What assisted living can learn from long-term care: nutrition management can become complicated, but not unduly so, for facilities housing residents aging in place.

There is no question that the emerging assisted living industry needs to respond to the desires of healthier and wealthier baby boomers, who are significantly more demanding than previous generations in many respects. This is particularly true when it comes to food. And assisted living companies are rightly responding to those desires by giving these residents the "sizzle" that they want--"club level" service inspired by high-end restaurants and hotels, prepared by classically trained executive chefs.

The experience also goes beyond what ends up on the plate. Assisted living communities are providing atmosphere and style, with beautiful dining room design and amenities such as Milwaukee's Jewish Home and Care Center's new dining room, which overlooks Lake Michigan. Some communities are designing more intimate dining spaces. Whatever the hook, today more delicious food served in a more luxurious setting is essential to attracting and retaining residents, and assisted living communities are making substantial investments to ensure that they have this competitive edge.

As residents continue to age, though, those same communities will have to find ways not only to satisfy their desires, but to meet their increasingly complex nutritional needs--needs largely dictated by the medical conditions that come with the normal aging process.

In traditional long-term care settings, registered dietitians (RDs) formulate and customize the dietary plans for each resident, but they are not present at the facility on a day-to-day basis (much less meal-to-meal). Assisted living facilities have even less frequent interaction with dietitians. They rely on Certified Dietary Managers (CDMs), who are trained in food safety and sanitation, nutrition, therapeutic diets, and foodservice management, to interpret, follow, and adjust individual resident dietary plans. It is their job to hit the "sweet spot" between providing appealing food and meeting the nutritional needs of residents who often have complex regimens springing from a wide variety of medical conditions.

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Common Medical Issues

When one considers that therapeutic modification of meals can take a great deal of time and expertise, and that some residents require meals at specific intervals that might differ from regular mealtimes, delivery of appropriate nutrition can become logistically complex. Even in assisted living settings, where residents are healthier than in traditional nursing homes, many will have or will develop conditions such as diabetes, respiratory problems, kidney or heart disease, or a myriad of other health challenges of varying severity that will change over time, requiring constant monitoring and dietary modification. Other more severe medical conditions will also occur among assisted living residents, affecting what, when, and how they eat. They include:

* cardiovascular disease 

* osteoporosis

* "the anorexia of aging"

* food/drug interactions that affect nutritional well-being

* stroke and consequent swallowing issues

* chronic obstructive pulmonary disease (COPD)

* cancer

* gastrointestinal illness

* malnutrition

It's imperative, therefore, that the food-service department be run by someone who has the nutrition knowledge required to modify menus based on the Department of Health and Human Services and United States Department of Agriculture's Dietary Guidelines for Americans 2005, which tackle cardiac wellness, hypertension, nutrient density, fiber intake, nutrient status of aging Americans, adequate calcium intake to help prevent bone fractures, etc. A CDM has such training. Other approaches include:

Alternative 1 Support the Chef by Broadening His/Her Skill Base

It is easy to imagine the typical assisted living executive chef becoming overwhelmed by these requirements. Such chefs are not specifically trained in the medical nutrition therapy that is often required for many medical conditions.

Assisted living communities are beginning to address this need. More menus carry standardized heart-healthy items. Others address such chronic health issues such as diabetes, but as the demands for even more customized diets increase, is it reasonable or advisable to saddle an executive chef with these responsibilities?

One solution is to provide executive chefs with the same training that CDMs receive, either at their culinary schools or afterward. This equips them with the knowledge and tools necessary to work effectively with consulting dietitians, who develop individual nutritional care plans. The training also prepares them to manage the foodservice operation on a turnkey basis, including being the point person on food safety and sanitation and adapting specialized diets to the needs and preferences of residents.

Alternative 2 Train Existing Staff

Some administrators worry that providing residents with a foodservice "amenity" requires an intensive search and expense to find an already trained and certified dietary manager. In fact, most traditional long-term care facilities develop dietary managers organically from within. They find that there is usually a "point person" leading the foodservice operation who is appropriate and open to professional advancement.

What sort of training is available for such a staff person? Many community colleges and universities across the country offer dietary manager training programs, and four universities offer the training program completely by correspondence. There are online programs, as well. Approved by Dietary Managers Association (DMA), the programs include 120 classroom hours plus a 150-hour field experience that can be completed in the facility in which they work. Once an individual has completed the training program, he or she is eligible to take the Dietary Manager Credentialing Exam, a national standardized exam that earns them the CDM credential. Many chefs who have completed a culinary arts program may need only to enhance their training with a nutrition therapy class to be eligible to take the exam.

The Certifying Board for Dietary Managers approves a list of tasks a CDM is qualified to perform based on education, training, and experience. This knowledge has been demonstrated by passing a nationally recognized credentialing exam and fulfilling the requirements needed to maintain certified status. CDMs perform the following managerial and nutritional services tasks:

* conduct routine patient/client nutritional screening, including food/fluid intake information

* calculate nutrient intake

* identify nutrition problems and needs

* implement diet plans and physicians' diet orders with appropriate modifications

* utilize standard nutrition care procedures

* document nutritional assessment data in the medical record

* review intake records, do visual meal rounds, and document appropriateness of food intake

* participate in patient/client care conferences

* counsel patients on basic diet restrictions

* specify standards and procedures for food preparation

* continuously improve care and service using quality management techniques

* supervise preparation and serving of therapeutic diets and supplemental feedings

* manage a sanitary foodservice environment

Conclusion

As assisted living continues to evolve and residents continue to age, having the capabilities to both serve attractive meals and meet clinical needs could be seen as the next step in the continuum of the high-level "concierge" service that this segment of the industry is already promoting. Certainly the two need not be mutually exclusive, and some forward-thinking companies like Claridge Court of Prairie Village, Kansas, have found in giving their chefs this training. And, unlike adding entire dining wings, sophisticated lighting, top-end finishes, and impressive menus, this does not need to be an expensive proposition. The training itself is approximately $885 including all material, with ongoing education either free or at a nominal cost. This investment gives the facility the potential to keep residents in assisted living longer. And that, as we know, is the overwhelming preference of residents themselves, as well as their families.

How and to what extent a company implements a program of special diets will depend on a number of factors including available resources (and resourcefulness!). One thing is certain: Without the knowledge that the training and credentialing bring, any program of this sort would not be feasible.

Katherine Church, RD, is Director of Credentialing, Dietary Managers Association. For further information, phone [phone]. For more information about the elderly and their nutrition requirements, visit www.eatright.org/cps/rde/xchg/ada/hs.xsl/advocacy_940_ENU_HTML.htm. To send your comments to the author and editors, e-mail [e-mail].

BY KATHERINE CHURCH, RD