Karen Schoeneman Consul6ng 1

Transcription

1 + The New Dining Practice Standards and CMS Feeding Tube Guidance Revisions Karen Schoeneman, Owner Karen Schoeneman Consulting + How Did The New Dining Standards Happen? 2 CMS and Pioneer Network co-sponsored a symposium on the food and dining requirements, and culture change innovations, scheduled for 2010 Goal was to bring clinical experts and dining innovators to do presentations in a town hall style meeting in which audience could put their thoughts into the record. + Date was Feb 11, Karen Schoeneman Consul6ng 1

2 + Event snowed out, Baltimore area 4 closed for a week 1200 people who signed up couldn t come Pioneer Network saved the momentum by turning the event into a series of webinars, one for each of the intended speakers And the national workshop that had been scheduled for the following day, was rescheduled for May. + National workgroup - Over 60 people represented 5 All the speakers The national clinical groups The national provider and advocate and culture change groups CMS, FDA, CDC Big recommendation standards of practice are too restrictive change them + Pioneer Network gathered the national clinical groups 6 All the groups that set standards of practice for food and dining, and therapeutic diets, and tube feeding, etc. worked together for several months Group reviewed research that showed very little benefit for older adults of restrictive diets. Much worse problem for them when they don t like their food, they lose weight Karen Schoeneman Consul6ng 2

3 + Groups reviewed CMS guidance 7 CMS Nutrition Tag 325 had been revised a few years ago using national experts The standards group agreed with CMS verbiage to individualize, and to attempt regular diet as much as possible. The group wrote a report, which was signed off by the combined national groups to greatly liberalize diets + These groups signed the new 8 standards American Association for Long Term Care Nursing American Association of Nurse Assessment Coordination American Dietetic Association (they already had issued new liberalizing standards of their own) American Medical Directors Association + More groups 9 American Occupational Therapy Association American Society of Consultant Pharmacists American Speech-Language-Hearing Association Dietary Managers Association Karen Schoeneman Consul6ng 3

4 + More groups 10 Gerontological Advanced Practice Nurses Association Hartford Institute for Geriatric Nursing National Association of Directors of Nursing Administration in Long Term Care National Gerontological Nursing Association + Why are there no government agencies in the list? 11 Government does not set standards of practice CMS in its regulations advises providers to use good standards of practice Standards come from clinical standard setting bodies, based on research There are no disagreements between CMS guidance and the new standards + Introduction Section of the New 12 Standards 50% to 70% of residents leave at least 25% of their food uneaten at most meals 60% to 80% of residents have an order for supplements 25% of residents experience weight loss ADA reports that under-nutrition negatively affects length of life as well as quality of life Karen Schoeneman Consul6ng 4

5 + New Standards Reflect: 13 Evidence-based research Current clinical thinking and Consensus among national clinical groups + Definition of regular diet 14 A regular diet is what should be prepared and offered to meet nutritional needs in accordance with the current recommended dietary allowances of the National Academy of Sciences Regular diet is used as a standard menu planning guide, while residents have the right to make choices Individualized Nutrition Approaches/Diet Liberalization 15 AMDA - A frequent cause of weight loss is the therapeutic diet, and the use of low-salt, lowfat, and sugar-restricted diets should be minimized in LTC ADA Quality of life and nutritional status of older residents of LTC may be enhanced by liberalization of diet. Unpalatable diet can lead to poor food and fluid intake. Weight loss is far greater concern than minimal benefits of medicalized diet Karen Schoeneman Consul6ng 5

6 + Diet Liberalization - Continued 16 All persons moving into LTC should receive a regular diet unless there is a STRONG medical historical reason for a restricted diet. Some homes have made the regular diet with ranges of consistency their ONLY AVAILABLE DIET; they monitor clinical outcomes + Regular diet = Choice 17 Individualized Diabetic/Calorie Controlled Diet ADA There is no evidence to support no concentrated sweets or no sugar added diets for older adults in LTC These restrictive diets are no longer considered appropriate Only benefit to sliding scale insulin is with new diagnosis when clinician is attempting to estimate insulin dosage Glucose monitoring best only once a day if person is stable/chronic A1C between 7 and 8 is reasonable accd. to AMDA 18 Karen Schoeneman Consul6ng 6

7 Individualized Low Sodium Diet 19 ADA randomized trial of adults 55 to 83 yrs old showed that normal-sodium diet improved congestive heart failure outcomes Typical 2gm sodium diet only decreases systolic BP by 5mmHg and diastolic BP by 2.5mmHg and HAS NOT BEEN SHOWN TO IMPROVE CARDIOVASCULAR OUTCOMES FOR RESIDENTS OF LTC Use low sodium diet only when benefit to the individual has been documented. Individualized Cardiac Diet 20 Low saturated fat (low cholesterol) diets have only modest effect on reducing blood cholesterol in LTC population and should be used only when benefit has been documented. Cardiac diet usually only decreases lipids 10-15%, but medication decreases it 30-40% while still allowing individual food choices Individualized Altered Consistency Diet AMDA swallowing abnormalities are common but do not necessarily required modified diet and fluid texture. Provide foods of consistency and texture that allow comfortable chewing and swallowing ADA dietitian and speech pathologist should consult to individualize CMS excessive modification may decrease quality of life and nutritional status. No interventions consistently prevent aspiration 21 Karen Schoeneman Consul6ng 7

