a sample pack so the patient can trial flavours A shaker is provided by the company to assist with reconstitution. The local first link product has a vanilla flavour which contains 4.6g of fibre per sachet, which is beneficial to bowel function especially in the elderly population & care home residents. Page 1 of 22

2 Powder-based ONS may not be suitable in certain patients (needs to be decided on a case-by-case basis). Audit criteria Inclusion criteria All adult patients (those 16 years and over) currently prescribed oral nutritional supplements, branded or generic, as an acute or repeat prescription within the previous 6 months, unless they fall under any of the exclusion criteria (see specific exclusion criteria s) General Review Process (see review process section for discontinuation) 1. Patients will be reviewed to identify if there is a documented plan in place in relation to their ONS prescription with an agreed treatment goal. Patients should fulfil the ABCS criteria if not it should be recommended that their ONS prescription is discontinued. 2. The use of an appropriate screening tool e.g Malnutrition Universal Screening Tool (MUST) (Appendix 3) should be documented upon initiation. It is expected that only individuals with a MUST score of 2 or more who have failed a trial of four weeks food fortification (unless food fortification inappropriate, e.g. swallowing difficulties) should have been initiated on ONS. If not these patients should be recommended for discontinuation of ONS. 3. There will then be a check to ensure the patient has had a regular review. a) For any patient with no up to date weight (within the previous month for care home patients or the previous 3 months for domiciliary patients where it is possible to weigh the patient), request an up to date weight is taken and recorded.. b) Recalculate the the patients BMI and MUST score based on current situation, i.e. is disease no longer active (See appendix 1 for MUST score). Review with GP as to whether those that have now decreased to MUST scores less than 2 require a review to discontinuing ONS, or where very high quantities being issued these can be reduced. c) Assess whether patient has met treatment goal - if this is the case discontinue the ONS. 4. Certain patient groups should be highlighted for referral to dietician a) Any patient with a body mass index (BMI) of 16kg/m² or less and no dietetic referral refer without delay. b) Any patient who has had little or no nutritional intake for the last 10 days and has had no dietetic referral refer without delay. c) Any patient who has lost more than 15% body weight within the last 3-6 months, except patients at the end of their lives, with no dietetic referral refer without delay. d). Any patient where ONS is their sole source of nutrition, with no dietetic referral refer without delay e) Any patient with complex nutritional needs who haven t been reviewed by a dietician - e.g. renal disease, liver disease, swallowing problems, poorly controlled diabetes, eating disorder gastrointestinal disorders refer to prescriber to arrange referral to local community dietetic service. 5. Need to consider whether a patient being reviewed is already under a dietician or secondary care in relation to their ONS prescription and who has recommended a specific product (e.g. product with additional fibre or protein) to meet their individual need, where there is no suitable formulary alternative exclude. Where there is an alternative and actively reviewed contact dietician prior to change. Page 2 of 22

