1. Rhythms of Daily Living Dining & Choice STRATEGIC OBJECTIVES – TACTICAL IMPLEMENTATION Rhythms of Daily Living © Dining & Choice STRATEGIC OBJECTIVES – TACTICAL IMPLEMENTATION Aligning Experiences – Expectations – Resources – Outcomes

2. June 9, 2004 VANHA 2 Why Do 65% Of NH Residents Eat Less Than 75% Of Most Meals* ?  Primary Factors That Contribute To Malnutrition In Nursing Homes 1. An Inappropriate Dining Experience For The Resident. 2. Meal Delivery Methodology and Systems Not Conducive To Eating. 3. Good Nutrition is of no value if it is not consumed *Excerpted From Ch 14 Of Report To Congress “Appropriateness of Minimum Staffing Ratios In Nursing Homes” Authored By J. F. Schnelle et al, Borun Center For Gerontological Research

3. June 9, 2004 VANHA 3 Must Rising Acuity Levels Mean Lower Dining Quality ? ©

4. June 9, 2004 VANHA 4  What Are Factors of Rhythms Of Daily Living For Dining?  service  choice of where you eat  Defined and met expectation  Reputation – consistency  Timeliness  Presentation of meal  Taste  Do not rush me  NeighborsAtmosphere, aroma  cleanliness  choice  Residents eat when hungry  friendliness  Generational expectations  Personal eating habits  Choose to dine at a time of the resident’s choice No The Simple Answer Is No!

5. June 9, 2004 VANHA 5 Skilled Care Dining Today Restricted Service Times, Too Short For Quality & Assistance < 20 Minutes For Dining The Quality Gap

6. June 9, 2004 VANHA 6 Bridging The Quality Gap Serve The Resident, Not The System  The System – Individual Preparation, Bulk Service  Prepare Individual Menu Items For Storage  Place On A Tray For Transport To Feeding Area  Transport and Leave In Cart  Distribute and Unwrap At Scheduled Meal Time  The Alternative – Bulk Preparation, Individual Service  Prepare Menu Items In Bulk  Transport To Dining Room Servery  Plate Individually and Serve Upon Request

7. June 9, 2004 VANHA 7 Balancing the Natural Rhythms of Resident Living and Care Work  A “More Normal” Pattern of Living and Work  Residents Eat What And When They Want Over A Longer Meal Service  Pre-Meal Medications, Bathing and Other Activities Are Less Pressured  Staff Provides Assistance As Required  24 Minutes Is Average Optimal Feeding Assistance Time With A Range From 5 To 70 Minutes Depending On ADL Status*  48% Of Nursing Home Population Require Some Degree of Assistance*  A Dining Experience, Not A Feeding Period  Shift Dining Service Focus From Trays To Residents and Quality  Collaborative Service Support  Aroma Therapy  Course Presentation  Minimal Distraction Environment * Excerpts From Ch 14 Of Report To Congress “Appropriateness of Minimum Staffing Ratios In Nursing Homes” Authored By J. F. Schnelle et al, Borun Center For Gerontological Research

8. June 9, 2004 VANHA 8 Rhythms of Daily Living The core of RDL is the opportunity to exercise choice – residents’ for how they choose to live their day and staff choice for care delivery. This creates a collaborative coalition of residents and caregivers working together in a living environment. RDL facilitates the delivery of care, the experience of living and the dignity of self-determination. RDL is a management principle that aligns the natural rhythms of residents and the support they need. The organizing principle of RDL is that people should be able to make meaningful choices in their daily lives – on their own or with assistance. RDL relies on caregivers to help define and achieve outcomes that balance individual choice and system efficiency.