8 + Altered Consistency - Continued 22 There is little to no long term evidence that use of thickened liquids prevents aspiration pneumonia, and there IS evidence that this can cause dehydration. But there IS evidence that improved oral care reduces risk of aspiration Many residents with swallowing difficulties can have water if good oral care is used Individualized Tube Feeding 23 Before instituting tube feedings, consult with team and resident/family about cost/benefits Tube feeding does not ensure comfort or reduce suffering, it may cause diarrhea, abdominal pain, and it can increase risk of aspiration Feeding tubes have not been shown to reduce aspiration or prolong survival in residents with end stage dementia + Tube Feeding - Continued 24 PEG tubes do not improve quality of life. There are associated discomforts such as abdominal distension, diarrhea, restriction of free movement when attached to the device Team should confer with resident and family about their goals if at end of life Research shows using assisted oral eating can cause weight gain, as alternative to tube feeding Karen Schoeneman Consul6ng 8

9 Individualized Real Food First 25 Wholesome food is preferable to supplements If a resident needs soft consistency, foods that are naturally soft are preferred such as yogurt, mashed potatoes, pudding, and finely chopped foods that retain their flavor Homes eliminating supplements have found significant increase in food consumption and reduced incidence of weight loss + Real Food Continued 26 Oral supplements often are wasted; Offering variety of foods and fluids is more effective for nutrition than supplements; Snacks are more accepted than supplements, and this also reduces costs Offer real food before offering supplements, fresh garden food, real milk shakes, etc. Individualized Honoring Choices 27 Recommended are open dining times, choices from menus, buffets, family style dining, snack bars. Key is to individualize and consider medical needs in context of offering choices Buffets and snacks optimize intake, making food available 24 hours a day is recommended Karen Schoeneman Consul6ng 9

10 + Choices - Continued 28 Offer choices in accordance with individual preferences numerous times a day New red flag a tray line with trays prefilled according to a diet card, and limited meal hours are seen as contrary to concept of choice and individualization Residents have the right to refuse diet considered best by the team or doctor Shifting Traditional Professional Control to Individualized Support of Self Directed Living ADA despite growing body of evidence discouraging therapeutic diets in older adults, these diets are still regularly prescribed. Research has not demonstrated benefits of restricting sodium, cholesterol, fat, or carbohydrates in older adults Self-directed living includes honoring resident choices, even in the face of family disagreement 29 + Self Directed Living Continued 30 If the patient is sufficiently informed about the risks and benefits of acceptance or refusal of a proposed intervention and refuses, the clinician should respect the patient s decision (Mayo Clinic Proceedings, 2005) Recommendation All decisions default to the person. Karen Schoeneman Consul6ng 10

11 + New Negative Outcome 31 Mealtime dining studies show that enabling residents to choose what they want to eat DOES NOT RESULT IN NEGATIVE NUTRITIONAL OUTCOMES When a person does not want to follow diet orders (or any orders) we worry about potential harm. But we haven t contemplated the harm to the person from denying choices. No one should be told you can t have this because it isn t on your diet. + CMS 2012 Changes to F Tag Guidance for Feeding Tubes + New Negative Outcome - 33 Continued Denying foods of choice and sneaking in decaf instead of real coffee, is an assault to quality of life Making choices should not be called noncompliant or going against doctor s orders as if the practitioner is right and the resident is wrong. Taking away choice has been shown to hasten death, and also to deprive people of good quality of life, practitioners should adept to residents, not the other way around Karen Schoeneman Consul6ng 11

12 + F322 Feeding Tubes - Intent 34 Although regulatory language is naso-gastric tubes, this tag will refer to any feeding tube Intent is that the tube is used only after assessment determines it is medically necessary Tube is used according to standards of practice Services are provided to restore normal eating is possible + Unavoidable reg. language 35 defined Tubes should not be used unless unavoidable. This is now defined as There is a clear indication for using a feeding tube or there is sufficient evidence that it provides a benefit that outweighs associated risks. Tube use should be consistent with advance directive choices/wishes + Assessment includes 36 Medical/nutritional status and history Clinical status (ability to chew and swallow, factors affecting appetite) Review of interventions already attempted and the response Karen Schoeneman Consul6ng 12

13 + Benefits and Risks 37 Benefits Addressing nutrition/hydration deficits, promoting wound healing, allowing resident to gain strength that may restore normal eating Risks Diminishing socialization/human contact, loss of experiencing pleasure from food, tube complications/discomfort, restrictions used to resident from pulling out tube + Extended use of tube feeding 38 For a resident with advanced dementia or other neurological disorder is controversial. Literature suggests little evidence that enteral feeding improves clinical outcomes (prevents aspiration or reduces mortality) + Resident already on tube at 39 admission Physician and ID team should review basis for tube and resident s current condition to determine if there is continued rationale for its use and in concert with resident goals or advance directives Resident (or RP if resident is unable) should be involved in this review in order to determine current wishes Karen Schoeneman Consul6ng 13

14 + Technical Care Issues 40 Staff providing care should be competent with feeding tube nutrition and care, according to advice of medical director and policy Aspects include: Monitoring tube location, proper care of tube (securing, cleaning, skin care, infection precautions, proper flushing) + Technical Care Issues 41 As scheduled or if it unexpectedly comes out Tube or plug become damaged Facility policies should state instances in which change can be done in house or not Specific guidance provided for nutrition through tube, flow, complication, stomach upset, aspiration + CMS Jeopardy deficiency for 42 Failure to ensure proper placement, care, or monitoring of tube and consequently resident developed serious complications such as peritonitis Failure to maintain proper posture while feeding resident, resulting in aspiration and development of aspiration pneumonia Karen Schoeneman Consul6ng 14