3 General exclusions Any patient who is excluded by the prescriber. Patients on enteral feeds i.e. PEG tube, RIG, NJ, jejunostomy, any ONS these patients have needs discussing with dietician reviewing patient prior to change. Exclude patients from review to formulary powdered ONS where: 1. Is there any factors that need to be taken into consideration with regards to whether a powdered shake would be appropriate e.g. dexterity issues or fragility where there is no carer or individual who could aid with this. For those who live alone and have no assistance (carers or relatives) in food preparation prescribe ENSURE COMPACT. If a patient is in a nursing home prescribe powdered ONS. 2. A history of not liking any of the flavours that come as powdered shakes. 3. Patients on juice based supplements (these patients only suitable to review to discontinue). 4. Patients on compact (125ml) products - if not suitable to discontinue review to formulary compact product (Ensure Compact) instead where it is cost effective. 5. Patients with an intolerance to soya, allergies to soya or milk protein. 6. Patients with galactoseamia. 7. Patients who have failed a previous switch of medication i.e. caused undue distress. 8. Patients already on a powdered shake even if non formulary as very similar composition and cost. 9. Anyone who needs lactose free products as the recommended formulary products contain lactose. (For full lists of allergen and religious information for Nualtra products refer to (Appendix 8). 10. Patients currently under review by the dietician, please liaise with the dietician regarding the suitability. Specific Patient Groups for caution/exclusion as indicated 1. Any patient with complex nutritional needs e.g. renal disease, liver disease, swallowing problems, poorly controlled diabetes, gastrointestinal disorders or eating disorders- should really be under a dietician as above. 2. Any patient who is a substance misuser refer to Appendix 2 for advice. 3. Recent change in risk e.g. co-morbidity or oncology should be incorporated into recalculation of MUST score. 4. Is the patient receiving palliative care? If early stage review in line with the below. If late stage palliative care (final days or weeks of life), discontinue ONS as nutritional content is no longer of prime importance. 5. Unstable diabetes due to the carbohydrate content - ideally should be reviewed by diabetes nurse specialist, less suitable for powdered ONS. Nutricrem may be more appropriate but this would need assessment. 6. Renal disease - due to the phosphate & potassium levels if the patient is on electrolyte restrictions. If a Dietitian is not involved in the patients care, prescribe Ensure Plus Juice & refer to a renal Dietitian Cautions- where further clarification is needed 1. Patients who do not appear to be taking the existing medication that is being proposed to switch as prescribed (e.g. due to inconsistency in the pattern of ordering their repeat prescription) - refer to prescriber to determine appropriateness to change or to archive and exclude. 2. Patients on repeat dispensing highlight for review before next batch issued OR discuss with practice and decide what course of action is to be taken for such patients. Page 3 of 22

4 3. Patients/carers for whom the method of communication outlined in the SOP may not be appropriate (e.g. patients who are deaf, illiterate etc.) - refer to prescriber to determine appropriateness to change. 4. Any patient that those involved in the switch feel is unsuitable for the mentioned change in medication refer to prescriber for clarification or exclude and highlight as appropriate. For example, vulnerable patients might require a face-to-face or telephone discussion with the prescriber. This reason must be documented on the data collection form. 5. Any patient with no up to date weight- within the previous month for care home patients or the previous 3 months for domiciliary patients where it is possible to weigh the patient - ask for a new weight as per review process. 6. Any patient without a documented nutrition treatment goal refer to prescriber to request this. 7. Any patient who is a substance misuser refer to the prescriber to assess in line with PrescQIPP guidance. 8. Any patient prescribed less than 2 oral nutritional supplement doses per day refer to prescriber to assess whether they can increase their intake to the recommended dosage or whether it is more appropriate to discontinue. Method 1. Search the practice clinical system for all adult patients (using the standardised search) currently prescribed oral nutritional supplement defined within this SOP as an acute or repeat item (initially focus mainly on 2kcal/mL products) branded or generic, repeat or acute items. Following review of each patient s electronic medical record, record all relevant data using the data collection form (appendix 1) or similar, for each patient identified. 2. Exclude patients according to the specific exclusion criteria. Any patient excluded from the switch should have a relevant read code and explanation added to their electronic medical record for audit purposes and any future work. 3. Refer patients requiring clarification or individual authorisation at this stage, to the relevant prescriber. 4. Invite patients who require a review of their oral nutritional supplements to a clinic (nurse/pharmacist/gp led) to be assessed for suitability, using the patient letter in appendix 2. Practices may prefer to send a letter informing patients of their switched or discontinued treatment, where this doesn t require review see appendices 3 and Switch or discontinue ONS for those who are suitable. If the change is made on a different day to the data collection due to referral of queries to the prescriber etc., ensure that there has been no clinically significant change to a patient s circumstances and/or medication immediately prior to undertaking the change (i.e. all information recorded on the data collection form is still accurate). Add a relevant code to the additional information/pharmacy box to record that this has been carried out. 6. Carry out the change for all suitable patients by: - Adding the new ONS product to the patient s list of medicines, if suitable to switch. Where there is a starter pack for the preferred product (for example powdered ONS) add this to the acute (should explain to prescription clerks that needs issuing first and then removing from prescription once requested). Alternatively the starter pack could be given out at clinic appointment. - Archiving the previous ONS into past drugs, adding formulation switch or ONS stopped, as appropriate. - Creating an entry in patient consultation/journal notes confirming the change. Use wording ONS review as per CCG policy, letter sent to patient. READ codes for changing or stopping medication should be used: Inappropriate medication stopped 8B1w Page 4 of 22

