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Dining Practice Standards 101: Part 2 Contributed by Rose Hoenig, RD, CSG. LD, and Carol S. Casey, RD, CDN, LDN, SFPM, FSM Review Date 12/11 G-1753.

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Presentation on theme: "Dining Practice Standards 101: Part 2 Contributed by Rose Hoenig, RD, CSG. LD, and Carol S. Casey, RD, CDN, LDN, SFPM, FSM Review Date 12/11 G-1753."— Presentation transcript:

1 Dining Practice Standards 101: Part 2 Contributed by Rose Hoenig, RD, CSG. LD, and Carol S. Casey, RD, CDN, LDN, SFPM, FSM Review Date 12/11 G-1753

2 New Standards of Practice These nationally agreed upon new food and dining standards of practice support individualized care and self-directed living vs traditional diagnosis-focused treatment for people living in nursing homes. The document includes the new Standards of Practice.

3 Standards of Practice Individualized Nutrition Approaches/Diet Liberalization Individualized Diabetic/Calorie-Controlled Diet Individualized Low-Sodium Diet Individualized Cardiac Diet Individualized Altered Consistency Diet Individualized Tube Feeding Individualized Real Food First Individualized Honoring Choices Shifting Traditional Professional Control to Individualized Support of Self-Directed Living New Negative Outcome

4 10 Dining Practice Standards Reflects current thinking and consensus, which are in advance of research Reflects evidence-based research available to date The current thinking portions of each of the new Dining Practice Standards represent a list of recommended future research rs/DiningPracticeStandards/

5 It Is All About F-Tag 281 F281 §483.20(k)(3) (3) The services provided or arranged by the facility must— (i) Meet professional standards of quality and Intent §483.20(k)(3)(i): The intent of this regulation is to assure that services provided meet professional standards of quality, in accordance with a specific definition

6 F-Tag 281 (cont’d) Interpretive Guidelines §483.20(k)(3)(i): “Professional standards of quality” means services that are provided according to accepted standards of clinical practice Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting

7 F-Tag 281 (cont’d) A professional organization, licensing board, accreditation body, or other regulatory agency may publish standards regarding quality care practices. Recommended practices to achieve desired resident outcomes also are found in clinical literature.

8 F-Tag 281 Standards of Practice Standards are published by professional organizations, such as:  Academy of Nutrition and Dietetics  American Medical Association  American Medical Directors Association  American Nurses Association  National Association of Activity Professionals  National Association of Social Work (Cont’d)

9 F-Tag 281 Standards of Practice Current manuals or textbooks on nursing, social work, physical therapy, health care guidelines, etc Clinical practice guidelines published by the Agency of Health Care Policy and Research Current professional journal articles Based on:

10 Interpretive Guidelines §483.20(k)(3)(i): If a negative resident outcome is determined to be related to the facility’s failure to meet professional standards and the team determines a deficiency has occurred, it should be cited under the appropriate quality of care or other relevant requirement

11 Elements of Each Dining Standard Basis in current thinking/research Relevant research trends Recommended course of practice References “ All Decisions Default to Personal Choice”

12 Dining Practice Standard 1 Individualized Nutrition Approaches: Diet Liberalization

13 Liberalized Diets Research Evidence-based research continues to support that therapeutic diets are detrimental at worst, neutral at best for the elderly

14 Liberalized Diets Research Restrictive diets are a frequent cause of weight loss Physicians are encouraged to liberalize diets Medical needs are balanced with quality of life Prevention of weight loss is viewed as a priority Resident’s goals and wishes are followed

15 Letting Go of Therapeutic Diets Fear of regulations may fade over time Individualized and resident- informed choice frequently found in regulations It is our duty to educate residents of the consequences, good or bad, of their choices then allow them to make choices

16 Dining Practice Standard 2 Individualized Diabetic/ Calorie-Controlled Diet

17 Research on Diabetic Diets Intensive treatment of diabetes sometimes is not appropriate for all individuals in the long-term care (LTC) setting No evidence to support no- concentrated sweets, no-added-sugar diets for older adults in LTC—using medication rather than dietary changes can enhance the joy of eating AMDA: Target of A1c 7 – 8 discourages use of sliding scale insulin

