NY Nurses conf Schoeneman dining.pptx

Transcription

3/23/14 +
New Dining Standards of Practice – How Do We
Get There?
Karen Schoeneman
+
2
How Did They Happen?
n CMS
and Pioneer Network co-sponsored a
symposium on the food and dining
requirements, and culture change
innovations, scheduled for 2010
n Goal
was to bring clinical experts and
dining innovators to do presentations in a
town hall style meeting in which audience
could put their thoughts into the record.
© Karen Schoeneman Consulting
+
3
Pioneer Network gathered the
national clinical groups
n All
the groups that set standards of practice
for food and dining, and therapeutic diets,
and tube feeding, etc. worked together for
several months
n Group
reviewed research that showed very
little benefit for older adults of restrictive
diets.
n Much
worse problem for them – when they
don’t like their food, they lose weight
© Karen Schoeneman Consul6ng 1 3/23/14 +
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Groups reviewed CMS guidance
n CMS
Nutrition Tag 325 had been revised a
few years ago using national experts
n The
standards group agreed with CMS
verbiage to individualize, and to attempt
regular diet as much as possible.
n The
group wrote a report, which was signed
off by the combined national groups – to
greatly liberalize diets
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5
These groups signed the new
standards
n American
Association for Long Term Care
Nursing
n American
Association of Nurse Assessment
Coordination
n American
Dietetic Association (they
already had issued new liberalizing
standards of their own)
n American
Medical Directors Association
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6
More groups
n American
Occupational Therapy
Association
n American
Society of Consultant
Pharmacists
n American
Speech-Language-Hearing
Association
n Dietary
Managers Association
7
More groups
n Gerontological
Advanced Practice Nurses
Association
n Hartford
Institute for Geriatric Nursing
n National
Association of Directors of Nursing
Administration in Long Term Care
n National
Gerontological Nursing
Association
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8
Why are there no government
agencies in the list?
n Government
does not set standards of
practice
n CMS
in its regulations advises providers to
use good standards of practice
n Standards
come from clinical standard
setting bodies, based on research
n There
are no disagreements between CMS
guidance and the new standards
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Introduction Section of the New
Standards
n 50%
to 70% of residents leave at least 25%
of their food uneaten at most meals
n 60%
to 80% of residents have an order for
supplements
n 25%
of residents experience weight loss
n ADA
reports that under-nutrition negatively
affects length of life as well as quality of life
10
New Standards Reflect:
n Evidence-based
n Current
research
clinical thinking and
n Consensus
among national clinical groups
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11
Definition of “regular diet”
n A
regular diet is what should be prepared
and offered to meet nutritional needs in
accordance with the current recommended
dietary allowances of the National Academy
of Sciences
n Regular
diet is used as a standard menu
planning guide, while residents have the
right to make choices
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1. Individualized Nutrition
Approaches/Diet Liberalization
n AMDA
- A frequent cause of weight loss is
the therapeutic diet, and the use of low-salt,
low-fat, and sugar-restricted diets should
be minimized in LTC
n ADA
– Quality of life and nutritional status
of older residents of LTC may be enhanced
by liberalization of diet. Unpalatable diet
can lead to poor food and fluid intake.
Weight loss is far greater concern than
minimal benefits of medicalized diet
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Diet Liberalization - Continued
n All
persons moving into LTC should receive
a regular diet unless there is a STRONG
medical historical reason for a restricted
diet.
n Some
homes have made the regular diet
with ranges of consistency their ONLY
AVAILABLE DIET; they monitor clinical
outcomes
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Regular diet = Choice
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15
2. Individualized Diabetic/Calorie
Controlled Diet
n  ADA
– There is no evidence to support “no
concentrated sweets” or “no sugar added” diets
for older adults in LTC
n  “These restrictive diets are no longer considered
appropriate”
n  Only
benefit to sliding scale insulin is with new
