NUTRITIONAL ASSESSMENTS & RECOMMENDATIONS

Transcription

1 NUTRITIONAL ASSESSMENTS & RECOMMENDATIONS Linda Crandall, RD, LD Crandall Corporate Dietitians Learning Objectives: Review the New Dining Practice Standards honoring choice and shifting traditional professional control to self-directed living. Describe diet liberalization: Diabetic, Low Sodium, Cardiac, Altered Consistency Diets and Tube Feeding. Also describe Real Food First. Discuss new Negative Outcome and how to prevent this citation. DISCLOSURE OF COMMERCIAL SUPPORT Linda Crandall, RD, LD does not have a significant financial interest or other relationship with manufacturer(s) of commercial product(s) and /or provider(s) of commercial services discussed in this presentation. 1

2 Nutritional Assessments and Recommendations (Preventing weight loss and freedom of choice) By Linda Crandall RD, LD, CEO Crandall Corporate Dietitians September 29, 2015 Unintentional Weight Loss Prevalent concern in Senior Housing Significant weight loss is: 5% x 1 month 7.5% x 3 month 10% x 6 month Insidious (gradual weight loss) 50-70% of residents leave 25% or more of uneaten food at most meals 60-80% of residents receive dietary supplementation Impact of Under Nutrition and Weight Loss: Length and quality of life compromised Poor medical outcomes Increased mortality 2

3 Common factors to these issues: Residents on restricted, therapeutic diets Restricted diets have the potential for inadequate intakes Lack of choice for when to eat, what to eat, with whom to eat, how much to eat, and where to eat Defining Therapeutic Diets A diet intervention ordered by a health care practitioner as part of a treatment: For a disease or clinical condition To eliminate, decrease, or increase certain nutrients in the diet (e.g., sodium, potassium). Source: Academy of Dietetics Therapeutic Diet In addition to increasing the risk for weight loss, a therapeutic diet also may increase the risk for pressure ulcers, poor intakes, and compromise health status more The benefits of a liberalized diet approach can outweigh the risks 3

4 Benefits of a Liberalized Diet Residents tend to consume more of their meals Aids in prevention of malnutrition Maintains stable body weight Preserves residents dignity while dining by allowing the resident to choose what food & beverages they want Is more home-like Person Directed Dining or Cultural Change Versus Medical Model Cultural Change/Person Directed Dining Choice of When, What, How much, With Whom, and Where to eat Liberalized Diets (Regular) Open Dining Restaurant-style Service Residents have menu selection Fortified foods first Medical Model Community chooses When, What, How Much, With Whom, and Where to eat Therapeutic Diets Strict meal times Tray Service Facility chooses menu Supplements first for weight loss Benefits of Resident Choices What to Eat Where to Eat When to Eat How Much to Eat With Whom to Eat 4

5 The American Dietetic Association s paper on Nutrition for Older Adults in Health Care Communities includes: Nutritional status can be enhanced by using less restricted diets Advocacy for individualizing the nutrition approaches for each resident Usage of regular diets or regular diets with texture modification for disease specific conditions should be our goal such as: Diabetes Cardiovascular Chronic Kidney Obesity/Desired Weight Loss Palliative Care Dementia/Alzheimers New philosophies on nutrition and dining are on a challenging journey: Cultural shifts from institutionalized care to individualized/personal care Creating a more home-like environment Informing residents of options and choices available to them so they can make informed choices Education of risks/benefits and alternatives Development of Negotiated Risk Agreements Resident Choice 5

6 How did these changes come about? Partnership between CMS and the Pioneer Network A co-sponsored symposium to initiate a cultural change pathway The Pioneer Network includes organizations and individuals from across the nation dedicated to advocating for public policy change New Dining Practice Standards The nationally agreed upon standards are: Self-directed care Individualized care These standards are recommended for people living in senior care communities, however are not required Source: Standards of Practice Individualized Nutrition Approaches / Diet Liberalization Individualized Diabetic / Calorie- Controlled Diet Individualized Low-Sodium Diet Individualized Cardiac Diet Individualized Altered Consistency Diet Individualized Tube Feeding Individualized Real Food First Individualized Honoring Choices Shifting traditional professional control to Individualized support of self-directed living 6

7 Agencies that Support the New Dining Practice Standards Academy of Nutrition & Dietetics American Medical Directors Association American Nurses Association National American Occupational Therapy Association American Speech Language Hearing Association of Nutrition & Foodservice Professionals Association (ASHA) Association of Activity Professionals National Association of Social Work The New Dining Practice Standards Regular diet is the goal Residents have the right to refuse prescribed diets Resident s choice is paramount Examples: 1. Resident with diabetes requested black forest chocolate cake with Frosting 2. Resident on NAS diet adding additional salt at table What should the wait staff do? Strict VS Liberalized VS Regular Diets Strict / Not Liberalized Diet 1800 Kcal Diabetic Diet Liberalized Diet Consistent Carbohydrate Diet (CCHO) 2 Gram Na Diet No Added Salt (NAS) Cardiac Diet (Low-Fat / Low-Cholesterol, 2 Gram Na) Low-Fat / Low Cholesterol, NAS Regular Diet Regular diet with diet desserts and *sugar substitute * Advise resident regarding sugar use Regular diet with resident limiting *salt use at the table * Advise resident regarding salt use Regular diet with skim milk, limit eggs 3 x week, no fried foods, limit gravies, cream sauces, & cream soups; For dessert fruit, gelatin, low-fat cake or cookies i.e. angel food cake, 7

