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Sir Moses Montefiore Jewish Home

Dietary Coordinators Bridging the Gap
Sir Moses Montefiore Jewish Home

Camelot Nursing Home
Hunters Hill Montefiore Home

Residential – Metropolitan, 80 + beds

Award descriptors:
Health and wellbeing, Clinical care / medication management, Communication and engagement

About the program
In residential aged care food is a frequent area of complaint despite the many improvements that have been made in the industry from award winning hotel services to celebrity chefs. However, the complexity of the older palate goes beyond that due to increased care needs ranging from special diets, to malnutrition and feeding assistance. Within residential aged care, such nutritional care needs are typically managed by dietitians, speech pathologists and occupational therapists following referral from a registered nurse or other clinician.

Yet, not all residential aged care facilities have regular access to such allied health specialists, or if they do (as in our case), their workload does not afford them the time to go beyond nutritional prescribing. So while such specialists may prescribe a special diet, what we saw was a communication breakdown between their prescription and actual practice by our catering department. While reactive responses rectified the issues, risks continued to rise and with 700+ residents it became clear our model was not sustainable.

The outcome was the creation of the Dietary Coordinator role initially to assist with reducing the Dietitian and Speech Pathologist’s workload. After several years of refinement, the key focus of the role has become cross-departmental communication including managing resident dietary information; point-of-contact for catering and nursing teams when dietary questions arise; educating catering staff on the delivery of correct meals; auditing; managing supplements and thickened fluids; and assisting in streamlining referrals to allied health specialists.

What we did
Objectives included: improve resident safety at meal times such as those on texture-modified foods/fluids; increase awareness among staff and residents on dietary accuracy; and improve management of supplements.

Outcomes include: tracking near misses and incidents; improved cross-departmental accuracy of dietary information; point-of-contact for nursing, catering and allied health specialists; resident liaison; and a buddy checklist for catering staff.

Encouragement of innovation
Our approach with using Dietary Coordinators is unique to residential aged care. As food/fluids are delivered over six times a day, communication cross-departmentally is critical and this is managed directly by our Dietary Coordinator. Supporting this is a range of nutrition and dietetic risk screening systems from place cards, to tea trolley lists, dietary needs charts and supplements lists. This ensures staff deliver the correct end product at all times, while also preventing issues escalating before an allied health specialist can review them.

Planning and implementation
Communication of resident nutrition and dietetic information (and its frequent changes) was identified as our greatest issue. Initially we recruited a part-time Dietary Coordinator to maintain dietary forms and reduce our Dietitian’s and Speech Pathologist’s workload. However, over time cross-departmental communication has become the most critical focus of the role.

Monitoring and evaluation
Feedback is daily via shift briefings within the catering department. Near misses and incidents are reviewed and rectified to ensure compliance and non-repeat. Tray checks occur multiple times weekly to confirm accuracy with dietary information. Errors identified are added to the near miss report. There are mid-meal audits, ongoing education, and feedback. Meanwhile, the process is driven by automated alerts of dietary changes to the Dietary Coordinator who updates catering documentation respectively.

Utilisation of a range of approaches/techniques
Since recruitment of our initial part-time Dietary Coordinator, the role is now two full-time equivalents (FTEs). They are employed staff, not contractors. The role has evolved over time to incorporate ongoing quality improvements such as the recent education on smoothie/milkshake preparation and the implementation of a communication book between nursing and catering.

Resident/Consumer engagement
Helping ensure every resident receives the correct meal safely every time is the primary reason for creating the Dietary Coordinator role. With 2000+ meals produced daily, this is accomplished through a well-documented nutrition and dietetic communication process managed by the Dietary Coordinator that links nursing, catering and allied health specialists. Through our near miss and incident definitions, we have seen improved management and resolution of issues before they become critical, such as a resident receives a soft diet when they are on a pureed diet which could have an adverse health effect.

Stakeholder engagement
Catering is our biggest stakeholder with responsibility to safely cater for over 700 residents each day. Partnering with our allied health specialists ensures accurate diagnosis and prescription of residents’ nutrition and hydration needs, while feedback to nursing staff helps address referrals and maintain care plans.

Why we did it
When it comes to food in residential aged care, providing a balanced three-course menu in a welcoming setting is only part of the equation. What about catering for those on special diets due to clinical needs such as allergies, texture-modified foods/fluids, adaptive equipment, and supplements? These needs can change daily be it a new resident or a change in care needs of an existing resident.

The risk of a catering employee serving the wrong meal is high. Its complexity clearly does not rely on one person to ensure each resident is fed safely, yet research shows much of this is reliant on nursing staff communicating the ever changing dietary needs of residents to catering staff. Dietitians and speech pathologists are involved, but typically in a limited capacity for diagnosis and prescription. In addition, they are rarely full-time employees in a residential aged care setting.

After much consultation with the various players, cross-departmental communication of resident nutritional and dietetic needs was identified as our biggest problem. Recruiting additional dietitians was not financially viable. Neither was adding the ongoing responsibility to nursing or catering as they are not the subject experts. Instead, we created the position of Dietary Coordinator with responsibility to centralise communication between catering, nursing, allied health specialists and residents. Improved process and catering specific initiatives have resulted including: tracking of near misses and incidents; tray spot checks; catering handovers; tea trolley lists; buddy checklists; and colour-coded dietary charts.

