The 4Ps of Nutrition: performance, power, policy and position Sandra Capra AM,PhD,FDAA Professor of Nutrition, University of Queensland Chair, International Confederation of Dietetic Associations September 2009HNEH Quality Exposition

Nutrition is not just a pretty extra I want to argue that nutrition is a fundamental to quality health care I want to pose the argument that nutrition has been a “cinderella” in the health system for too long I want to claim that errors in nutritional management through lack of resources and policies are heavy costs to the system and to the people. September 2009HNEH Quality Exposition

September 2009HNEH Quality Exposition

Nutrition is a core foundation of health Underpins good health Underpins reduction of chronic disease Underpins quality services Underpins quality of life Is multidisciplinary Is cheap Is effective September 2009HNEH Quality Exposition

Performance – nutrition delivers! Nutrition as a strong performer in health and health care systems Medical nutrition therapy Functional nutrition therapy Food service Public interest in nutrition But performance is perceived to be affected by –Invasion of the field by underqualified persons clouding the ‘truth’ and the evidence –Trivialising nutrition September 2009HNEH Quality Exposition

Reducing stress – increasing stress- nutrition blog.iqmatrix.com September 2009HNEH Quality Exposition

September 2009HNEH Quality Exposition

September 2009HNEH Quality Exposition

The proportion of same-day separations increased between 1998–99 (47.9%) and 2007–08 (56.3%). The average length of stay (including same-day separations) in hospitals was 3.3 days in 2006–07 and 2007–08. Between 1998–99 and 2007–08, for patients staying at least one night: –average length of stay varied between 6.2 days and 6.5 days for public acute hospitals –average length of stay decreased from 5.9 days in 1998–99 to 5.4 days in 2007–08 for private hospitals September 2009HNEH Quality Exposition

But….. Those who enter with malnutrition stay longer – much longer. Average LoS for those with malnutrition at entry is about double that of those who entry well nourished. September 2009HNEH Quality Exposition

Table 1: Estimated change in projected health and residential aged care expenditure due to selected NHHRC reform proposals Expenditure (millions of 2006–07 dollars) Original projected health and residential aged care (high care) expenditure ($m) 85,063167,729246,056 Total health and (high care) aged care expenditure as per cent of GDP Less net savings due to proposed interventions Improved availability of sub-acute care –127–190 Reduced rate of increase in obesity –624–2,566 Faster decline in smoking rates –363–262 Patient enrolment with a primary health care service (Medical home) –380–635 Reforms to aged care –5191,412 Improved access to basic dental care –73–110 Improved treatment of diabetes –125–188 Implementation of personal electronic health records –430–627 Improved safety and quality of care –660–976 Total net savings –3,301–4,142 Total health and residential aged care expenditure after net savings from selected NHHRC reforms ($m) 85,063164,428241,914 Total as per cent of GDP September 2009HNEH Quality Exposition

Functional and Medical Nutrition Therapies stern.edu/nutrition/images/A ppleCutout.jpg September 2009HNEH Quality Exposition

Anti-inflammatory September 2009HNEH Quality Exposition

September 2009HNEH Quality Exposition

Power Nutrition as a powerful tool for health Poor nutrition costs money September 2009HNEH Quality Exposition

WHO September 2009HNEH Quality Exposition

Images/Nutrition-Image1.gif September 2009HNEH Quality Exposition

Policy Setting systems that will deliver benefits Nutrition on the policy agenda The ACHS EquiP4 revisions under standard 1.5 “Organisation providing safe and care and services” includes a new standard that concerns ensuring that nutritional needs are met, introducing screening and including nutrition in the care plans among other specified activities. These are currently under discussion. September 2009HNEH Quality Exposition

A Healthier Future for All Australians National Health and Hospitals Reform Commission Final Report June 2009 September 2009HNEH Quality Exposition