5 Medication changed 8B316 - Creating and printing the relevant patient letter using the template previously downloaded onto the GP system (appendices 4, 5 and 6 ). If the patient is a care home resident a letter should be sent to the care home to advise them of the change (appendix 7). 7. Provide details of the total number or a list of patients changed to their community pharmacy, as appropriate. Page 5 of 22

6 Review process- preferred product switches Switching to a preferred product: Patients prescribed non-formulary ONS where there is a cost effective alternative assess for suitability to switch to a formulary alternative, in line with local guidance. ONS TYPE ENERGY HIGH ENERGY Brand name- 200ml unless specified FP10 price* ENSURE PLUS (237ml) 1.12 Flavours Vanilla, strawberry, dark chocolate, milk chocolate, butter pecan PROTEIN AND CALORIE CONTENT PER BOTTLE/POT 350 kcal (1.5 kcal/ml) 15 g protein FORTISIP 1.4 Banana, orange, strawberry, toffee caramel, tropical, vanilla, chocolate, neutral 300kcal and 12g protein FRESUBIN ENERGY 1.4 Chocolate, Neutral, Tropical Fruits, Vanilla, Banana, Strawberry, Cappuccino, Lemon and Blackcurrant. 300kcal and 11.2g protein AYMES COMPLETE 1.12 Vanilla, Strawberry,Banana, Chocolate, 300kcal and 12g protein RESOURCE ENERGY 1.92 FOODLINK Complete 0.61 Apricot, Chocolate, Strawberry/Raspberry, Banana, Coffee and Vanilla Vanilla (added fibre),natural, Strawberry,Banana, Chocolate 300 kcal and 11.2g protein 386kcal,18.3g Proteinbased on strawberry flavour FORTISIP COMPACT (125ml) 1.45 Vanilla, Strawberry, Banana and Mocha 300kcal and 12g protein ALTRAPLEN COMPACT (125ml) 1.45 Vanilla, Strawberry, Banana, Hazel Chocolate 300kcals, 12g Protein FRESUBIN 2 KCAL 1.98 Vanilla, Fruits of the Forest, Apricot-Peach, Cappuccino, Neutral and Toffee 400kcals, 20g protein ENSURE TWOCAL 2.22 Banana, neutral, strawberry and vanilla 399kcals, 16.8g protein FRESUBIN 2KCAL MINI (125ml) 1.25 Vanilla, fruits of the forest, apricot and peach 250kcals, 12.5g protein FORTISIP 2KCAL 2.14 Vanilla and strawberry 400kcals, 20g protein Notes Substitute with FOODLINK COMPLETE powdered ONS Substitute with ENSURE COMPACT where cost effective Page 6 of 22

7 ENSURE COMPACT (118ml) 1.35 Milk chocolate, vanilla 300 kcal (2.4 kcal/ml) 13 g protein FORTISIP COMPACT FIBRE (125ml) 2.09 Mocha, vanilla, strawberry 300kcal, 12g protein and 4.5g fibre per bottle ENSURE PLUS FIBRE 2.02 Vanilla, Strawberry, Banana, Chocolate, Raspberry 310kcals, 13g Protein and 5.0g fibre FRESUBIN 2KCAL FIBRE 1.98 Chocolate, Lemon, Cappuccino, Vanilla, neutral and Toffee. 400kcals, 20g protein FIBRE ENRICHED FRESUBIN ENERGY FIBRE 2.05 RESOURCE 2.0 FIBRE 1.88 Chocolate, Vanilla, Strawberry, Banana, Caramel and Cherry Vanilla, Summer Fruits, Strawberry, Apricot, Neutral and Coffee 300kcals, 11g protein and 4g fibre 400 kcal, 18g protein and 5g Substitute with FOODLINK COMPLETE with added fibre powdered ONS fibre Substitute with FOODLINK COMPLETE with added fibre powdered ONS FRESUBIN 2KCAL FIBRE MINI (125ml) 1.25 Chocolate and vanilla 250kcals, 12.5g protein and 2g fibre FOODLINK W/FIBRE 0.67 VANILLA ONLY 399kcals, 18.6g Protein ENSURE CANS (250ml) 2.26 Vanilla, Chocolate, Coffee 251kcals, 10g Protein STD ENERGY PROTEIN ENRICHED FRESUBIN ORIGINAL 2.14 Mocha, Blackcurrant, Peach,Nut, Vanilla, Chocolate 200kcals, 10g Protein FOODLINK Complete 0.61 FORTISIP COMPACT PROTEIN (125ml) 2 Vanilla (added fibre),natural, Strawberry,Banana, Chocolate Berry, Mocha, Vanilla,Strawberry, Banana, peach & mango, 386kcal,18.3g Proteinbased on strawberry flavour 300kcal and 18g protein FORTSIP EXTRA 2.22 Vanilla, strawberry 320kcal and 20g protein Substitute with FOODLINK COMPLETE- note double calories and protein may reduce quantity Subsitute with ALTRAPLEN PROTEIN Page 7 of 22

