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Survival strategy a la home-delivered meals.

Here are the in's and out's of setting up a new service

There are many changes and trends afoot in health care that will have a significant impact on the future of long-term care providers. The Clinton Administration has tackled major health care reform, and there will be effects on long-term care. State legislative bodies have targeted nursing facilities for budget reductions this year. Current state regulatory efforts are geared toward decreased utilization of institutionally-based services. Nursing facility levels of care are being downgraded by state utilization review agencies to lesser levels, based on the need to save tax dollars and to provide care in the least costly environment. Concurrently, excess hospital capacity has prompted many acute care providers to establish rehabilitation and hospital-based skilled nursing units. These units have negatively impacted the census of numerous freestanding nursing facilities.

These trends and changes are prompting nursing facilities to take a more proactive approach toward managing the future. Community outreach is one very positive means of doing so. For institutional facilities, supporting programs that promote wellness and improve the quality of life for older adults in their homes is a key component of a successful marketing strategy. Although hospitals have traditionally been the driving force behind many of these community-based programs, nursing facilities can also play a role.

Affiliation with or operation of a home-delivered meals program may be one of the best means to address this task. That, certainly, has been our nursing home chain's experience.

The Background

In order to understand the need for such a service, it is necessary to recognize that the elderly are at serious risk of malnutrition. Support agencies and professionals alike have expressed concern that the elderly, especially those living alone, are susceptible to social isolation, loneliness, low-income and inadequate intake of energy and nutrients. Studies report that end-of-the-month food shortages may occur for many low-income elderly as they wait for the next month's Social Security check to arrive. Even in those programs where the elderly are receiving meals from a meal program, some clients do not eat for one or more days despite their participation. This is because most programs provide meals five days per week although clients at risk require meals on a seven day basis.

Mobile meal program history may date back as far as 1954. Initial ventures were strictly private and funded by non-profit organizations or county agencies. In 1972, the elderly nutrition program was funded by Congress to provide nutritionally sound meals for older Americans. Subsequently, amendments to the Older Americans Act in 1978 formally recognized the priority of serving frail homebound elders. In 1984, final regulations of the Administration on Aging strongly encouraged but did not require nutrition programs to offer home-delivered meals to clients in need seven days per week.

In view of this environment, it becomes readily apparent that nursing facilities have much to offer and even more to gain from affiliating with a home-delivered meals program. Indeed, as we have found, the potential synergy is extraordinary.

The Program

Relationship with home-delivered meal programs can take various forms. For example, a program may be operated directly by a facility using volunteers for food deliveries. Facilities can also become affiliated with freestanding programs by providing work space and meals. In some cases, a local area agency on aging may contract directly with a facility to provide meals for the agency and transport the meals for a fixed fee. Regardless of the form of the program, there are common concerns related to the cost and quality of the service provided.

Costs must be kept very low in order for the elderly to afford the service and for programs to help subsidize them. Also, the quality of the meal service must meet rigid standards for nutritional content as well as presentation.

Resources to achieve this already exist. Numerous nursing facilities have operated cost-effective, quality-run food service programs for their own residents for years. Beyond this, most facilities were constructed with the ability to accommodate future expansion and can therefore meet the space, storage and cooking needs of outside meal services. A nursing facility may use its existing menus as the basis for homebound client menus, since the menu is prepared and revised annually under the auspices of a registered dietitian. Noon meals may be identical for both programs; there are no separate or additional steps in the food preparation process.

Production efficiencies are realized by preparing larger quantities of weekend or dinner items and using them the following day as an appetizer or as part of a cold-bagged meal for clients. Salads, desserts and appetizers are readily adaptable for this. This is the approach used in our 7-day program; we also run three 5-day programs, and altogether produce 1,800 meals in our 9 kitchens. Obviously, purchasing food in larger quantities allows for volume discounts and enhances the ability to keep food costs down.

Food service equipment, which is usually oversized, can be adjusted closer to capacity. Tray lines staffed by dietary employees experienced in food service tray assembly can easily adjust to home-delivered meals with slight modifications in scheduling. Tray line operation times may be adjusted to begin earlier. There may be differences between the type of tray and dinnerware used, but employees themselves need make no work adjustments since the menu, serving sizes and assembly sequence are identical.

Another advantage in using the same menu is the additional experience and competence employees acquire. Due to the increased volume of meals, dietary staff complete the learning curve more quickly, resulting in a more efficient workforce.

Depending on the volume of meals prepared and the way in which a program is structured, some labor staff adjustments may be necessary. A coordinator for home-delivered meal service may be essential to prepare and assemble cold-bagged meals, oversee the assembly and return of trays and coordinate volunteer pickup. In our case, we promoted one of our dietary staffers as coordinator and added a replacement staffer.

In all cases, the additional labor can easily be justified based upon increased productivity and the reimbursement received from the meal service. Our income covers the direct costs and overhead (up to $9,000 a year), though we may have some added costs in added cooking, utilities, etc. This is more than compensated for by the marketing advantages of such a program for our facilities.

The Result

There are many external environmental aspects to consider when operating a home-delivered meal program. First and foremost is the relationship the facility develops with the volunteer base that assists with the delivery of meals. Volunteerism is crucial to an effective public relations program, since volunteers become facility representatives in the community.

Also, the identification of frail elderly at risk assists a facility with becoming a strong advocate for the elderly. Frail elderly being served by a program become natural referrals for the facility. Since the public becomes knowledgeable regarding the provider's food service capabilities and commitment to community health, they become more cognizant of the facility's ability to provide future services.

With the role of long-term care providers changing so rapidly, promotion of preventive care and wellness for the frail elderly should be a strategic goal. Concepts that promote independence and contribute to the ability of older adults to remain at home will enhance the prospect that the community will have a positive image of the long-term care facility and will help assure its survival in the changing health care arena.

Steven A. Gold, MS, CNHA, is President of Sentara Life Care Corporation, based in Norfolk, VA. Amy Williams, RD, MS, is that company's Director of Nutritional Services.
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Author:Williams, Amy
Publication:Nursing Homes
Date:Jul 1, 1993
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