Transitioning to Person- Centered Dining BY, JOYCE LAMILLA, M.ED; RD/LD BEN E. KEITH FOODS
Objectives: Identify the benefits of liberalized diets Identify potential regulatory tags related to NOT implementing person centered dining in long-term care facilities How to apply information learned to make a road map on how to move your facility towards person-centered dining
What we Know Over 60 year olds are the fastest growing segment of the population. The elderly are at risk for weight loss, malnutrition, dehydration, and skin breakdown. Research shows that 50-75% of residents leave over 25% of their food uneaten at most meals. 60-80% of residents have a physician or dietitian order to receive dietary supplements. 25% of residents experienced weight loss over time.
Happier, Healthier Clients Clients eat better when they can choose what to eat, when they eat, and with whom they will eat. Clients with the freedom to choose have better intakes, less weight loss and an improved quality of life.
Journal of the Academy of Nutrition and Dietetics The premier source for the practice and science of food, nutrition and dietetics Tray Service Generates More Food Waste in Dining Areas of a Continuing-Care Retirement Community - J Am Diet Assoc. 1997;97:879-882 We have known for over 15 years that traditional tray service is not the best for our residents, but communities have been slow to change.
Culture Change Defined Culture Change: Culture Change is the common name given to the national movement for the transformation of older adult services, based on person-directed values and practices where the voices of elders and those working with them are considered and respected. Involves re-thinking values and practices in all aspects of the nursing home All resident care and activities are decided by the resident. Living environment designed to be HOME-like Staff, residents, and family work together to create an environment that provides dignity, rights and freedom. Move away from caregivers creating the agenda and schedules for the residents and giving the control to the residents.
CMS Regulations:OBRA 87 The Nursing Home Reform Law of 1987 is the basis of Culture Change. Culture change and self-directed care is mandated by the Centers for Medicare & Medicaid Services (CMS). Requires that nursing homes care for residents in an environment that will promote maintenance or enhancements of the quality of life of the resident. Provide services and activities to attain the highest practical physical, mental, and psychosocial well-being. Residents Bill of Rights
What is Pioneer Network? The Pioneer Network was formed by a small group of professionals in LTC to advocate for person-directed care in 1997. They called for radical change in the culture of aging in LTC. Where older adults are able to express choice and practice self-determination in meaningful ways at every level of daily life.
What are Person-Directed Practices? Resident s choice in aspects of daily life: Time of getting up and going to bed Time of eating and times outdoors Favorite pastimes Method of bathing Content of meals and the way they are served
Ramifications of not embracing culture change. F-Tags related to the dining experience F241 Dignity All instances, not limited to dining. F242-Self Determination and Schedules choices in waking, eating. F279 Attain or Maintain Highest Practical Physical, Mental, and Psychosocial well-being of each resident. F252- Environment Home-like setting Food off trays in Dining Room CMS reports that the most frequent questions and concerns that it receives focus on the physical environment and dining, as well as foodrelated issues.
Liberalized Diets Research Restrictive diets are a frequent cause of weight loss Evidence-based research continues to support that therapeutic diets are detrimental at worst, neutral at best for the elderly. 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
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.
Research on Honoring Choices Resident Satisfaction Increases with Resident s Personal Choice Homelike environment optimize energy intake It is all about choice, RESIDENT CHOICE ATTITUDE ADJUSTMENT keep an open mind
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
Evaluate Meals: What Do Residents Want? Is food colorful and eye-appealing? Review menu and incorporate residents favorites Review plate waste of menu items Does food smell aromatic? Are portion sizes appropriate? Expand meal times, choices, cook to order Know residents food choices
Traditional Today s Menu Is: Roast Beef Mashed Potato & Gravy Glazed Carrots Dinner Roll/Margarine Chocolate Pie Box Menu done for the last 35+ years Preferences followed No choices Over production Same menu for 6 months
If you had the choice Chicken Fried Steak Tenderized Cube Steak with a crunchy breading. Served with buttered mashed potatoes, cream gravy & a choice of vegetable of the day. Meatloaf An old fashioned recipe, homemade & served to you hot with your choice of potato & vegetable of the day. Chicken Breast Melt A juicy grilled chicken breast smothered with sautéed onions & bell pepper & topped off with melted Swiss Cheese. Served with your choice of rice, French Fries, or mashed potatoes & gravy, and the vegetable of the day. All meals served with a choice of salad, vegetable and dessert. Side choices are: rice, French Fries, mashed potatoes, tater tots, green beans, corn, or vegetable of the day.
Marketing Meal service :Untapped marketing potential for a nursing home or assisted living. Families are touring multiple facilities. Your meals can be a your most effective and least expensive marketing tool.
Restaurant Style/Culture Change Person-Centered Dining It gives your guest choices. It gives dignity back to your guest. It gives you market advantage. It falls in line with the New Dining Practice Standards from the Pioneer Network.
