Personalised Care Plans in Care Homes Muriel Gall Team Lead Dietitian Food First Team

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

Introduction & Background Two GP practices with 200 care home beds (spend on ONS increasing at ~50% per year)Two GP practices with 200 care home beds (spend on ONS increasing at ~50% per year) EvidenceEvidence –NICE (CG32, 2006) Nutritional screening eg. MUSTNutritional screening eg. MUST diet should be optimised in addition to ONS ie. promoting Food Firstdiet should be optimised in addition to ONS ie. promoting Food First –Audits of prescribing criteria indicates 30–70% inappropriate prescriptions (Gall et al., 2001; Kennelly et al., 2009)

Development of Service Evaluation of current practiceEvaluation of current practice –Accuracy of MUST –Meal and snack observations – serving sizes, sauces; portion sizes, evidence of food fortification, toileted prior to meals, sufficient staff to support assisted feeding, compliance with ONS – provided report to care home sauces; portion sizes, evidence of food fortification, toileted prior to meals, sufficient staff to support assisted feeding, compliance with ONS – provided report to care home –Developed care pathway and provided in-house training

CARE PATHWAY Training for care home staff on:Training for care home staff on: 1)MUST 2)Food First Approach – 3 principles –2 fortified milky drinks. –Fortifying one dish at each meal time. –2 nourishing snacks between meals. Monthly monitoring of weights and MUST. Any resident found to have a MUST score of 1 or moreMonthly monitoring of weights and MUST. Any resident found to have a MUST score of 1 or more –taken onto dietetic caseload, with a care plan based on the food first principles and resident’s preferences, care pathway and ONS where appropriate –Evaluated residents’ nutritional outcomes

Equivalent 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 fortify milkcustard milk puddings porridge mashed potatoes soup sponge pudding icecreamvegetablesgravy

Nourishing foods used for fortification

Products – 2 per day Product Protein (g) Energy (kcals) A Aymes / Complan Shake 1 sachet made with 200ml full cream milk B Fortified Milk – 200ml Full cream milk, dried milk powder, double cream + Nesquick C Ensure Plus 220ml 14330

Acknowledgement: Caroline Walker Trust

Nutritional 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 months –1/10(10%) wt stable –4/10(40%) gained wt kg –After 6-9 weeks of food first approach: 7/10(70%) gained wt ( kg) 7/10(70%) gained wt ( kg) 3/10 lost wt (0.4 – 1.5kg)3/10 lost wt (0.4 – 1.5kg) A further 5 residents were nutritionally at riskA further 5 residents were nutritionally at risk –all wt loss of 2.6 – 9.3kg in previous 1-4 months) –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 ONSNone started on ONS 15 residents on project dietitian’s caseload15 residents on project dietitian’s caseload

Spend (sterling)

Units of ONS Prescribed

Effects of the service on Patient Care Patients receive more regular dietetic assessment of their nutritional status.Patients receive more regular dietetic assessment of their nutritional status. More patients are managed by ‘food first’ rather than supplementsMore patients are managed by ‘food first’ rather than supplements Advice on appropriate food and fluid fortificationAdvice on appropriate food and fluid fortification Patient centred and personalised advice on nutrition with regards to their disease state.Patient centred and personalised advice on nutrition with regards to their disease state. Support for care home staff, residents, families and GPs for end of life careSupport for care home staff, residents, families and GPs for end of life care

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