Personalised Care Plans in Care Personalised Care Plans in Care Homes 2010-2014Homes 2010-2014

Muriel GallMuriel Gall

Team Lead DietitianTeam Lead Dietitian

Food First TeamFood First Team

HypothesisHypothesis

• A specific dietetic-led service with personalised A specific dietetic-led service with personalised care plans optimises nutritional status of care care plans optimises nutritional status of care home residents and reduces inappropriate home residents and reduces inappropriate prescribing of oral nutritional supplements (ONS)prescribing of oral nutritional supplements (ONS)

Introduction & BackgroundIntroduction & Background

• Two GP practices with 200 care home beds (spend on ONS Two GP practices with 200 care home beds (spend on ONS increasing at ~50% per year) increasing at ~50% per year)

• EvidenceEvidence

– NICE (CG32, 2006) NICE (CG32, 2006) • Nutritional screening eg. MUSTNutritional screening eg. MUST• diet should be optimised in addition to ONS ie. promoting diet should be optimised in addition to ONS ie. promoting

Food FirstFood First

– Audits of prescribing criteria indicates 30–70% inappropriate Audits of prescribing criteria indicates 30–70% inappropriate prescriptions (Gall et al., 2001; Kennelly et al., 2009)prescriptions (Gall et al., 2001; Kennelly et al., 2009)

Development of Service• Evaluation of current practice Evaluation of current practice

– Accuracy of MUSTAccuracy of MUST– Meal and snack observations – serving sizes,Meal and snack observations – serving sizes,

sauces; portion sizes, evidence of food fortification, sauces; portion sizes, evidence of food fortification, toileted prior to meals, sufficient staff to support toileted prior to meals, sufficient staff to support assisted feeding, compliance with ONS – provided assisted feeding, compliance with ONS – provided report to care homereport to care home

– Developed care pathway and provided in-house Developed care pathway and provided in-house trainingtraining

CARE PATHWAYCARE PATHWAY• Training for care home staff on:Training for care home staff on:1)1) MUSTMUST2)2) Food First Approach – 3 principlesFood First Approach – 3 principles

– 2 fortified milky drinks.2 fortified milky drinks.– Fortifying one dish at each meal time.Fortifying one dish at each meal time.– 2 nourishing snacks between meals.2 nourishing snacks between meals.

• Monthly monitoring of weights and MUST. Any resident found to Monthly monitoring of weights and MUST. Any resident found to have a MUST score of 1 or morehave a MUST score of 1 or more

– taken onto dietetic caseload, with a care plan based on the taken onto dietetic caseload, with a care plan based on the food first principles and resident’s preferences, care pathway food first principles and resident’s preferences, care pathway and ONS where appropriateand ONS where appropriate

– Evaluated residents’ nutritional outcomesEvaluated residents’ nutritional outcomes

Equivalent to 4 plain biscuits = 140kcalsEquivalent to 4 plain biscuits = 140kcals

• Fairy cake• Malt loaf (1 slice with butter)• Fruit scone (1/2 scone with butter & jam)• Hot cross bun (1/2 bun with butter & jam) • Sausage roll (medium)• Crisps (standard packet)• Ham sandwich (1 slice, butter & ham)• Icecream (1scoop)• Yoghurt (thick and creamy)• Meringue nest with whipping cream• Cereal bar • Dried fruit (handful, e.g. raisins, sultanas)

Types of food to fortifyTypes of food to fortify

milkmilkcustardcustard

milk puddingsmilk puddingsporridgeporridge

mashed potatoesmashed potatoessoupsoup

sponge puddingsponge puddingicecreamicecream

vegetablesvegetablesgravygravy

Nourishing foods used for fortificationNourishing foods used for fortification

Milk powder 1 heaped tablespoon 50 calories

Whole milk 75mls 50 calories

Margarine 1 heaped teaspoon 75 calories

Double cream Whipping cream Single cream

1 tablespoon 135 calories 110 calories 30 calories

Cheese Small matchbox (30g) 125 calories

Jam / honey 1 heaped teaspoon 50 calories

Products – 2 per dayProducts – 2 per day

ProductProduct Protein (g)Protein (g) Energy Energy (kcals)(kcals)