Who worked with us
The Dietary Coordinators have created multiple in-house cross-departmental communication partnerships. Collaboration with catering is critical to ensure communication of resident dietary needs are put into practice, systems monitored, risks assessed and staff educated. This in turn ensures our chefs create the right matrix of meals such as for those with allergies, on texture-modified diets or supplements. For our catering staff whether they are new or long term employees, they must know what each resident can and cannot eat/drink every time, e.g. allergies or other restrictions. This has led to daily catering handovers to track near misses and incidents and revised dietary charts based on ongoing feedback. With over 2000 meals produced daily without such tight screening systems in place there is a high risk of getting things wrong which could result in adverse health effects for residents.

Partnering with nursing ensures the Dietary Coordinator is alerted to changing parameters such as resident weights, residents returning from hospital, or updated care plans. Reporting back to allied health specialists on for example changes to a resident’s care, or need for an urgent referral further aid in the communication process and helps dietitians and speech pathologists prioritise their case load.

In addition, we have found that our Dietary Coordinators have created a unique partnership with residents to support them when for example needs change such as the addition of supplements to their diet.

What we learned
We can report the following outcomes from the Dietary Coordinator role: 

  • Acts as a single point-of-contact between nursing, catering and allied health concerning residents’ nutrition and dietetic needs
  • Relays information from nursing and catering teams to allied health specialists which they may have otherwise not been aware of
  • Streamlines referrals to dietitians, speech pathologists and occupational therapists
  • Supports dietitians, speech pathologists and occupational therapists in implementing prescribed dietary needs which reduces risk, reliance and costs on such services for day-to-day issues
  • Tracks near misses, supports incidents and critical incidents. This includes data from catering handovers, tray checks, audits, and stakeholder feedback
  • Has increased cross-departmental consistency and accuracy of dietary information which helps minimise errors
  • Developed appropriate education and training for catering staff via a buddy checklist system to improve accuracy in the delivery of correct foods and fluids
  • Improved management of supplements and thickened fluids including resident education on their use and benefits
  • Greater resident and family knowledge of the availability of specialised meals including one-on-one resident support.

Transferability
Our research indicates most residential aged care facilities do not have dietitians or speech pathologists on staff. Many are contractors for a few hours a week or a few days a month at best. Subsequently, resident nutrition and dietetic needs are left in the hands of nursing to communicate to catering and vice-versa. The risks associated with this are huge.

Due to its cross-departmental focus, the budget for the recruitment of a Dietary Coordinator could be shared. Additionally, to reduce costs and minimise risk, the role could initially be part-time with a focus on ensuring what has been prescribed by the allied health specialists is put into practice; communication between nursing and catering; and managing the routine accuracy of dietary forms. These day-to-day administrative issues subsequently reduce reliance on the dietitians or speech pathologists which in turn reduces overall costs. When such specialists are required they are more focused on clinical diagnosis and prescription. Furthermore, this approach eliminates the responsibility of nursing or catering to manage residents’ day-to-day dietary needs.

From our findings, we recommend to initially trial the Dietary Coordinator role on a part-time basis. This reduced our risk and costs to see if the concept would work which it did. As the Australian aged population is growing, there will be even more pressure for such cost effective roles in residential aged care to support the ever-changing clinical dietary needs of residents. 

Sustainability
We have measured sustainability through various outcomes. Recruiting additional dietitians was not and is not financially viable for us, however, we compromised by establishing a Dietary Coordinator role. What started initially as a part-time role is now 2FTEs. Some of this has been due to the evolution of the role based on lessons learnt, success of the role and knowing that with 2000+ meals produced daily - getting the right meal to the over 700 residents is a huge cross-departmental responsibility.

For our dietitians and speech pathologists it has helped better manage their case load and referrals. Instead, the Dietary Coordinator can manage day-to-day issues before they escalate such as tray checks, and support nursing, catering and residents with specific individual needs. The Dietary Coordinator also conveys information received from catering/nursing staff to the dietitians and speech pathologists which allows them to reprioritise their caseloads, for example sudden changing dietary needs due to a decline in health such as thickened fluids only or requirement for a pureed diet.

We continue to collaboratively monitor feedback. Currently we are reviewing the definition of near misses as it may be too broad. While the robustness of our system demonstrates a sustainable model, we do expect further expansion of this role into the future. Financially, the Dietary Coordinator approach is clearly more cost effective than employing additional dietitians, speech pathologists or associated contractors which all come at a premium, and/or are difficult to recruit into residential aged care.

Conclusion
In conclusion, our findings demonstrate the need for Dietary Coordinators in RAC to provide a cost effective cross-departmental communication bridge that is not reliant on the limit resources of Dietitians or Speech Pathologists. For our residents, it ensures a safe meal is delivered to every resident every time.

More information on this program: 
Robert Orie, , or phone (02) 8345 9100

 
Changed
Friday, 21 December 2018 - 6:58am