Isn t it more Expensive? Person-Centered Dining reduces food waste-how? Decreased supplement usage Less in Inventory Think like a business- Portion Cost Cost Savings= Happy Administrator
Person-Centered Dining Fresh cooked to order food Eliminates waste Lowers PPD cost Choices, choices, choices Happy Residents See Dining Practice Standards
How Does It Work??
The Culture Change Process Satisfied Resident Open Dining Room Hours Dessert Cart Presented Resident Orders When Seated Hot Fresh Food Delivered Order Turned into Kitchen Kitchen Prepares Hot, Fresh Cooked to Order Food Salad Cart Presented
Menu Services An Internet based menu puts you in control and offers: Selective menus to meet your client s needs Ability to customize menus Diets and diet extensions Quantify recipes to exact needs Nutritional analysis Portion Cost NEED TO CHANGE MENU AT LEAST QUARTERLY, preferably sooner.
Sample Menu
Let s Get Started! Develop a committee to analyze implementation: RD, CDM, Chef, CNAs, DON, Administrator, Medical Director, Activities, Social Services and a Representative of your food service distributor.
Tips for Implementing Person-Centered Dining Talk to your residents Assess your operation Where am I now? Where do I want to be? What resources do I need to get there? Involve EVERYBODY Develop an Action Plan and Timeline
Strategic Planning To commit to a total improvement in the dining experience, you will need a long-term plan This plan can be developed while simple changes are being put in place The plan can be developed one part at a time as a phased-in plan All staff need to be committed and to have input for buy-in
Questions to Ask What menu will you serve? What serving utensils will you need? What table covers/color scheme will you use? Who will do the decorating? What is the timeline? Will you need additional staff? Will your staff need additional training? Is your medical staff on board with liberalizing diets?
Equipment Package Check List Most facilities have at least some of this equipment. This is a list of all items to do restaurant style menus. Minimum Four burner stove top Flat Grill (min. 24 x 24 ) *Recommend 36 Deep Fryer Oven Open top refrigerator unit. Recommend 72 Steam table Shelving and ticket holder Optional heat lamp or food warmer
Assess Training Needs Does Staff have restaurant kitchen experience? Know how to use production sheets? Know how to prepare all of the menu items? Know how to take orders? What method will you use?
How You Will Serve? Direct dining is best in the main dining room Orders are taken at table Plate is served when order is submitted and brought directly to table no pre-plated dishes with saran wrap or lids Beverages, salads and soups served table side no pre-poured beverages Carts for beverages, cereals, soups, and desserts help enhance the direct dining service
Train Wait Staff Focus on service Role play with staff Guidelines: Use eye contact and address diners by name Give them options and listen to their choice Talk to them directly, not just reading from menu Serve on left, remove from the right Wear clean aprons with name tags Be enthusiastic and respectful Be courteous
Make it Homelike! No hairnets in dining area No gloves unless infection or cuts are present; staff should wash hands and avoid touching food All staff to wear clean aprons and smile!!! No rushing allow plenty of time for socialization Don t clear too early, but do clear before serving the next course
Food Production Considerations To Ensure Foods Taste Like Home Foods should be cooked using proper techniques and to the correct degree of doneness. Foods should be seasoned correctly Foods should be served at the proper temperature Food should be portioned attractively on the plate Meals should be presented to clients in an appealing manner.
Start a Dessert Cart Takes only a cart and staff to roll through the dining room Helps use up leftovers Can use simple desserts with added sparkle for eye appeal: Chocolate pudding with whipped topping and crushed Oreos No-cook Jell-O pudding pies with whipped topping Chocolate chip cookies drizzled with chocolate syrup Always provide fruit and/or sugar-free option Ice cream and/or sherbet
Keys to a Good Program Quality of the menu Let residents decide Respect residents cultural heritage and the influence it has on his or her food preferences CNA involvement and participation Administration backing & financial commitment (new equipment) Cooks that know how to cook not just reheat Commitment to staff training Restaurant style plating and garnishing Attention to detail Open communication with residents
Challenges for Success The population is getting younger and more vocal in their choices Gone are the days where people did things they were told to do without questioning The population is more informed than ever, more vocal when making choices and not settling for just acceptable The population is more diversified, thus having more varied food choices
The sky is the limit You can implement any and all of these ideas for little effort and little cost. Use these ideas to let your imagination run wild. You can surely think of other things you can do with ease. Remember that the sight of attractive food and the smell of delicious aromas are both appetite stimulants and can help increase your clients appetites. Ask your food service distributor to help you achieve your goals.
Resources Action Pact, Inc. www.culturechangenow.com Eden Alternative www.edenalt.org Meeting of Pioneers in Nursing Home Culture Change www.pioneernetwork.net/resources/publications New Dining Practice Standards www.pioneernetwork.net/data/documents/newdiningpracticestandards.pdf Relationship: The Heart of Life and Long Term Care www.pioneernetwork.net/resources/publications The Pioneer Challenge: A Radical Change in the Culture of Nursing Homes www.pioneernetwork.net/resources/publications The Pioneer Network www.pioneernetwork.com The Power of Language to Create Culture www.pioneernetwork.net/culturechange/poweroflanguage/