A nutrition intervention program for high-risk residents.

The author's Diet Plus approach to maintaining residents' weight and saving costs

According to the Nutrition Screening Initiative Survey, half of hospitalized elderly and 40% of long term care residents may be malnourished and therefore at risk for nutrition-related problems. Malnutrition increases hospital length of stay, and is a primary risk factor for the development of infection, poor wound healing, pressure sores, weakness, and impaired cognitive ability. Studies estimate that it costs 2-5 times more to care for malnourished patients. All of this has a tremendous effect on quality of life and quality and cost of care.

The first step in good nutritional care is to identify residents at risk for nutritional problems.

Those residents include, but are not limited to, the following:

* Residents who have had a significant weight loss or who are below Ideal Body Weight

* Residents with low Albumin and/or Hemoglobin/Hematocrit levels

* Residents with pressure ulcers, severe infection or fever

* Residents with consistently poor food/fluid intakes

* Residents who have dysphagia, chronic diarrhea, or persistent nausea and vomiting

This requires teamwork. There must be a good referral program in place for adequate communication between Nursing and Dietary. A thorough nutritional assessment must be completed on each high-risk resident in order to proceed with a nutrition plan.

A note about today's nutrition planning: In recent years, there has been a growing dependency on the use of commercial supplement products as a "knee jerk" reaction to nutritional problems. Although commercial products have their place and can benefit some residents, they tend to be very costly and at times not as pleasant as other alternatives. There are many cost-effective ways to add calories to current menu items, without greatly increasing the volume of food which a resident must consume.

Over the years many institutional cooks have been trained to cook for restrictive diets. Sometimes this is warranted, but when individuals are weak and depleted, are difficult to feed, or just unable to consume a given quantity of food, every bite counts. If the food is not palatable, residents won't eat. In response to this, many long-term care facilities are liberalizing diets and offering only a few plans -- for example, Regular/No Added Salt, Mechanical Soft, Puree, No Concentration Sweets, No Concentrated Sweets Puree. Within these criteria, creative food preparation and service are imperative.

However, the majority of residents do not need overly restrictive diets. Getting residents to eat is the key, and palatable food will be much more appealing to residents with depressed appetites. Many facilities can benefit from a "blanket approach" to nutrition intervention with the ultimate goal of packing each bite with as many calories as possible.

The Diet Plus Nutrition Intervention Program (NIP) we developed focuses on enhancing the diet by adding approximately 1500 calories and 20 grams of protein to the diet. Residents classified as high-risk by the nursing staff and dietitian, are placed on the NIP. Tray cards identify these high-risk residents using a large red dot at the corner. This red dot alerts the dietary staff to place a red napkin on the tray, and add the high-calorie foods, as outlined in Table 1. Nursing staff can identify residents who need extra attention by the red napkin on the tray.

All disciplines should be involved in developing the actual food program and recipes in your facility. It is wise to inservice your dietary and nursing staffs on the reasons for the program and on the importance of their role in the program's success.

It is important to follow residents on the NIP closely to determine the effectiveness of the program. Tracking weights, food intake and skin condition is particularly important. Findings are documented monthly and individual adjustments are made as needed.

Benefits

Our studies have indicated that, despite poor prognosis and no change in actual food intake, 75% of residents on NIP maintained or gained weight. Normal albumin levels were achieved and skin condition was maintained or improved. The total number of decubiti in the facility decreased by 40%. The cost savings of this are obvious, with research estimating the cost of the average pressure sore at approximately $15,000, with costs ranging from $5,000-$40,000 for one ulcer (including staff time, prescriptions, medications, supplies and, at the higher end of the scale, debridement and surgery).

Another measurable cost savings is in reduced commercial supplement expense. We estimate a minimum 25% cost savings with the NIP approach versus the use of commercial supplements. For examples of cost savings, see Tables 2 and 3.

Recognized Quality Improvement

Sharing results with physicians, staff and families lets them know about your quality improvement efforts. In return, you will probably hear some of the same things we did:

* Families observed improved appearance, more willingness to eat, improvement in comfort and improvement in general well-being.

* Residents reported feeling "better all over," no longer feeling tired or weak, improvement in skin condition, improved weight status, increased appetite.