8 Strict VS Liberalized VS Regular Diets Strict / Not Liberalized Diet Liberalized Diet Regular Diet Strict Renal Diet (80 Gram Protein, 2 GM Na, 2 GM K+) Dysphagia Levels Level 1 - Puree Level 2 - Dysphagia Mechanically Altered Level 3 - Dysphagia Advanced Thickened Liquid Levels: Thin Nectar-Like Honey-Like Pudding-Like Liberal House Renal (80 GM Pro, 3 GM Na, 3 GM K+) Allows use of potato & tomato products sparingly Mechanical Soft Puree (Omit level 2 Dysphagia Mechanically Altered) Food are offered to the resident that are naturally of appropriate consistency Beverages are offered to the resident that are naturally of appropriate consistency Regular Diet with dairy limited to ½ cup per day (no other dairy products) Avoid: Bananas, cantaloupe, honeydew, oranges & orange juice Individualized consistency per resident s preference & tolerance i.e. Ground meats with regular consistency vegetable & starch sides Frazier's Free Water Protocol allows thin water 30 minutes after a meal & between meals with excellent oral care Source: Mayo Clinic Benefits of Freedom of Choice Improved desire to eat (more food variety and improved food flavor) Residents participation in nutrition decisions. Dignity and control for the resident Decisions default to the resident Various and Creative Ways to Prevent Unplanned Weight Loss Liberalized Diets Appealing menu program with seasoned recipes and variety Residents input on menus Creative puree food, finger foods, etc. Food first vs Oral supplements Variety of fortified foods / Preferred snacks Enticing hydration and snack carts Choices of what, when, how much, with whom, and where to eat 8

9 Various and Creative Ways to Prevent Unplanned Weight Loss (continued) Appealing dining experience with proper assistance Hospitality oriented staff Restaurant style service Complimentary ice cream shops Omelet / Pasta station Dessert cart / Salad bar Always available menus Selective menus Various and Creative Ways to Prevent Unplanned Weight Loss (continued) Soup kettle Anniversary / Birthday meals Candlelight Dinners / Family meals Movies with popcorn Food brought in by families Cookouts / Community pot lucks Theme / Cultural / Holiday meals Directed Dining (When to eat) F-242 Self Determination and Participation: Staff must adjust to allow residents choice and self determination Resident can select a meal schedule that is consistent with their home-like habits Offer options of open dining patterns/ snacks 9

10 Directed Dining (When to eat) F-368 (Frequency of Meals): No more than 14 hours between a substantial evening meal and breakfast The intent is met when dining opportunities (open dining hours) are planned to meet the requirement for no more than 14 hours and yet allow resident choices Directed Dining (When to eat) F-364 (Food that is palatable, attractive, and at the proper temperature): Challenges with extended dining hours, buffets, etc. can be met with: Batch cooking Taking frequent temperatures to maintain safety suggest every 30 minutes to 1 hour Hot Food Hot, Cold Food Cold Having hot food leaving the kitchen be 135 F or greater (some state laws still require 140 F) (per revised F-371) Reheating food to 165 F if held over 2 hours Directed Dining (What and how much to eat) F-363 (Menus and Nutritional Adequacy): Assure meals served meet nutritional needs of resident according to recommended dietary allowances Have menus approved and dated by dietitian Ensure residents who choose to sleep in and miss breakfast or skip another meal or food group are offered a continental breakfast or substitute and are monitored for decline in Nutritional Status Care Plan Document Discuss choices with resident Ongoing monitoring of nutritional status, i.e., weight, labs, etc. 10

11 Directed Dining (What and how much to eat) F-367 (Therapeutic diets must be prescribed by the attending physician) F-325 (Resident maintains to the extent possible, acceptable parameters of nutritional status): F-155 (Right to refuse treatment) Facility staff should: 1. Obtain residents food and consistency preferences 2. Make efforts to liberalize diets liberalized means default to resident for quality of life with individualized approaches Try Regular Diet 3. Educate and guide resident (not control) inform of risks and benefits offer alternatives 4. Individualize plan of care Directed Dining (What and how much to eat) Facility staff should (continued): 5. On an ongoing basis, monitor and re-evaluate the residents nutritional status, i.e., labs, weights, intakes 6. Ensure preferred food choices are available for the resident 7. Educate staff in residents right to choose and in diets 8. Document all of above 9. Negotiated Risks documentations with IDT 10. Develop, implement, and review policies and procedures that ensure residents are offered choices that promote comfort and dignity 11. Have the medical director involved in developing, implementing, and enforcing policies and procedures Directed Dining (What and how much to eat) Facility staff should (continued): 12. Physician notified of change in resident s condition or failure of accepting the treatment plan 13. If resident is non responsive, the resident s family representative is notified and involved in choices for the resident 14. No longer identify residents as Non-compliant use positive wording such as rights of choice and self determination 15. To NOT allow choice is now identified as harmful (even if good care is given)!! 11

12 Implementation of Person Directed Dining or Cultural Change Start slow Write policies and procedures developed with input from residents Obtain resident s food preferences Liberalized diets to Regular per resident s preference (default to resident and their quality of life by individualizing approaches) Review menu with residents make necessary changes with help of RD Use preferred fortified food as first line of intervention Educate staff and residents on Cultural Change Plan Implementation of Person Directed Dining or Cultural Change (continued) Work on the following one at a time: When Open dining hours What Variety in menus resident input Resident s choice of diet How much Portion choices With whom Who to eat with Where to eat Choice of eating location Then move on to another area to work on until all five areas are implemented Give Your residents an Eatertainment Experience 12