Dining done right: keeping your facility full by revamping your dining service and menu.

It is not just a person's heart that can be captured through his stomach, but the love and loyalty of facility residents and their family's pocketbooks, according to a group of researchers who studied quality dining in nursing homes.

A good meal can be a major factor in determining a resident's quality of life and a feature a family looks for when choosing a home in which to place a loved one. So, fine-tuning your meal program can help keep your facility's enrollment numbers high and attract new residents, researchers Bronwynne C. Evans, Neva L. Cogan and Jill Armstrong Shultz noted in their report, Quality Dining in the Nursing Home: The Residents' Perspectives.

Evans is assistant professor at Washington State University's Intercollegiate College of Nursing in Spokane, Wash. Crogan is assistant professor at the University of Arizona's College of Nursing in Tucson, Ariz. Shultz is professor of food science and human nutrition at Washington State University in Pullman, Wash.

The trio's report, published in the Journal of Nutrition for the Elderly, identified the "perfect" meal, according to 20 residents at a 140-bed eastern Washington state nursing home. The residents, between the ages of 61 and 93, reported on the good and bad about eating institutional food and what they thought their mealtimes should be like.

Little is really known about residents' perspectives on this issue, according to the report. Much of what researchers and nursing home operators do know is negative. Residents often dislike their food because it looks bad, tastes terrible, lacks variety or simply isn't what they want.

To keep residents asking for a second helping, your facility's meals need to look, smell and taste as good or better than anything your residents used to eat at home.

Give us choices

A major problem cited by the study's participants was lack of variety on a typical nursing home's menu. Most residents wanted the ability to choose alternatives to the meal's pre-selected entree, according to the report. Rotating menus was another popular option. Seniors also said being asked to help select new items to change the menu periodically would be a great idea. "We were invited to ... a food fair so that they could improve on what they were feeding the patients here," one resident remarked in the study. "It was delightful how you could go over to that fair and find three new salads and four new soups!"

It is also important that residents be allowed to enjoy traditional foods. The report called this "a key to remembering happier times." Family members can help fill this void by regularly bringing foods from home such as bread, homemade jam, custard or special salads to "satisfy residents' appetites and emotional needs."

Hallmark House Nursing Center, a long term care facility in Pekin, Ill., revamped its menus to give its residents ample choice in meals and extended eating hours.

Implementing the menu change took planning and an investment. The facility's kitchen was remodeled--at the cost of $500,000--with Hallmark adding non-traditional long term care kitchen items such as a char-broiler, deep fryer and cold station for making sandwiches and salads, as well as a cappuccino/hot chocolate machine and juice bar. The entire project took about six months, according to Hallmark House Administrator Lynn Brady.

"We had to totally rearrange [the kitchen], add equipment and update the plumbing, electrical and the fire suppression system," she said. "We could have done less but our theory was to do it right the first time."

Meal times at Hallmark now feature a restaurant-style menu that includes a daily special instead of a tray line where residents generally received the same thing.

The menu also changes from meal to meal, further enhancing a restaurant-like experience for the residents. "Our menu includes anything from an omelet to surf and turf [shrimp and steak]," Brady said. In addition, the Hallmark facility's "restaurant" has extended hours: The kitchen is open from 5 a.m. to 8 p.m., and residents may eat at any time during the day.

Looking for a few good ... people

Facilities with a top-notch dining room staff earned high praise from the study's participants. Such a staff must be led by experienced cooks. As one resident matter-of-factly stated in the report, "If they hire a cook, they should be able to cook, don't you think?"

Residents also said in the report that an ideal staff would be courteous, caring and have a good work attitude. Such traits can be evident in simple things such as helping a resident open a yogurt container or furnishing diet soda and cookies upon request, according to the study.

At Hallmark House, the facility's cooks went from preparing large-batch meals to individual-order cooking. The idea was a hit, according to Brady. "The residents love the food and we have had no weight losses in the last two months," she said. "We have residents come here just because of the dining program." The switch to individual-order cooking simply required a few instructions from Brady and about two weeks to adjust, she said.

Make honesty a policy

Study participants also pointed out the less-pleasant reality of dishonest staff. One resident reported in the study that the facility lied about the availability of cinnamon rolls. The resident was told there was none left but later witnessed staff giving rolls to other residents. "I think if they give cinnamon rolls to one person, they should give them to everybody who can eat them!" the resident said in the study.

While this may seem trivial, such an action gives residents a bad feeling about their nursing home, according to Erik Gandes, author of Ask What You Want to Know at Nursing Homes (But Remember to Ask). That feeling gets passed on to the residents' families, who may transfer them to other facilities, or worse--decide to keep them out of long term care altogether, he said.