Malnutrition is not a normal response to the aging process, but many residents come to us in this state. There are many causes, and there are many possible interventions. The Nutrition Intervention Program is one strategy that has proven successful in the long-term care setting. With a team approach, early identification of high-risk residents is achievable. A calorie-dense diet, along with pleasant meal presentation and adequate assistance with feeding, are key factors in improving the health and well-being of high-risk residents.

TABLE 1

NUTRITION INTERVENTION PROGRAM

* Residents identified as High Risk will be placed on the Nutrition Intervention Program.

* High Risk Residents may include residents who are below IBW, have experienced weight loss, have a stage II, III, or IV decubitus, have low albumin levels, have poor food intake, etc.

* A red napkin will be placed on the resident's tray, to alert nursing staff to pay close attention to the resident's food/fluid intake.

The Dietary Department will add the following items to the Resident's Diet:

Breakfast

Half and Half 8 ounces (in place of milk) 1 Tablespoon Margarine High Vitamin C Juice with 1 Tablespoon Corn Syrup

Lunch

8 ounces Whole Milk 1 Tablespoon Margarine High Vitamin C Juice with 1 Tablespoon Corn Syrup

2:00 P.M.

*1/2 cup Pudding

Dinner

8 ounces Whole Milk 1 Tablespoon Margarine High Vitamin C juice with 1 Tablespoon Corn Syrup *1/2 cup Ice Cream

HS

*8 ounces Milk Shake

* Flavor fatigue is avoided by providing a variety of pudding, ice cream and milk shakes including such favorites as Key Lime Shake, Peach Cooler, Chocolate Dream, Cherry Vanilla Drink, Strawberry Frost, and Strawberry Banana Delight.

The above foods add approximately 1,500 calories and 20 grams protein.

Note: Diabetics on Restricted Diets will have individual interventions.

TABLE 2

FORTIFIED BITE

Examples of available calorie sources right in the kitchen:

Food                                 Calories        Cost

1 Tablespoon:

Corn Oil Margarine                     102           $.02
Oil                                    120           $.016
Mayonnaise                             101           $.03
Half & Half                            101           $.013
Honey                                   64           $.036
Brown Sugar                             51           $.011
Jelly                                   54           $.04
Supplement - 1 calorie/cc               22           $.063

1/2 Cup:

Half & Half                            160           $.104
Supplement - 1 calorie/cc            124.8           $.432
Supplement - 1.5 calorie/cc            176           $.50

Source: Puree Pizzazz. |C~ Nutrition Consulting Company, 1990,
Akron, OH 44333.

Prices for all products were obtained from a major food vendor
in Northeast Ohio and may not represent your current prices.
TABLE 3

SAMPLE CASE STUDY

The facility was spending nearly $23,000 per year on
supplements prior to implementing the Nutrition Intervention
Program June 1, 1993.

30 Residents had orders for daily commercial supplements:

                           Approx. Cost
                           Per Resident        Facility Daily
Product                    (30 Residents)      Supplement Cost

Supplement
 (1 calorie/cc)                                     $13.76
Supplement
 (1.5 calorie/cc)                                     5.50
High Protein
 (1.5 calorie/cc)                                    19.60
High Protein
 (2 calorie/cc)                                       7.74
Pulmonary Product                                     5.60
Commercial Milk
 Shake                                               10.14
                              $2.078(*)             $62.34
TOTALS                      $758.47/yr          $22,754/yr

* Approximate daily cost per resident determined by total daily
cost divided by number of residents.
Using NIP for 30 Residents:

                           Approx. Cost
                           Per Resident        Facility Daily
Product                    (30 Residents)      Supplement Cost

3 Tbs. Margarine
 per day                       .06                     1.80
1-1/2 cup Half & Half
 (1 cup at Breakfast,
  1/2 cup in Pudding)          .405                   12.15
2 cups Whole Milk              .03                      .99
  (cost difference over
  2% Milk)
1 cup Juice                    .296                    8.88
3 Tbs. Corn Syrup              .09                     2.70
1/2 cup Ice Cream              .13                     3.90
1/2 cup Pudding                .08                     2.40
1 cup Milkshake                .354                   10.62
  (approximate average)      $1.445                  $43.35
    TOTALS                 $527.43/yr            $15,822/yr

30% SAVINGS! $6,932 Saved Per Year!

Becky Dorner, RD, LD, is President of Nutrition Consulting Services of Bath, OH. During a 10-year career, she has been a staff dietitian, food service director, regional dietitian and university instructor, and was recently named Young Dietitian of the Year by the American Dietetic Association.