8 ENSURE PLUS ADVANCE (220ml) 2.02 Vanilla, Strawberry, Banana, Chocolate, coffee 330kcals, 20g protein FRESUBIN PROTEIN ENERGY 2.08 Vanilla, chocolate, wild strawberry, tropical fruits and cappuccino 300kcals, 20g protein ALTRAPLEN PROTEIN 1.49 Vanilla, Strawberry 300kcals, 20g protein DESSERTS MODULESmost available as 120ml bottles with cups to measure 30ml-40ml servings Notes * Source: MIMS April2017 FORTICREME COMPLETE (125g) FRESUBIN CREME & 2KCAL (125g) ENSURE PLUS CRÈME (125g) RESOURCE DESSERT ENERGY (125g) NUTILIS FRUIT STAGE 3 (150g) FRESUBIN YOCREME (125g) 1.96 Vanilla, Banana, Chocolate, forest fruits 200kcals, 11.9g Protein 1.96 Vanilla, wild strawberry, cappuccino, praline and chocolate. 200kcals, 12.5g Protein 1.88 Vanilla, Neutral,,Banana, Chocolate 171kcals, 7.1g Protein 1.63 Vanilla, Chocolate and Caramel 200kcals, 6g Protein 2.36 Strawberry. Apple 206kcals, 10.5g Protein 2.04 Neutral, Lemon, Apricot-peach, Raspberry and Biscuit 187Kcals, 9.3g Protein NUTRICREM 1.44 Vanilla,Strawberry, Chocolate orange 225kcals, 12.5g Protein PRO-CAL SHOTS (30ml serving) CALOGEN INCL EXTRA (40ml serving) FRESUBIN 5KCAL SHOT (30ml serving)) ALTRASHOT (30ml serving) 2.41 Neutral, strawberry and banana 100kcals, 2g Protein 2.99 Neutral, strawberry 160kcals, 2g Protein 2.8 Neutral, Lemon 150Kcals and 0g protein 2.1 Vanilla, Strawberry 105KCals, 1.5g protein Ensure Plus and Ensure compact prices dropped april 2017 Indicates products for review to discontinuation only as little cost-effectiveness from switch to formulary alternatives Indicates preferred product Substitute with NUTRICREM Substitute with ALTRASHOT- WHEN PRODUCT LAUNCHED- April note significant increased calories and protein so may reduce quantity Page 8 of 22

9 References: 1. PrescQIPP NHS Programme. Guidelines for the appropriate use of ONS for adults in primary care. Version 2.0. Bulletin 68. June Available at 2. Appropriate Prescribing of oral nutritional supplements in the first line treatment of adult malnutrition in primary care Available at Blood/Appropriate%20Prescribing%20of%20oral%20nutritional%20supplements%20in%20the%20first%20line%20treatment%20of%20adult%20malnutrition%20in%20pri mary%20care%20v1% pdf 3. Malnutrition Universal Screening Tool (MUST). Available at Page 9 of 22