18 Dining Practice Standard 3 Individualized Low-Sodium Diet

19 Research on Low-Sodium Diets May benefit some individuals, but in frail elderly more lenient blood pressure goals and more lenient diets are needed A liberal approach sometimes is needed to maintain nutritional status Typical 2-gram sodium diet achieved only modest effect on blood pressure and is not shown to improve cardiovascular outcomes in LTC residents

20 Dining Practice Standard 4 Individualized Cardiac Diet

21 Research on Cardiac Diets Diets are not shown to improve control or affect symptoms Dietary Guidelines for Americans and/or DASH diet can achieve goals Important to balance restrictions with adequate nutrition Aggressive lipid reduction in LTC is more effectively achieved through use of medications

22 Dining Practice Standard 5 Individualized Altered Consistency Diet

23 Research on Altered Consistencies Swallowing abnormalities do not necessarily require modified texture Collaborate with doctor, speech pathologist, registered dietitian, and other professionals Look beyond symptoms to underlying causes to avoid excessive modification of food/fluid Sometimes it is necessary to evaluate tolerance of aspiration risk, compared to the slow process of wasting away

24 Dining Practice Standard 6 Individualized Tube Feeding

25 Research on Tube Feedings Is not an automatic step when other strategies have failed Does not ensure patient’s comfort or eliminate aspiration risk (abdominal distention, diarrhea, and restricted movement) Is not always appropriate for advanced disease states What does/did the patient want?

26 Research on Tube Feedings Tube placement will not resolve oral secretions/gastric content issues Weight gain from tube feeding is not shown to correlate with improved clinical outcomes Decreased socialization and depravity of the social experience at mealtimes are strong considerations by many ( Cont’d)

27 Enteral Feeding Decisions Patient Rights and Informed Consent/Refusal Across the Healthcare Continuum, 2005 Mayo Clinic Proceedings See pages 52 – 56 of Dining Practice Standards for Enteral Algorithm for Decision Making

28 Arguments for placing a tube for feeding include improving nutritional status. Studies in the elderly with dementia have shown little to no improvement in weight. Tube feedings also are considered for wound care as a means to improve wound healing. Data over a 6-month follow-up have shown no impact on pressure ulcers or infections associated with wounds. Feeding tubes do not improve quality of life. An association with physical or psychosocial discomforts related to the tube feeding is a negative consideration.

29 Dining Practice Standard 7 Individualized Real Food First

30 Research on Real Food First Provide naturally soft, smooth texture before pureed foods when possible (yogurt, puddings, ice cream, and vegetable soufflés) Create meals comparable to home Select from approved sources from family and friends, gardens Serve food before supplements Choose homemade before commercial Use flavor enhancers

31 Flavor Enhancement Taste and smell losses occur with aging, which can decrease food enjoyment, reduce food consumption, and negatively influence nutritional status. Flavor enhancers can compensate for the diminished sensory function, which is a contributing factor to impaired appetite and decreased intake in the elderly. What are flavor enhancers? They are food additives commonly added to foods, designed to enhance the existing flavors of products. You can use commercially manufactured flavor enhancers, but the best flavor enhancers are those found in an ordinary spice rack or pantry. You can make bland, tasteless meals a thing of the past with the improvements of culture change and dining practices.

32 Examples of Flavor Enhancers Spices and herbs: Basil, garlic, dill, rosemary, lavender, mint, pickling spices, thyme, sage, etc Seasonings or flavor enhancers: Ancho powder, chili powder, Accent ® (monosodium glutamate [MSG]), Spike ® (hydrolyzed vegetable protein), anchovies and anchovy paste, balsamic vinegar, Bon Appetit ® Seasoning Salt, capers, Chef Paul Prudomme’s ® Seasoning Blends ®, Chile peppers, citrus fruits (juice and zests), grapes, molasses, Old Bay ® Seasoning, onions, pepper, peppermint oils and extracts, sugar, date sugar, Tabasco ®, tahini, truffle oil, cooking wine, etc Resource:

33 Staff Creativity Combines With Resident Choices The standard cooking techniques, recipes, and bland foods are no longer the Gold Standard Staff must bring creativity to food preparation, trying new recipes, new cooking techniques and food combinations, and flavor enhancements Staff and residents must form an alliance in menu choices and selections

34 Additional Factors to Assess for Decreased or Poor Appetite Diagnostic or assessment factors that could impair appetite Active diseases and conditions that have the potential to negatively affect appetite Potential food and drug implications Surgical interventions—anesthesia has a tendency to interfere with appetite Environmental issues, including texture and appearance of food


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