Karen Schoeneman Consul6ng 1

Transcription

1 + New Dining Standards of Practice How Do We Get There? Karen Schoeneman + How Did They Happen? 2 n CMS and Pioneer Network co-sponsored a symposium on the food and dining requirements, and culture change innovations, scheduled for 2010 n 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. + Pioneer Network gathered the national clinical groups n All the groups that set standards of practice for food and dining, and therapeutic diets, and tube feeding, etc. worked together for several months n Group reviewed research that showed very little benefit for older adults of restrictive diets. n Much worse problem for them when they don t like their food, they lose weight 3 Karen Schoeneman Consul6ng 1

2 + Groups reviewed CMS guidance 4 n CMS Nutrition Tag 325 had been revised a few years ago using national experts n The standards group agreed with CMS verbiage to individualize, and to attempt regular diet as much as possible. n The group wrote a report, which was signed off by the combined national groups to greatly liberalize diets + These groups signed the new 5 standards n American Association for Long Term Care Nursing n American Association of Nurse Assessment Coordination n American Dietetic Association (they already had issued new liberalizing standards of their own) n American Medical Directors Association + More groups 6 n American Occupational Therapy Association n American Society of Consultant Pharmacists n American Speech-Language-Hearing Association n Dietary Managers Association Karen Schoeneman Consul6ng 2

3 + More groups 7 n Gerontological Advanced Practice Nurses Association n Hartford Institute for Geriatric Nursing n National Association of Directors of Nursing Administration in Long Term Care n National Gerontological Nursing Association + Why are there no government agencies in the list? n Government does not set standards of practice n CMS in its regulations advises providers to use good standards of practice n Standards come from clinical standard setting bodies, based on research n There are no disagreements between CMS guidance and the new standards 8 + Introduction Section of the New 9 Standards n 50% to 70% of residents leave at least 25% of their food uneaten at most meals n 60% to 80% of residents have an order for supplements n 25% of residents experience weight loss n ADA reports that under-nutrition negatively affects length of life as well as quality of life Karen Schoeneman Consul6ng 3

4 + New Standards Reflect: 10 n Evidence-based research n Current clinical thinking and n Consensus among national clinical groups + Definition of regular diet 11 n 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 n Regular diet is used as a standard menu planning guide, while residents have the right to make choices + 1. Individualized Nutrition Approaches/Diet Liberalization n AMDA - A frequent cause of weight loss is the therapeutic diet, and the use of low-salt, low-fat, and sugar-restricted diets should be minimized in LTC n 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 12 Karen Schoeneman Consul6ng 4

5 2/28/ Diet Liberalization - Continued n All persons moving into LTC should receive a regular diet unless there is a STRONG medical historical reason for a restricted diet. n Some homes have made the regular diet with ranges of consistency their ONLY AVAILABLE DIET; they monitor clinical outcomes + 14 Regular diet = Choice Individualized Diabetic/Calorie Controlled Diet n ADA There is no evidence to support no concentrated sweets or no sugar added diets for older adults in LTC n These restrictive diets are no longer considered appropriate n Only benefit to sliding scale insulin is with new diagnosis when clinician is attempting to estimate insulin dosage n Glucose monitoring best only once a day if person is stable/chronic n A1C between 7 and 8 is reasonable accd. to AMDA Karen Schoeneman Consul6ng 5

6 + 3. Individualized Low Sodium Diet 16 n ADA randomized trial of adults 55 to 83 yrs old showed that normal-sodium diet improved congestive heart failure outcomes n 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 n Use low sodium diet only when benefit to the individual has been documented Individualized Cardiac Diet 17 n 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. n Cardiac diet usually only decreases lipids 10-15%, but medication decreases it 30-40% while still allowing individual food choices + 5. Individualized Altered Consistency Diet n 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 n ADA dietitian and speech pathologist should consult to individualize n CMS excessive modification may decrease quality of life and nutritional status. No interventions consistently prevent aspiration 18 Karen Schoeneman Consul6ng 6

7 + Altered Consistency - Continued 19 n 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. n But there IS evidence that improved oral care reduces risk of aspiration n Many residents with swallowing difficulties can have water if good oral care is used + 6. Individualized Tube Feeding 20 n Before instituting tube feedings, consult with team and resident/family about cost/ benefits n Tube feeding does not ensure comfort or reduce suffering, it may cause diarrhea, abdominal pain, and it can increase risk of aspiration n Feeding tubes have not been shown to reduce aspiration or prolong survival in residents with end stage dementia + Tube Feeding - Continued 21 n 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 n Team should confer with resident and family about their goals if at end of life n Research shows using assisted oral eating can cause weight gain, as alternative to tube feeding Karen Schoeneman Consul6ng 7