AA Aymes / Complan Aymes / Complan Shake Shake 1 sachet made with 200ml full 1 sachet made with 200ml full cream milkcream milk

1616 388388

BB Fortified Milk – 200mlFortified Milk – 200mlFull cream milk, dried milk powder, Full cream milk, dried milk powder, double cream + Nesquickdouble cream + Nesquick

1212 300300

CC Ensure Plus 220mlEnsure Plus 220ml 1414 330330

GOVERNMENT

RECOMMENDED POOR

APPETITE B’fast

Lunch

Dessert

Tea

Calories 2160 960

Acknowledgement: Caroline Walker Trust

Nutritional Care – House 1Nutritional Care – House 1• 10 residents on ONS – 6/10 on dietitians case load10 residents on ONS – 6/10 on dietitians case load

– 5/10 (50%) had lost 1.4 – 6.7kg in previous 4 months5/10 (50%) had lost 1.4 – 6.7kg in previous 4 months– 1/10(10%) wt stable1/10(10%) wt stable– 4/10(40%) gained wt 1.5 - 6.7kg4/10(40%) gained wt 1.5 - 6.7kg– After 6-9 weeks of food first approach:After 6-9 weeks of food first approach:

• 7/10(70%) gained wt (0.5 - 6.2kg)7/10(70%) gained wt (0.5 - 6.2kg)• 3/10 lost wt (0.4 – 1.5kg)3/10 lost wt (0.4 – 1.5kg)

• A further 5 residents were nutritionally at risk A further 5 residents were nutritionally at risk – all wt loss of 2.6 – 9.3kg in previous 1-4 months)all wt loss of 2.6 – 9.3kg in previous 1-4 months)– After 6- 9 weeks of food first approach:After 6- 9 weeks of food first approach:

• 4/5 (80%) had gained weight 0.1 – 3.0kg4/5 (80%) had gained weight 0.1 – 3.0kg• 1/5 (20%) had lost wt 1.5kg1/5 (20%) had lost wt 1.5kg• None started on ONS None started on ONS

• 15 residents on project dietitian’s caseload15 residents on project dietitian’s caseload

Practice 1 - BNF units used April - December2010

020406080

100120140

Apr-1

0

Jun-

10

Aug-1

0

Oct-10

Dec-10

Month

nu

mb

er o

f u

nit

s

Practice 1 BNF7.2

Practice 1 BNFTotal 7.1-7.4

Comparisons of 3rd quarter (Sept-Dec) expenditure on ONS in the highest spending DG&S practices

£0.00£2,000.00£4,000.00£6,000.00£8,000.00

£10,000.00£12,000.00£14,000.00£16,000.00£18,000.00

GP practice

3rd Quarter 08/09

3rd Quarter 09/10

3rd Quarter 10/11

SpendSpend (sterling) (sterling)

0

100000

200000

300000

400000

500000

600000

700000

2007

- 08

2008

- 09

2009

- 10

2010

- 11

2011

- 12

2012

- 13

2013

- 14

Annualspending trend

Units of ONS PrescrUnits of ONS Prescribedibed

0

5000

10000

15000

20000

25000

30000

35000

2009 -2010

2010 -2011

2011 -2012

2012 -2013

2013 -2014

Units annuallyPrescribed

Effects of the service on Patient CareEffects of the service on Patient Care

• Patients receive more regular dietetic Patients receive more regular dietetic assessment of their nutritional status.assessment of their nutritional status.

• More patients are managed by ‘food first’ rather More patients are managed by ‘food first’ rather than supplementsthan supplements

• Advice on appropriate food and fluid fortificationAdvice on appropriate food and fluid fortification• Patient centred and personalised advice on Patient centred and personalised advice on

nutrition with regards to their disease state.nutrition with regards to their disease state.• Support for care home staff, residents, families Support for care home staff, residents, families

and GPs for end of life careand GPs for end of life care

SummarySummary

• A specific dietetic-led service with personalised A specific dietetic-led service with personalised care plans optimises nutritional status of nursing care plans optimises nutritional status of nursing home residents and reduces inappropriate home residents and reduces inappropriate prescribing of oral nutritional supplements (ONS)prescribing of oral nutritional supplements (ONS)