1. Commissioning a Malnutrition Service in Greenwich Rachel Oostra Dietetic Advisor NHS Greenwich CCG 30.09.2015

3. Situation In 2013/2014 Greenwich CCG spent £700k on sip feeds in the community There was only a skeleton Community Dietetic Service to address malnutrition Greenwich did not have a Home Enteral Feeding Team which was identified as both a clinical and financial risk There was no training or support in primary care to address malnutrition for mobile patients

4. Task To develop a high quality,cost effective service to address malnutrition for the population of Greenwich To develop innovative ways of integrated working with the local authority to identify malnutrition early To gather data and evidence to demonstrate how this service could meet Greenwich CCG’s QIPP agenda To reduce the spend on sip feeds by addressing the variables in prescribing trends among general practices

5. Actions Meeting with stakeholders and identifying the gaps in nutritional services in Greenwich Through networking with dietetic colleagues and sharing models of good practice Collecting evidence from dietetic colleagues to calculate a projected saving that could be achieved by introducing a new service Successful QIPP proposal Developing funding streams through the Better Care Fund

6. Nutrition Support/ Food First Team Food first Project in nursing homes training all nursing home staff on MUST and Food First to address QIPP Providing nutrition support for housebound patients with a MUST score ≥2 LA and community based training for early identification to increase awareness and address malnutrition in the community Team consisting of 1.5 dietitians and 1 nutrition assistant. Deliver practice nurse / HCA training for care pathway referral. GP clinics to review :- Mobile malnourished patients on sip feed: stroke, dementia Gastroenterology patients – Coeliac, IBS plus others Weight management clinic for patients with a BMI ≥40 or ≥35 with a comorbidity Team comprising of 3.5 dietitians and a nutrition assistant Home Enteral Nutrition Team (HEN) Multidisciplinary service to review all adult patients receiving enteral nutrition via a tube. All HEN patients including housebound and nursing / care homes Team comprising of nutrition nurse. speech and language therapist, dietitian, admin Support of nasogastric fed patients in the community MMMM Malnutrition Service Primary Care Team

8. Results Costs The projected additional budget for the service was £417 000 with an estimated annual saving of £262 000 Benefit Realisation Plan 1.1 Key Outcome / Benefit 1 – Reduction in spend on HEN feed and equipment 1.2 Key Outcome / Benefit 2 – Reduction in spend on SIP Feeds 1.3 Key Outcome / Benefit 3 – Reduction in avoidable admissions 1.4 Key Outcome / Benefit 4 – Reduction in total unscheduled bed days 1.5 Key Outcome / Benefit 5 – Reduction in preventing non – red flag referrals

9. Outcomes Quality Develop an integrated Malnutrition Service Provide easy access to a dietitian Provide early intervention and treatment across all areas Increase awareness of malnutrition and dehydration in the community Innovation Involve professionals from health and social care Work with catering teams to introduce ‘Food First‘ in care homes Support domiciliary care workers to identify the early signs of malnutrition Deliver specialised dietetic service at local GP practices

10. Outcomes Productivity Equip staff to identify causes of malnutrition and dehydration early Deliver safe nutritional care across all areas Reduce hospital admission, length of stay and inappropriate investigations Avoid waste of nutritional products Prevention Reduce the risk of infection and complications Improve wound care in those patients with pressure sores Tackle malnutrition to improve nutritional status, clinical outcomes and reduce healthcare use