diagnosis when clinician is attempting to estimate
insulin dosage
n  Glucose
monitoring best only once a day if person
is stable/chronic
n  A1C
between 7 and 8 is reasonable accd. to AMDA
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3. Individualized Low Sodium Diet
n  ADA
– “randomized trial of adults 55 to 83 yrs
old showed that normal-sodium diet improved
congestive heart failure outcomes
n  Typical
2gm sodium diet only decreases
systolic BP by 5mmHg and diastolic BP by
2.5mmHg and HAS NOT BEEN SHOWN TO
IMPROVE CARDIOVASCULAR OUTCOMES
FOR RESIDENTS OF LTC
n  Use
low sodium diet only “when benefit to the
individual has been documented.”
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4. Individualized Cardiac Diet
n Low
saturated fat (low cholesterol) diets
have only modest effect on reducing blood
cholesterol in LTC population – and should
be used only when benefit has been
documented.
n Cardiac
diet usually only decreases lipids
10-15%, but medication decreases it
30-40% while still allowing individual food
choices
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18
5. Individualized Altered
Consistency Diet
n  AMDA
– swallowing abnormalities are common
but do not necessarily required modified diet
and fluid texture. Provide foods of consistency
and texture that allow comfortable chewing
and swallowing
n  ADA
– dietitian and speech pathologist should
consult to individualize
n  CMS
– excessive modification may decrease
quality of life and nutritional status. No
interventions consistently prevent aspiration
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Altered Consistency - Continued
n There
is little to no long term evidence that
use of thickened liquids prevents aspiration
pneumonia, and there IS evidence that this
can cause dehydration.
n But
there IS evidence that improved oral
care reduces risk of aspiration
n Many
residents with swallowing difficulties
can have water if good oral care is used
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20
6. Individualized Tube Feeding
n Before
instituting tube feedings, consult
with team and resident/family about cost/
benefits
n Tube
feeding does not ensure comfort or
reduce suffering, it may cause diarrhea,
abdominal pain, and it can increase risk of
aspiration
n Feeding
tubes have not been shown to
reduce aspiration or prolong survival in
residents with end stage dementia
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Tube Feeding - Continued
n PEG
tubes do not improve quality of life.
There are associated discomforts such as
abdominal distension, diarrhea, restriction
of free movement when attached to the
device
n Team
should confer with resident and
family about their goals if at end of life
n Research
shows using assisted oral eating
can cause weight gain, as alternative to
tube feeding
22
7. Individualized Real Food First
n Wholesome
food is preferable to
supplements
n If
a resident needs soft consistency, foods
that are naturally soft are preferred such as
yogurt, mashed potatoes, pudding, and
finely chopped foods that retain their flavor
n Homes
eliminating supplements “have
found significant increase in food
consumption and reduced incidence of
weight loss”
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Real Food – Continued
n Oral
supplements often are wasted;
n Offering
variety of foods and fluids is more
effective for nutrition than supplements;
n Snacks
are more accepted than
supplements, and this also reduces costs
n Offer “real
food” before offering
supplements, fresh garden food, real milk
shakes, etc.
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8.Individualized Honoring Choices
n Recommended
are open dining times,
choices from menus, buffets, family style
dining, snack bars.
n Key
is to individualize and consider
medical needs in context of offering
choices
n Buffets
and snacks optimize intake, making
food available 24 hours a day is
recommended
25
Choices - Continued
n Offer
choices in accordance with individual
preferences numerous times a day
n New
red flag – a tray line with trays prefilled according to a diet card, and limited
meal hours are seen as contrary to concept
of choice and individualization
n Residents
have the right to refuse diet
considered “best” by the team or doctor
+ 9.
26
Shifting Traditional Professional Control to
Individualized Support of Self Directed
Living
n  ADA
– despite growing body of evidence
discouraging therapeutic diets in older adults,
these diets are still regularly prescribed.
Research has not demonstrated benefits of
restricting sodium, cholesterol, fat, or
carbohydrates in older adults