10 Surname DOB Gender Age NAME of current ONS Daily DOSAGE of current ONS Typical Monthly Quantity (units - i.e. sachets/ bottles) prescribed Indication for Treatment Last recorded Height (meters) Date Last recorded weight (Kg) Date Last recorded BMI Date MUST Score in Patient Records Residential Institute or Housebound Diabetic (Yes/ No) Most recent GFR (ml/minute/1.73 m2) MEETS MUST CRITERIA (Y/N/Ukn) ACTION Taken: Changed to AC, Changed to AS, Stop, Exclude Increasing/Decreasing Quantity issued (Inc/Dec) Projected Quantity (units) the next month (sachets/ bottles) Further Assessment/ Review Required by Practice/Dietician (Prac/Diet) Cost per month before review Cost per month after review Efficiency savings per month Projected Annual Efficiency Savings Usual GP Appendix 1 data collection form Practice support data collection form: Practice Name NOTES (Any relevant) Summary Total number of patients identified Total number of patients Discontinued Total number of patients switched Work completed by: <insert name and job title> Date completed: <insert date> Page 10 of 22

11 Appendix 2 Advice on patients with substance misuse Substance misuse is NOT a specified ACBS indication for ONS prescription. Prescribing ONS for this patient group (alcohol and drug misusers) raises concern, due to the cost and lack of evidence on clinical benefit. This patient group have a range of nutrition related problems such as: Poor appetite and weight loss Nutritionally inadequate diet Constipation (drug misusers in particular) Dental decay (drug misusers in particular) This is due to a number of reasons, including: Poor nutrition knowledge and skills Poor memory Poor access to food Drugs themselves can often cause poor appetite, acidic saliva leading to dental problems, constipation, craving sweet foods (drug misusers in particular) Poor dental hygiene (drug misusers in particular) Chaotic lifestyles Lack of interest in food and eating Irregular eating habits Low income, intensified by increased spending on drugs or alcohol Homelessness / poor living accommodation Infection with HIV or hepatitis B and C Eating disorders with co-existent substance misuse ONS prescribing in Substance Misusers often produces the following issues: Used to replace meals and therefore is of no benefit Once started the individual can become very reliant on them making it difficult to stop They may be given/sold to other members of the family/friends Only prescribe ONS for substance misusers if they meet ACBS criteria and are malnourished or at risk of malnutrition (MUST score of 2 or more). Page 11 of 22

12 Page 12 of 22

13 Appendix 3 MUST SCORE Page 13 of 22

14 Page 14 of 22

15 Page 15 of 22

16 Appendix 4 Example patient letter invitation for review Page 16 of 22

17 Date as Postmark Title Initial Last Name Home Full Address (stacked) Dear Calling Name IMPORTANT INFORMATION REGARDING YOUR REPEAT PRESCRIPTION As part of a review of prescribing, we are currently reviewing patients prescribed oral nutritional supplements in line with both local and national guidance. These products are not medications but support many patients to maintain a healthy weight and nutritional balance in their diet. They are suitable for prescribing on the NHS for patients with certain conditions, who meet specific criteria, during times where their nutritional needs cannot be met by a fortified diet alone. Some of the available products are more cost-effective or have a better balance of nutrients. Consequently, we have reviewed these alongside national guidance and come up with a list of preferred products for our local patients and when they should be prescribed on the NHS, when they should be purchased over-the-counter and when they are no longer needed. After careful review of your records, we are writing to advise that you need to come in for a review of your oral nutritional supplements before your next supply. If you have any queries regarding this letter please contact the practice. Yours sincerely Appendix 5 Example patient letter switching of ONS Page 17 of 22

18 Date as Postmark Title Initial Last Name Home Full Address (stacked) Dear Calling Name IMPORTANT INFORMATION REGARDING YOUR REPEAT PRESCRIPTION As a practice we are committed to ensuring all of our patients are receiving the best possible care and that we are prescribing effectively and cost-efficiently. We are currently reviewing patients who have been prescribed oral nutritional supplements. You currently receive a prescription of an oral nutritional supplement. These products are not medications but support many patients to maintain a healthy weight and nutritional balance in their diet. They are suitable for prescribing on the NHS for patients with certain conditions, who meet specific criteria, during times where their nutritional needs cannot be met by a fortified diet alone. Some of the available products are more cost-effective or have a better balance of nutrients. Consequently, we have reviewed these alongside national guidance and have produced local preferred products for prescribing to our patients. After reviewing and updating your care plan, we have changed your current prescription as follows: Foodlink Complete/Nutriplen/Ensure Compact/ (*delete as appropriate) is an alternative to [insert current product used]. All other items on your prescription remain the same and have not changed. Your new product will be prescribed as assorted flavours on the prescription so you will need to inform the pharmacy which flavours you prefer. A starter pack will be issued so that you can try all of the flavours and advise the pharmacy on your preferred choices. (Foodlink complete- only). Your new product comes as a powder sachet which requires making up with 200ml of fresh whole milk in the shaker which will be provided with your initial prescription for Foodlink complete. Many patients prefer this as the drinks have a fresh taste similar to a normal milkshake and the sachets are compact for storage purposes, as well as having a higher nutritional content then many of the readyto-drink products. Page 18 of 22

