Nutrition services: feast or famine? As in so many areas, OBRA has changed the scenery in food service.

As in so many areas, OBRA has changed the scenery in food service

The nutrition community has often claimed to have the interests of the patient foremost. They want the patient to have the best test results, eat 100% of all RDA's, savor great meals (three a day), dine in gracious surroundings and accept all of our education as law. (This would be done, of course, in deference to our training and education, as well as our flawless presentation.) We have used our quest for quality care as a reason for higher budgets and more equipment - and we meant this with all of the best intentions.

There was only one problem: No one asked the residents what they wanted. Health care was delivered from the top down. The dietitian determined what was necessary for the patient's well-being and produced what the dietitian perceived as a service.

Enter the Omnibus Budget Reconciliation Act (OBRA). The emphasis was shifted to residents' rights, dignity and quality of care. We no longer had patients, we had residents. We were no longer in control. The nursing home facility was a resident's home, not just a medical facility. This required a significant change in the dietitian's philosophy.

One of the most obvious changes was the menu. Now we spend more time with the resident to determine food preferences and previous meal patterns. Families are consulted with to obtain previous food preferences if the resident is unable to communicate with us. We were required to have menu substitutions before OBRA, but now we tell the residents that they have a choice. We make certain that the staff is aware of options for each meal. Dietary managers do plate waste studies to gauge resident menu item acceptance. Menus are often selective with choices at one or all meals. More care is taken to adjust menus to facility populations, rather than blindly following corporate patterns. Facility food committees are recommended which meet monthly to voice opinions about meal service in all areas. In these committees a real dialogue is established between dietary and residents to provide the best selection of foods within the facility's ability to provide.

One word of caution, though: Federal and state requirements are very strict regarding nutritional content of menus. This is often difficult to explain to residents who don't understand why they have to have six ounces of protein and four to five services of fruit and vegetables per day. Many residents protest the amount of food that they must eat. They don't want to throw anything away. These concerns are real and must be dealt with on an individual basis.

The dining room has now become a focal point for resident rights and dignity concerns. OBRA mandates that facilities take the residents out of wheelchairs, if possible. Recently, though, I had a resident council stage a "sit in" on this subject. They claimed the right to sit in their wheelchairs. Stay tuned!

The dining room must reflect a home-like atmosphere. This does not require a dietitian to explain. I ask my facilities to use common sense. Would these residents play this music at home? What language would be spoken around the dinner table? Would they be ignored by their guests at home? Staff is required to speak English usually and talk with the residents, not just with each other. At home we don't eat from paper or plastic products, and we use glasses rather than packaged beverages with straws. We put food on the table, not on trays.

A key question: When I ask the staff if they would eat meals in the facility, almost all say no. Their reasons usually prompt a joint effort at solving what should have been obvious problems. It's worth remembering, though, that even though some residents will appreciate all of our work, there are always a few that will fight all attempts at change. We need to carefully work with these residents to determine ways to assist them.

Nutrition care, in general, has changed completely. Dietitians request more liberalized diets wherever possible. After all, is it logical to expect a lifelong pattern of diet noncompliance to change at 90 years? Also, when is overweight or underweight really an issue? And why would a lifelong diabetic suddenly comply with calorie control at 85? Is a cholesterol level of 230 in a 94-year-old man really life-threatening? As many of my residents say, "Hon, I've lived this long eating this way, so I must be doing something right."

That may not be necessarily true, but it does give me pause for thought. Still, an argument could be made that better nutrition might have prevented nursing home admittance in the first place.

What are logical parameters for nutrition care for the elderly? I would like to see more laboratories use geriatric adjusted values. That would free dietitians from addressing actual non-problems, given the age and diagnosis. Doctors need to liberalize their attitudes, too. Restrictive diets are appropriate for acute care, but this is residents' home, and should not appear institutional.

OBRA insists on quality of care measurements. This does not mean that we merely accept resident refusal to eat as the end of our attempts. The food service director and dietitian must continue to counsel with the resident. We try many creative ways to ensure compliance, such as diet desserts, eye-appealing purees, texture combinations, tasty snacks and beautiful presentation. Liberalization of diets continues to provide the most choices as well as selective menus for special diets. And detailed charting is essential for residents who are compliant with diet treatment.

One of the least understood areas of OBRA is the resident assessment instruments such as MDS, the Triggers, RAPS and Patient Care Plans. These instruments provide a road map for resident care. The nutrition section must show how and why we are proceeding with a specific resident's plan.

One thing I didn't expect from OBRA was the occasional necessity to recognize failure. When dealing with real people who can say no, failure is common. Failure to try is the only sin. Many times the patient care team develops a wonderful strategy for a resident, only to have him or her flatly refuse it. Then we commiserate with each other and talk about missing the "good old days." Sometimes, though, we see progress where we never expected it.

OBRA has its advantages and disadvantages. It has caused the dietitian to totally revise the delivery of nutrition care, but now we are accountable to our residents and they are responsible for their care. Ideally this will provide a partnership allowing individualized treatment to provide the highest quality care for each person. Often the results are gratifying. As one of my residents said, "Bet you never thought I'd eat broccoli. Don't tell my kids, they'd never believe it."

Dianne K. Ruppe, RD, LD, is a registered and licensed dietitian with Dietetic Associates of Boca Raton, FL.