1. Delivering Success Working Smarter- Not Harder in the area of Malnutrition Corrina Grimes AHP Consultant Public Health Agency

2. A Public Health Problem …  Malnutrition originates in the community  Malnutrition affected 29% of Adults admitted to hospital (BAPEN 2014)  Malnutrition contribute to and also occurs as a result of illness

3. Malnutrition…. At first glance

4. However there are many elements…. Identify Your Dolls

5. Malnutrition

6. Malnutrition Dietary Intervention Approach

7. Regional Medicine Management Dietetic Initiative… Working Smarter- Not Harder Identify the Dolls we could affect change

8. Drivers…….  Pharmaceutical Clinical Effectiveness Programme  NICE Guidance CG32 Nutritional Support For Adults & QIPP  Promoting Good Nutrition Strategy

9. The Pharmaceutical Clinical Effectiveness Programme (PCE)  (PCE) Programme is an umbrella term for a suite of medicines management initiatives, initiated by DHSSPS and now implemented by the HSC Board which include:  The PCE Programme's initiatives continue to contribute to the Department's efficiency strategy  It is based upon the principle that IMPROVEMENT IN THE QUALITY AND SAFETY OF SERVICES WILL LEAD TO HEALTH GAINS AND ASSOCIATED EFFICIENCIES.

11. Oral nutrition

12. NICE CG32 Nutrition support in adults: Oral nutrition support, Enteral tube feeding & Parenteral nutrition & QIPP  Nutritional support to reduce or prevent malnutrition  Utilised skills of a Dietitian to ensure appropriate use of Oral nutritional supplements with a food first approach

13. “Every careful observer of the sick will agree in this, that thousands of patients are starved in the midst of plenty, from want of attention to the ways which make it possible for them to take food.” (Florence Nightingale) Promoting Good Nutrition Strategy Scope :  Strategy relates to adults in all health and social care settings including individuals in their own home.  For the purpose of this strategy malnutrition will be considered as under-nutrition and does not cover obesity or eating disorders

14. Synergy and Symbiosis.. Work Smarter – Not Harder A joint Initiative Synergy The interaction or cooperation of two or more organizations, substances, or other agents to produce a combined effect greater than the sum of their separate effects:

15. Working Harder - Not Smarter… Demonstrating Symbiosis and Synergy Utilisation of:  Dietetic skills and competencies to ensure appropriate clinical assessment and intervention  Medicines Management (pharmacy) Team’s process and practice experience in other therapeutic areas and their operational and strategic support for this initiative  Data analysis, Informatics,Health Intelligence  Organisation and professional networks

16. Initiative Structure  Medicines Management Dietitians employed as part of Medicines Management team, professionally responsible to AHP Public Health Agency  Five Dietitians working across Northern Ireland integrated within the HSCB Medicines Management Team  Supported by four prescribing support assistants  Regional Medicines Management Dietitian Initiative Steering Group with key stakeholder membership

17. Initiative Overview  Dietetic assessment of patients in identified cohort  Implement prescribing change where appropriate  Provide training resource for primary care healthcare professionals  Evaluate the impact

18. Patient Cohort  Patients are identified within each practice who are prescribed Oral Nutritional Supplements (ONS)  Exclusions – patients under the care of a Trust Dietetic Department or last days of life  These patients are offered an appointment with the Medicines Management Dietitian :  within the practice (Clinic)  in the care home  domiciliary setting

19. Prescribing Cost of ONS/1000NIPUs for each practice in N.Ireland

20. Prescribing indicators for ONS for individual GP practices across N.Ireland

21. Outcomes ……

22. Inappropriate Prescribing Criteria used by London Procurement Partnership (LPP) to classify a prescription as appropriate:  Patient is at risk of malnutrition (MUST ≥2)  ACBS Indication  Trial of food first has failed  Applying this criteria to these 150 patients in the initial cohort  96% of ONS inappropriately prescribed  LPP data = 75% inappropriately prescribed

23. Productivity: April 2014  Total number of practices contacted = 47 across Northern Ireland  27 complete  Total number of patients offered an appointment = 946 – 506 complete

24. Prescribing changes Following assessment and tailored dietary advice by the medicines management dietitian the following prescribing changes were recommended:  56% of ONS discontinued  8% ONS amended  36% ONS continued

25. “ agree in this, that thousands of patients are starved in the midst of plenty, from want of attention to the ways which make it possible for them to take food.” (Florence Nightingale) Food First Approach…….

27. Annual efficiencies Annual efficiencies of £315k to date – This will be a rolling figure moving forward

28. Practice Feedback ‘ The GPs want me to pass on their appreciation with this initiative. They have found it really worthwhile’ Practice Manager E-mail

29. Settles the stomach when having acid reflux (1 milkshake ONS) Thought it was a vitamin/mineral drink, patient didn’t realise kcal content and didn’t want to gain weight (ONS was calogen) Appetite stimulant Patient Perceptions of ONS

30. Examples of how patients are using their ONS:  Calogen (a calorie supplement) being used as an emollient  Ensure Plus Juce used as a laxative  Thought GP gave it to her as she is not drinking enough fluids and doesn’t like water. Thought it was like Ribena (juice style ONS)  Pro-Cal perceived to be a calcium supplement as opposed to a calorie and protein supplement  Build up/tonic

31. The Rubik’s Cube Effect  Change on one size will have an impact on the others  Be mindful of the impact

32. The Rubik’s Cube Effect  Regional Medicine Management Dietetic Steering Group  Key stakeholder to share learning and identify solutions  Linkages with other local and regional initiatives

33. In Summary  Identify your dolls  Find your nemo and synergise  Remember the Rubik’s Cube effect……

34. Thank you