(Good) service, please

Like anyone eating away from home, study participants expected food to be served "on time." Adequate staffing goes hand-in-hand with that concern. Cold food becomes an unhappy but somewhat accepted occurrence. "If they don't have enough people, that is bad, because one person can't carry out 10 trays in just a short amount of time," one resident remarked in the report.

The report noted that one 120-bed long term care facility in Kansas coped with its food service problem by simply placing small food items on tables before the meals were served making the wait more bearable. The facility also encouraged family members to eat with the residents, increasing feelings of companionship. "Costs for the Kansas program were judged insignificant," the report stated, and "within one year, [resident] weight loss decreased 75 percent, fluid consumption in the dining room doubled and residents' complaints ,were halved."

Hallmark House's new service-oriented approach consisted of training all of the center's staff members to take orders and serve residents in the dining room. "The hardest part was getting the system organized," Brady said. "[Every day] they were changing the way they did things. I got involved at that point and said, 'This is the way we are going to do it.' I told them they must give it a full two weeks in order to see if [the new system] would work, and it did."

Not everyone loved the changes, according to Brady. The facility lost two cooks, a nurse and one laundry person who refused to adjust to the new procedures. But the rest of the staff were happy to roll up their sleeves. "We asked the staff to put themselves in the residents' shoes," Brady said. "They've been wonderful. They have accepted the change and wouldn't have it any other way."

We eat where we want

Choosing where to eat and with whom was important to study participants because it represented a real area of decision-making available to residents, according to the report. For example, some residents preferred eating in their rooms because of medical problems that might disturb others, or due to a desire for happier times. "That's the only time when you can get privacy," one resident stated in the report. "I just pretend I'm home, cooking for myself [again]."

Other residents enjoy the social element of eating together because it reminded them of family dinners at home. These residents also wanted a pleasant atmosphere in which to eat, full of laughter, good smells and especially music--something "which [nursing homes] do, but not often enough."

Robert Goldstick agrees with the concept. The Ferndale, Wash. musician and co owner of Heart and Soul Music has performed in nursing homes since 1993 and believes music is a key to making the dining experience perfect for everyone.

"Imagine that you are tied to a wheelchair and have lost all control over your life," Goldstick said. "You live in the [seemingly unending] cacophony that goes on in any institutionalized care giving facility. Then you realize that you are listening to the song that you fell in love to. Suddenly, you are transformed to a happier place and time. This is what happens to many people when they are exposed to music they love. If they loved it when they were younger, they will love it many times more now."

Please sir, I want more

Residents also love it when they have enough to eat. In the survey, the participants "needed to feel that they could ask for and receive appropriate amounts and types of food. Not too little that they go away hungry and not too much so that they are overwhelmed by the amount of food on their plates."

The report's participants also wanted to know that they were being served appropriate foods for their individual nutritional needs and that facility staff understood those needs. One resident expressed frustration in the report over the facility's misplacement of her dietary records: "Everyone thinks I'm diabetic ... and I'm not!"

Again, a seemingly trivial point--but not so trivial if you're the one waiting to be fed a diet that won't make you ill, author Gandes noted. "Food is truly one of the only joys left for some nursing home residents," he wrote. "To deprive them of this relatively simple pleasure borders on being cruel and heartless."

Family members can again augment care by supplying "goodies" for residents to keep in their rooms, the Journal of Nutrition report said. For example, one family supplied a small refrigerator for their mother's room--supplied with milk and bread--after understanding the loss of control she felt at no longer being able to snack any time she wanted.

While it's impossible to please everyone, long term care facilities must still perform as if they can please all their residents, according to the report: "It is imperative that resident likes and dislikes be elicited, prominently displayed for staff and honored, meal after meal.... [Such an effort will] result in more contented, well-fed nursing home residents and happier families."

To Learn More

* Fundamentals of Menu Planning by Paul J. McVety, Bradley J. Ware and Claudette Levesque reviews the principles of planning an institutional menu. John Wiley & Sons, $60, 877-762-2974, www.wiley.com.

* Quality Dining in the Nursing Home: The Residents' Perspectives by Bronwynne C. Evans, Neva L. Crogan and Jill Armstrong from the Journal of Nutrition for the Elderly (Vol. 22, No. 3) discusses interviews with 20 nursing home residents who described the "perfect" meal. Haworth Press Inc., $18, 800-429-6784, www.haworthpress.com

* Nursing Home Menu Planning: Food Purchasing, Management by Herman E. Zaccarelli is the classic reference for how to create a proper menu Van Nostrand Reinhold [a division of John Wiley & Sons], $14.95, 877-762-2974, www.wiley.com

* Adding Value to Long Term Care by Dianne Lazer and Tobi Schwartz-Cassell shows how to improve the clinical environment for residents, staff and families. Includes examples of facilities that revamped their food service programs, and a facility assessment questionnaire on CD-ROM. Jossey-Bass [a division of John Wiley & Sons], $80, 877-762-2974, www.josseybass.com.