September 2009HNEH Quality Exposition

Malnutrition now updated in DRGs Malnutrition is the silent epidemic- 35%+ in health facilities, ( 15% in HACC clients in community (Leggo et al 2008), 50% in RACwww.daa.asn.au The kind of malnutrition we see most is now recognised in the classification system – –disease induced malnutrition, –malnutrition in a land of plenty –Malnourished overweight persons As a co-morbidity it affects the casemix weighting and therefore reimbursement systems. The diagnosis must be by an APD September 2009HNEH Quality Exposition

Position Positioning nutrition as a core health concern Having the policy is not enough – it must be actioned September 2009HNEH Quality Exposition

Primary Health Care Reform in Australia Report to support Australia’s first national primary health care strategy DoHA, 2009 These are poor Very little comfort here September 2009HNEH Quality Exposition

September 2009HNEH Quality Exposition

September 2009HNEH Quality Exposition Source: Splett P. 1996

Have we the workforce to deliver? We can do a good job and reduce errors mostly if there are enough qualified nutrition staff available Nutrition is everyone’s business and is multidisciplinary The professional nutrition staff should hold nationally recognised credentials. For nutrition this is the APD credential for any work that requires competence in medical nutrition therapy and foodservices in any form and in any setting. September 2009HNEH Quality Exposition

Source; Brown Capra and Williams ; Profile of the Australian dietetic workforce Nutrition and Dietetics; 2006;63: September 2009HNEH Quality Exposition

September 2009HNEH Quality Exposition

Standardised Terminology Errors relate to miscommunication in diagnoses and treatments Electronic medical records are here/coming by 2012 They will –Facilitate information sharing –Provide nformation to measure desired outcomes –Document outcomes and therefore drive the evidence base and standards of practice. We need to adopt the International Dietetics and Nutrition Terminology (IDNT) September 2009HNEH Quality Exposition

The lack of a standardized approach in nutrition language and terminology can lead to an inaccurate diagnosis which may then lead to inappropriate or ineffective nutrition interventions and lower quality. When nutrition and dietetics interventions are solely based or described by a medical diagnosis, there can be ambiguity in both the cause of any nutrition issues and nutrition management September 2009HNEH Quality Exposition

Medical diagnosis :Diabetes Type II Nutrition intervention : 7500 kJ diet, carbohydrate controlled Compared with Medical diagnosis : Diabetes Type II Nutrition diagnosis : inappropriate food choice Nutrition intervention : counselling and referral to diabetes education centre Medical diagnosis : cancer Nutrition intervention : high protein, high energy diet Compared with Medical diagnosis : cancer Nutrition diagnosis : Limited access to food Nutrition intervention : meals on wheels, home supplies of supplements September 2009 HNEH Quality Exposition

This contrasts with the “IFI” approach of the National Allied Health Classification Committee, which does not include sufficient terms or details to clearly identify what practitioners actually do. It adopts a functional approach, which groups many separate issues under single codes, leading to an inability to compare outcomes. September 2009HNEH Quality Exposition

b 530 Weight maintenance functions – Functions of maintenance of acceptable body mass index (BMI); impairments such as underweight, cachexia, wasting, overweight, emaciation and such as primary and secondary obesity Source: IFI coding Manual for Pilot Project 2007 September 2009HNEH Quality Exposition

Food as the tool to deliver nutrition September 2009HNEH Quality Exposition

Food in health care is a treatment Calling foodservice a “hotel” service means that it can be forgotten –Treated as less important –Subjected to cost cutting at times September 2009HNEH Quality Exposition

Would you eat these? September 2009HNEH Quality Exposition

My challenge Make the services as good as this!! September 2009HNEH Quality Exposition

Nutrition –the 4Ps Recognise the performance of nutrition in healthcare Recognise the power of nutrition to make a difference to quality services Adopt policies to make a difference Position nutrition services so they can deliver quality and excellence Be a leader September 2009HNEH Quality Exposition