n  Self-directed
living includes honoring resident
choices, even in the face of family
disagreement
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Self Directed Living – Continued
n “If
the patient is sufficiently informed about
the risks and benefits of acceptance or
refusal of a proposed intervention and
refuses, the clinician should respect the
patient’s decision (Mayo Clinic
Proceedings, 2005)”
n Recommendation
– All decisions default to
the person.
28
10. New Negative Outcome
n  Mealtime
dining studies show that enabling
residents to choose what they want to eat DOES
NOT RESULT IN NEGATIVE NUTRITIONAL
OUTCOMES
n  When
a person does not want to follow diet
orders (or any orders) we worry about
potential harm. But we haven’t contemplated
the harm to the person from denying choices.
No one should be told “you can’t have this
because it isn’t on your diet.”
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New Negative Outcome Continued
n  Denying
foods of choice and sneaking in decaf
instead of real coffee, is an assault to quality of
life
n  Making
choices should not be called “noncompliant” or going “against doctor’s orders”
as if the practitioner is right and the resident is
wrong.
n  Taking
away choice has been shown to hasten
death, and also to deprive people of good
quality of life, practitioners should adept to
residents, not the other way around
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30
Key is “Individualized”
n Standards
do not mandate these
liberalizing changes for all persons.
n Person’s
condition, history, preferences all
need to be looked at
n These
changes are dramatic and break the
old rules of restriction “for their own good.”
n Not
only the clinicians but the individuals
and their families know the old rules
31
What Does CMS Think of All This?
n CMS
participated in the Dining Task Force
n CMS
provided a video training for
surveyors introducing the new Standards
surveyortraining.cms.hhs.gov
n Click “I am a Provider”
n Click “Webcasts”
n Search “dining” and select its title, “New
Dining Practice Standards for Nursing
Home Residents”
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How About CMS Guidance?
n Tag
325 Nutrition – the Dining Standards
often refer to text at this tag about
liberalization, for example:
n “The facility’s care reflects a resident’s
choices….”
n “Research suggests that a liberalized diet
can enhance the quality of life and
nutritional status of older adults in LTC
facilities. Thus it is often beneficial to
minimize restrictions.. . .”
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33
More CMS Guidance from F325
n [Dietary
restrictions] “may impair adequate
nutrition and lead to further decline in
nutritional status. . . .”
n “Excessive
modification of food and fluid
consistency may unnecessarily decrease
quality of life and impair nutritional status
by affecting appetite and reducing intake.”
n “Identification
of a swallowing abnormality
alone does not necessarily warrant dietary
restrictions or food texture modifications.”
34
Feeding Tubes
n At
325 CMS makes these comments about
use of a tube at the end of life:
n  “For residents with dementia, studies
have shown that tube feeding does not
extend life, prevent aspiration pneumonia,
improve function or limit suffering.”
n “Decreased appetite and altered
hydration are common at the end of life,
and do not require interventions other
than for comfort.
+
35
The Garden Letter
n CMS
released a memorandum in favor of
homes growing their own produce and
serving it on the menu
n CMS
Survey and Certification
memorandum 11-38 is in your handouts
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36
Education is Necessary
n  Global
education for the whole home, its staff,
its residents, its families – on the value of these
new standards
n  Individual
education for a resident to help
them determine if they want a change for
themselves
n  They
need to know staff will monitor to
mitigate negative effects of the change
n  There
can be a testing out period, how did it
go, what did you think? Do you want to
continue?
37
Good News from Pioneer Network
n They
have realized that a home can’t just
make these changes instantly, the home
needs to evaluate policies and procedures,
educate care planning staff, explain to
residents and families.
n PN
has gathered a task force which has
completed development of a dining toolkit.
n Contains
sample policies, sample forms.
Will be available for sale soon.
© Karen Schoeneman Consul6ng 13

NY Nurses conf Schoeneman dining.pptx

Transcription

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