1. Rhythms of Daily Living Dining & Choice Rhythms of Daily Living © Dining & Choice Aligning Expectations – Resources – Outcomes

2. April 28, 2004 IAHSA - a celebration of age 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. April 28, 2004 IAHSA - a celebration of age 3 Must Rising Acuity Levels Mean Lower Dining Quality ? ©

4. April 28, 2004 IAHSA - a celebration of age 4 What Are Factors of a Quality Dining Experience?  Relaxed service  Choice of what, where and when you eat  Participation in the definition of generational experience expectations  Reputation – consistency of service  Timeliness  Presentation & Taste of meal  Do not rush me  Neighbors, Atmosphere, aroma, friendliness cleanliness  Residents eat when hungry & personal eating habits are accommodated No The Simple Answer Is No!

5. April 28, 2004 IAHSA - a celebration of age 5 Skilled Care Dining Today Restricted Service Times, Too Short For Quality & Assistance < 20 Minutes For Dining The Quality Gap

6. April 28, 2004 IAHSA - a celebration of age 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. April 28, 2004 IAHSA - a celebration of age 7 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.

8. April 28, 2004 IAHSA - a celebration of age 8 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. April 28, 2004 IAHSA - a celebration of age 9 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

10. April 28, 2004 IAHSA - a celebration of age 10 What are the Attributes of a Quality Dining Experience? Quality of menu item presentation Appetizing Taste Variety Atmosphere, environment Pleasant service Choice Consistency China/glassware Timely Appropriate temperature & consistency

11. April 28, 2004 IAHSA - a celebration of age 11 The Main Thing For Senior Care Choice

12. April 28, 2004 IAHSA - a celebration of age 12 “Some facilities studied, usually the lower turn-over ones, were in the process of thinking about how to increase individualized care. For example, the researcher asked, what are you doing if anything about resident choice. ‘We are looking at it. Ideally, we want them to eat when they want. We encourage them to tell us what care they want, a shower or bath, or to get up when they want.” Page 5-49 Appropriate of Minimum Nurse Staffing Ratios in Nursing Homes, Phase II Final Report prepared by Abt Associates for the Centers for Medicare and Medicaid Services, December 2001.

13. April 28, 2004 IAHSA - a celebration of age 13 Outcomes No complaints Socialization Weight stabilization Improved I/O’s Less plate waste Smiles Reduced staff turnover Improved skin integrity Reduced use of supplements Congenial and pleasant environment – warm & inviting

14. April 28, 2004 IAHSA - a celebration of age 14 Benefits  better interaction with staff & residents  freedom of choice  residents more social amongst themselves  better presentation  Food is hot/cold  Better texture  POS selection for menu items  Better I/O’s  Resident choice of time to eat/when hungry What Are Your Experiences?

15. April 28, 2004 IAHSA - a celebration of age 15 What Are Your Experiences? Obstacles  structure of ordering  staff resistance to change  inadequate staffing  training of staff to new tasks  Management of change (Fair Process)  Need to educate the staff in the process of change  Clear explanations of the reasons/outcomes of changes  How changes will impact staff security and knowledge of job tasks and resident served

16. April 28, 2004 IAHSA - a celebration of age 16 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

17. April 28, 2004 IAHSA - a celebration of age 17 PLAN & DEVELOP Organize Alter Codify Train Improve Choice Dining Alignment Process Overview Plan Evaluate Define Assess Implement

18. April 28, 2004 IAHSA - a celebration of age 18 Plan Transition Process and Commit Resources Write Program Transition Budget and Operating Narrative Organize Codify Organize For Culture Change Establish “Experience” Alignment Teams To Define/Implement Transition Codify Policies/Procedures and Training By Function Write & Task Procedures/Training Using RDL© Base Choice Dining Alignment Plan and Develop Plan Evaluate “Readiness” With Leadership, Managers & Residents/Families Define Outcomes Baseline and Expectations Evaluate Define Define Service Functions and Outcomes For Each Experience Identify Beneficiaries/Benefits and Diagram Service Functions

19. April 28, 2004 IAHSA - a celebration of age 19 Program Intersects Grid

20. April 28, 2004 IAHSA - a celebration of age 20 Program Intersects Grid

21. April 28, 2004 IAHSA - a celebration of age 21 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

22. April 28, 2004 IAHSA - a celebration of age 22 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]

23. April 28, 2004 IAHSA - a celebration of age 23 Choice Dining Alignment Continuous QualATI sm Alignment