9. June 9, 2004 VANHA 9  40% of Residents Gain Weight In The First Few Program Months  50% Reduction In The Number Of Residents Losing Weight.  Consistent Improvement In Resident Satisfaction  $0.18 – $0.21 Reduction In Food Cost Per Meal From Less waste.  85% Decrease In Use of Supplements  Higher Job Satisfaction  Improved Hydration  Outcomes Exceed Regulatory Requirements RDL Is Real Reported Results From Ten Communities That Have Implemented RDL

10. June 9, 2004 VANHA 10 Assessment Points for RDL Implementation Stages are defined against the requirements of:  Administration: fiscal, management and leadership considerations  Regulatory: compliance criteria (grouped by clinical and operational considerations)  Systems: software programs, forms, policy & procedures, protocols  Personnel: staffing requirements, training, HR. The impact on each care disciplines is identified by department  PP&E: Property, Plant & Equipment necessary to perform the tasks and functions

11. June 9, 2004 VANHA 11 STAGES of RDL  Readiness GAP Analysis  Establish clear understanding among all constituents (residents, staff and administration) as to the program impact on 6 principle areas.  Culinary Capacity  Establish a servery on the resident floor where all meals can be finished, plated and served.  Individualized Service  Establish a service program without the tray system. Meals are plated in the servery when the resident is in the dining room. Choice is based on pre-ordered menu items, however time of service is not flexible.  Point of Service Menu Choice  Establish the opportunity for the resident to choose alternate items from a menu during meal service.  Schedule Choice I[1][1]  Establish the opportunity for residents who are self-sufficient and independent to dine at a time of their choosing, within established service times.  Schedule Choice II  Establish the opportunity for residents who require assistance with dining but are able to determine when they would like to dine to do so within established service times.  7. Venue Choice (If Appropriate)  Establish the opportunity for residents to choose alternate places to dine.  [1] Schedule choice is the last and most difficult stage to implement because it affects the scheduling of all resident activities from bathing to medication and activities. [1]

12. June 9, 2004 VANHA 12 How Do You Individualize Care? 1. What Are Strategic Objectives?  Current Strengths  Opportunities Identified For Improvement 2. What Is The Vision for Community Dining Experience?  Choice  Menu, Time and Venue? 3. What Is History of “Transformation” Projects?  What Were Expectations  How Defined and Structured  How was it trained & accepted?  What Are The Most Important Experiences?  Resident Experiences  Staff Experience  Family & Other Stakeholders?

13. June 9, 2004 VANHA 13 The Customer Value Of Positive Experience A Memorable Feeling Created By You As A Result Of Us Relative Customer Value EXPERIENCE SERVICE GOOD RAW MATERIAL Source Of Customer Loyalty Created Within The Customer Created By A Provider

14. June 9, 2004 VANHA 14 Strategy Mapping As dining options and service evolution and enhancements are discussed, specific initiatives are defined and envisioned by community leadership, community constituencies, department management and staff. As these new “dining experiences" and expectations are defined, mapping aligns resources from vision to strategic objective to tactical implementation assuring effective implementation and benefits. Drs. R. Kaplan and D. Norton present this process in Strategy Maps. The mapping process allows communities to:  Clarify strategies and communicate them to all constituents  Identify key internal services that drive strategic success  Align resources to a common objective  Expose operational gaps and initiate appropriate corrective response

15. June 9, 2004 VANHA 15 Mapping Process Tasks  Identify Service Initiatives  Define Their Contribution to Strategic Objectives  Define Appropriate Measurements of Successful Experience Outcomes  Identification of Resource and Operational Intersects  Identification of Intersects and Roles of Collaborating Departments  Structure of the Process for Resource Allocation to Develop the Defined Initiative  Sequencing of The Tasks  Implementation of the Initiative.

16. June 9, 2004 VANHA 16 Program Intersects Grid

17. June 9, 2004 VANHA 17 PLAN & DEVELOP Organize Alter Codify Train Improve Choice Alignment Process Overview Plan Evaluate Define Assess Implement

18. June 9, 2004 VANHA 18 Continually Test For Outcome And Process Alignment Make Sure That Procedures Are Practiced, Understood and Working Procedures AssessTrainAssure Assess Current Practices Assure Expected Outcomes Train Improved Procedures (Test Understanding Of What and Why) Develop Improved Procedures, Revise Tools and Protocols