MMT Update Kimberley Malcolmson

GPs ONS Patients &Carers Southern Health Nutrition and hydration steering group LEaD Sue Benzie Nurses District Nurses Tissue Viability Nurses Link Nurses Care Homes Managers Nurses Health Care assistants Catering staff MM Teams Neil Hardy Community pharmacists Jason Peet Dietitians Isabelle Brady Ruth Redman Helen Hitchings Denise Thomas Hillary Warwick Debbie Sutton Hospitals Discharge summaries AuditTrainingResources Key contacts Prescription requests Letter template Pts discharged on supplements MUST Food first advice Appropriate ONS usage Appropriate use of ONS in GPs Use of MUST Nursing home pack Screening Tool Care pathways Catering Support Referral criteria Training programme ePACT Tags and monitoring Template for GP systems Formularies Patients Leaflets ONS Guideline Care Home In Reach Project Online Resources GP prescribing forums Consultation Script switch Quality of prescriptions MUST Catering training Hants County Council PaCT Hazel Turner Tanya Bond Patient leaflets Consultation MMT training

GPs ONS MM Teams Neil Hardy Community pharmacists Jason Peet AuditTrainingResources Key contacts Appropriate use of ONS in GPs ePACT Tags and monitoring Online Resources GP prescribing forums Script switch Quality of prescriptions MMT training

ePact Data – Spend overall ONS

ePact Data – % of Non preferred ONS North East cost of non preferred ONS £8,210 last 3 months =£32,840/year

ePact Data – Comparison

Plan ONS request form for NH and district nurses ePACT data Script switch Community Pharmacists GP re-audit GP Forum update Location of P4PC?Evidence Online resources Pt Leaflets: 204 downloads Formularies: 42 downloads Guidance: 47 downloads Presentation: 52 downloads MUST kit: 80 downloads ePact Data GP forum feedback

GPs ONS Dietitians Isabelle Brady Ruth Redman Helen Hitchings Denise Thomas Hillary Warwick Debbie Sutton Hospitals Discharge summaries AuditTrainingResources Key contacts Prescription requests Letter template Pts discharged on supplements Appropriate use of ONS in GPs Template for GP systems Formularies Patients Leaflets ONS Guideline Online Resources GP prescribing forums Consultation ONS initiated by 2 ary care setting ≈ 40% Evidence Letter template in use Online resources on P4PP Hospital D/C audited Plan Template for GP systems Letter audit Action D/C audit results

Across Winchester and Basingstoke sites Aim: Find out percentage of inpts on ONS under dietitian Find out % of pts with ONS on discharge summaries that were deemed needed by dietitians Method: Snapshot of inpts on ONS: All patients with ONS on electronic drug chart on one day Three months Jan-March of pts with ONS on TTO’s Inpt ONS audit

Basingstoke 48 Pts 77% known to dietitian 45 with MUST score 68% MUST of 1 or more 6pts not referred, once referred 89% under dietitian Winchester 59 Pts 45% known to dietitian 39 with MUST score 42% MUST of 1 or more

ONS on TTO’s Basingstoke 60 Pts 73% known to dietitian Winchester 97 Pts 46% known to dietitian

Plan Multiple choice options to be BD not TDS automatically on JAC (electronic prescribing) Amendment to nutrition policy on guidance for ONS perhaps a prompt in JAC to check MUST and BMI

GPs ONS Southern Health Nutrition and hydration steering group LEaD Sue Benzie Nurses District Nurses Tissue Viability Nurses Link Nurses Care Homes Managers Nurses Health Care assistants Catering staff AuditTrainingResources Key contacts MUST Food first advice Appropriate ONS usage Use of MUST Nursing home pack Screening Tool Care pathways Catering Support Referral criteria Training programme Care Home In Reach Project MUST Catering training Hants County Council PaCT Hazel Turner Tanya Bond Patient leaflets ONS initiated by 1 ary care setting ≈ 50% Evidence Patient leaflets incl wound care Evaluation from training Care Home audit and reports Care Home resource pack and training ONS usage in Calleva care homes Appropriate use of ONS in GPs Online Resources GP prescribing forums

North Hampshire Care Home ONS Audit Report Kimberley Malcolmson & Aude Cholet Prescribing support dietitians

Data collected 28 Nursing and Residential homes in North Hants area (Calleva) 2-3 hours per home (dependant on how many pts on ONS) 1100 Total occupied beds 100 Patients on supplements (9% of total)

Audit Standards 1.All residents on ONS should have a MUST score 2.All residents on ONS should meet at least one ACBS criteria 3.If ACBS criteria is disease related malnutrition, this should be established by a MUST score of 1 or more 4.All residents on ONS should have a clear nutrition care plan documented 5.All residents on ONS should be receiving fortified diet and/or extra snacks and/or nourishing drinks 6.All residents on ONS should be offered ONS as a supplement, not as a meal replacement unless strong rationale demonstrated 7.Residents on ONS should be offered ONS bd, or in excess of 400Kcal/d 8.All residents on ONS should have clear goals that ONS are hoped to achieve 9.ONS therapy goals should be monitored on at least a monthly basis

Results Individual Care Home report written and sent to medicine management team lead for GP practice(s) covering Care Home Recommendations made for supplements at that time based on nutritional and clinical assessment 3 Recommendations for prescriptions were for them to: Continue, or Stop, or Change (to meet therapeutic dose or avoid non recommended product)

Results MUST = Malnutrition Universal Screening Tool

Results 1 home recommended spend increased, 27 decreased 44% of prescriptions advised to be stopped (44 Patients) Total Daily cost of ONS before audit Total daily cost of ONS after audit Potential Saving per day Potential saving per year £240.43£125.35£ (47.9%) £42,004

Conclusion Potential saving = 42 K a year i.e. 45 hours/week of Band 6 Dietitian/year Need for ongoing training and support for Screening (MUST) Food fortification Nutrition Care planning Training so far 63 people trained (4 sessions) ongoing process Improvement in patient nutritional care possible

Plan Care home training and resource pack for nursing homes CHIRP Re-audit care homes ONS

GPs ONS Patients &Carers AuditTrainingResources Key contacts Appropriate use of ONS in GPs Online Resources GP prescribing forums Consultation Patients and carers influence ≈ ? Evidence Patient leaflets incl. wound care PlanNetworking

Plan ONS request form for NH and district nurses ePACT data Script switch Community Pharmacists GP re-audit GP Forum update Location of P4PC? Plan Template for GP systems Letter audit Action D/C audit results Plan Care home training and resource pack for nursing homes CHIRP Re-audit care homes ONS

Promote P4PC resources Southern Health resources launch and promotion Role out Nursing home/ district nurse request form Continuing ePact Data collection Develop measures of Quality of prescription not just Quantity MUST template on GP systems, build into other areas COPD, elderly care to improve screening Further work Hampshire wide

Cost of Malnutrition Cost of malnutrition in the UK £13 billion annually NICE have identified malnutrition as the 4 th largest potential saving for the NHS Those that are malnourished are more likely to: Visit GPs Spend longer in hospitals More likely to be admitted to hospital Appropriate use of ONS has been shown to reduce these costs to the NHS

BAPEN report provision of ONS to malnourished patients reduces complications such as Infections and wound breakdown by 70% Mortality by 40% Better nutritional care for individuals at risk can result in substantial cost savings to the NHS Studies have shown improved nutritional care can reduce emergency admissions, infection risk, improve wound care and reduce their associated costs BAPEN, Malnutrition Matters Meeting Quality Standards in Nutritional Care 2010