19 This product contains milk and soya protein, lactose (Food link complete sachets only- delete as appropriate) so if this is an issue let the surgery know. The strawberry flavour is not vegetarian/halal or Kosher as it contains colouring E120, which is also known as cochineal or carmine. All other flavours are vegetarian and the products do not contain any ingredients that are forbidden in halal or kosher diets. Please do not hesitate to contact your local pharmacist or GP if you would like more information. Yours sincerely On behalf of Page 19 of 22

20 Appendix 6 Example patient letter discontinuation of ONS Date as Postmark Title Initial Last Name Home Full Address (stacked) Dear Calling Name IMPORTANT INFORMATION REGARDING YOUR REPEAT PRESCRIPTION Dear As a practice we are committed to ensuring all of our patients are receiving the best possible care and that we are prescribing effectively and cost-efficiently. We are currently reviewing patients who have been prescribed oral nutritional supplements. You currently have a prescription of an oral nutritional supplement. These products are not medications but support many patients to maintain a healthy weight and nutritional balance in your diet. They are only suitable for prescribing on the NHS for patients with certain conditions, who meet specific criteria, during times where their nutritional needs cannot be met by a fortified diet alone. After reviewing and updating your care plan, we have removed your oral nutritional supplements from your prescription as it is no longer necessary for you to receive these from us. All other items on your prescription remain the same and have not changed. Please do not hesitate to contact your local pharmacist or GP if you would like more information. Yours sincerely On behalf of Page 20 of 22

21 Appendix 7 Example Care home standard letter Date as Postmark Title Initial Last Name Home Full Address (stacked) Dear Calling Name IMPORTANT INFORMATION REGARDING THE PRESCRIBING OF ORAL NUTRITIONAL SUPPLEMENTS Dear As a practice we are committed to ensuring all of our patients are receiving the best possible care and that we are prescribing effectively and cost-efficiently. We are currently reviewing patients who have been prescribed oral nutritional supplements. You will be aware of your residents receiving a prescription for an oral nutritional supplement. These products are not medications but support many patients to maintain a healthy weight and nutritional balance in their diet. They are only suitable for prescribing on the NHS for patients with certain conditions, who meet specific criteria, during times where their nutritional needs cannot be met by a fortified diet alone. Where a food first strategy is more appropriate, patients have met their nutritional target or they are no longer indicated, oral nutritional supplements have been removed from patient s prescriptions. Patients still requiring an oral nutritional supplement will be switched to the most cost-effective alternative that meets their needs. We have reviewed the available products alongside national guidance and come up with a list of preferred products for our local patients. PLEASE SEE INIDVIDUAL LETTERS (ENCLOSED) OF THE PROPOSED CHANGE FOR EACH PATEINT. In order to help us assess ongoing eligibility for prescribed oral nutritional supplements, we will require a monthly MUST (malnutrition universal screening tool) score available online at For new patients, we will require a recorded MUST score and weight loss, 3 days of documented dietary and fluid intake and evidence of a food first approach being used for the previous four weeks and a completed Nutritional Assessment Form. Useful information on food fortification and Making Every Mouthful matter are available at Please do not hesitate to contact us if you would like any more information. Yours sincerely Page 21 of 22

22 On behalf of Appendix 8 Religious and allergen information -Nualtra. Head of Medicine Optimisation SESSP, SAS & CC CCG s Sam Buckingham Date 5 th July 2016 GP Prescribing Lead Mo huda Date 5 th July 2016 Document Change History Version Date Editor Details of significant changes 2 April 2017 M Johnson Addition of MUST Score & Nualtra Product switches Page 22 of 22