8 + 7. Individualized Real Food First 22 n Wholesome food is preferable to supplements n 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 n Homes eliminating supplements have found significant increase in food consumption and reduced incidence of weight loss + Real Food Continued 23 n Oral supplements often are wasted; n Offering variety of foods and fluids is more effective for nutrition than supplements; n Snacks are more accepted than supplements, and this also reduces costs n Offer real food before offering supplements, fresh garden food, real milk shakes, etc. + 8.Individualized Honoring Choices 24 n Recommended are open dining times, choices from menus, buffets, family style dining, snack bars. n Key is to individualize and consider medical needs in context of offering choices n Buffets and snacks optimize intake, making food available 24 hours a day is recommended Karen Schoeneman Consul6ng 8

9 + Choices - Continued 25 n Offer choices in accordance with individual preferences numerous times a day n 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 n Residents have the right to refuse diet considered best by the team or doctor + 9. Shifting Traditional Professional Control to Individualized Support of Self Directed Living 26 n 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 n Self-directed living includes honoring resident choices, even in the face of family disagreement + Self Directed Living Continued 27 n 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) n Recommendation All decisions default to the person. Karen Schoeneman Consul6ng 9

10 + 10. New Negative Outcome 28 n Mealtime dining studies show that enabling residents to choose what they want to eat DOES NOT RESULT IN NEGATIVE NUTRITIONAL OUTCOMES n 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. + New Negative Outcome - 29 Continued n Denying foods of choice and sneaking in decaf instead of real coffee, is an assault to quality of life n Making choices should not be called noncompliant or going against doctor s orders as if the practitioner is right and the resident is wrong. n 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 + Key is Individualized 30 n Standards do not mandate these liberalizing changes for all persons. n Person s condition, history, preferences all need to be looked at n These changes are dramatic and break the old rules of restriction for their own good. n Not only the clinicians but the individuals and their families know the old rules Karen Schoeneman Consul6ng 10

11 + What Does CMS Think of All This? 31 n CMS participated in the Dining Task Force n CMS provided a video training for surveyors introducing the new Standards surveyortraining.cms.hhs.gov n Click I am a Provider n Click Webcasts n Search dining and select its title, New Dining Practice Standards for Nursing Home Residents + How About CMS Guidance? 32 n Tag 325 Nutrition the Dining Standards often refer to text at this tag about liberalization, for example: n The facility s care reflects a resident s choices. n Research suggests that a liberalized diet can enhance the quality of life and nutritional status of older adults in LTC facilities. Thus it is often beneficial to minimize restrictions More CMS Guidance from F n [Dietary restrictions] may impair adequate nutrition and lead to further decline in nutritional status.... n Excessive modification of food and fluid consistency may unnecessarily decrease quality of life and impair nutritional status by affecting appetite and reducing intake. n Identification of a swallowing abnormality alone does not necessarily warrant dietary restrictions or food texture modifications. Karen Schoeneman Consul6ng 11

12 + Feeding Tubes 34 n At 325 CMS makes these comments about use of a tube at the end of life: n For residents with dementia, studies have shown that tube feeding does not extend life, prevent aspiration pneumonia, improve function or limit suffering. n Decreased appetite and altered hydration are common at the end of life, and do not require interventions other than for comfort. + The Garden Letter 35 n CMS released a memorandum in favor of homes growing their own produce and serving it on the menu n CMS Survey and Certification memorandum is in your handouts + Education is Necessary 36 n Global education for the whole home, its staff, its residents, its families on the value of these new standards n Individual education for a resident to help them determine if they want a change for themselves n They need to know staff will monitor to mitigate negative effects of the change n There can be a testing out period, how did it go, what did you think? Do you want to continue? Karen Schoeneman Consul6ng 12

13 + Good News from Pioneer Network 37 n They have realized that a home can t just make these changes instantly, the home needs to evaluate policies and procedures, educate care planning staff, explain to residents and families. n PN has gathered a task force which has completed development of a dining toolkit. n Contains sample policies, sample forms. Will be available for sale soon. Karen Schoeneman Consul6ng 13