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Delivering SuccessWorking Smarter- Not Harder
in the area of MalnutritionCorrina Grimes
AHP Consultant
Public Health Agency
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
Malnutrition…. At first glance
However there are many elements….
Identify Your Dolls
Malnutrition
Malnutrition
Psycho- social issues
Policy and Standard
Impacts & Outcomes
Infancy to adulthood
Dietetics and Medicines
Management role and other professionals
roles
Promoting Good Nutrition Strategy
Malnutrition Dietary Intervention
Approach
Malnutrition
Oral Nutrition Supplemements
Oral Nutrition Supplemements
Enteral and Parenteral nutrition
Food First Approach
Regional Medicine Management Dietetic Initiative…
Working Smarter- Not Harder
Identify the Dolls we could affect change
Drivers…….
Pharmaceutical Clinical Effectiveness Programme
NICE Guidance CG32 Nutritional Support For Adults & QIPP
Promoting Good Nutrition Strategy
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.
Oral nutrition20
09
2010
2011
2009
2010
2011
2009
/10
2010
/11
2011
/12
2009
2010
2011
England Wales Scotland NI
£0
£2
£4
£6
£8
£10
£12UK regions: spend per head
Oral nutrition
NICE CG32Nutrition 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
“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
Synergy and Symbiosis..Work Smarter – Not HarderA 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:
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
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
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
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 Clinic
48%
Home 24%
Care home 28%
Prescribing Cost of ONS/1000NIPUs for each practice in N.Ireland
Prescribing indicators for ONS for individual GP practices across N.Ireland
Outcomes ……
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
Productivity: April 2014
Total number of practices contacted = 47 across Northern Ireland 27 complete
Total number of patients offered an appointment = 946– 506 complete
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
“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…….
Annual efficiencies Annual efficiencies of £315k to date
– This will be a rolling figure moving forward
Total cost Exclusions Inclusions Efficiencies0
100000200000300000400000500000600000700000800000900000
1000000
£
Practice Feedback
‘The GPs want me to pass on their appreciation with this initiative. They have found it really worthwhile’
Practice Manager E-mail
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
Patient Perceptions of ONSExamples 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
The Rubik’s Cube Effect
Change on one size will have an impact on the others
Be mindful of the impact
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
In Summary
Identify your dolls
Find your nemo and synergise
Remember the Rubik’s
Cube effect……
Thank you
