Speaker Notes for Presentation on ACI Nutrition Standards for Consumers of Inpatient Mental Health Services in NSW

Slide 1: Title Page The following presentation was developed by the Agency of Clinical Innovation Nutrition & Mental Health Working Group about the new Nutrition Standards for Consumers of Inpatient Mental Health Services in NSW.

Slide 2: NSW Agency for Clinical Innovation The NSW Agency of Clinical Innovation is one of the pillars within NSW Health.

The ACI works with clinicians, consumers, managers and the community to help design and promote better health care in NSW.

It has a wide range of clinical networks, institutes and taskforces such as the Nutrition Network, that has a focus on improving nutrition care in hospitals. For more information please go to their website.

Slide 3: Overview The presentation is divided into three sections – purpose of the presentation, background information and specific details on the Nutrition Standards for Consumers in Inpatient Mental Health Services.

Slide 4: Purpose The purpose of the presentation is to provide an overview of the ACI Nutrition Standards for Consumers in Inpatient Mental Health Services in NSW for all staff involved in all levels of the patient nutrition care journey.

Key staff include Nursing Staff, Allied Health, Food Service staff, NSW Local Health District / Speciality Network and Facility Nutrition Care Governance Committee representatives.

Mental Health Consumers have unique and varied needs. Compared to the general adult hospital population mental health consumers are: 1) Younger 2) Their average length of inpatient stay is

much longer with some consumers have been in the facilities for more than 25 years.

3) Increased physical co-morbidities of Mental Health Consumers especially for older people. For example: In Australia, 70% of people with a mental

illness die from cardiovascular disease (CVD) compared to 18% of the general population

People with serious mental health illnesses have twice the normal risk of dying from CVD

people with mental health illnesses are 2-3 times more likely to develop Diabetes mellitus

The rate of Obesity is 3 ½ times greater in people with serious mental health illnesses

Metabolic syndrome (clustering of central obesity and elevated lipids, glucose and blood pressure) is more prevalent. In some studies, the rate is double that of the general population.

People with severe mental illness have decreased average life expectancy of 25 years mainly due to high levels of untreated co-morbid physical illness.

Reminder : Please provide the “Introducing the ACI Nutrition Standards for Consumers of Inpatient Mental Health Services in NSW Factsheet” here with more information about their development.

Slide 5: Background: Nutrition Care Policy The Nutrition Care Policy was launched in 2011 for NSW Health facilities including inpatient mental health services.

The purpose of this Policy Directive is to enable all inpatients in NSW Health facilities to receive adequate and appropriate nutrition care. It was developed due to high rates of malnutrition and differences in terms of adequacy and access.

NSW Health acknowledges a duty of care to all patients to ensure access to safe, appropriate and adequate food and fluid, which are acceptable to patients and also to provide nutritional care and support through a coordinated approach by health service staff. As a result of this Policy Directive it is expected that NSW Health facilities will implement the mandatory requirements.

Nutrition care has a high clinical care and patient safety risk classification in accordance with the NSW Health Risk Matrix.

There are nine key elements within the policy:1) Policy and Governance – have a LHD /

Network and Local Nutrition Care Committees2) Nutrition Screening – such as Malnutrition

screening or Metabolic Monitoring3) Nutrition Assessment – Dietitian completing

a formal nutrition assessment4) Nutrition Care Planning - development of

nutrition care plans5) Planning and Delivery of Food and Fluids –

making sure menus meet the new standards

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and the diet ordering and meal delivery system is efficient, timely and safe

6) The Mealtime Environment – mealtime is protected from interruptions, consumers are prepared for meals and the environment enhances intake and enjoyment

7) Provision of Assistance to Eat and Drink – consumers are given assistance with eating and drinking as required

8) Staff education & Training – staff are provided with education on good nutrition, malnutrition and their roles and responsibilities

9) Evaluation – audits of weight, nutrition screening and patient food satisfaction surveys.

Slide 6: Background: Patient Nutrition Care Journey This Patient Care Nutrition Care Journey was developed by the ACI and reflects components of the Nutrition Care Policy.

It summarises the patient’s nutrition care journey from admission to discharge and illustrates clearly all components of nutrition care.

It also demonstrates the complexity of nutrition care and again just how many people are involved in ensuring that our consumers receive and consume food and beverages that are clinically suitable and in a normalised environment. Malnutrition screening and metabolic monitoring are core business within mental health facilities and should be part of nutrition screening and monitoring.

A Nutrition Care Committee with mental health representation is key to ensuring that the consumer has the best possible outcomes.

The Nutrition and Mental Health Working Group has developed a toolkit with valuable tools that can assist with the facility implementing some of the key aspects of this nutrition care journey.

Slide 7: Background: Nutrition Care & Accreditation The Nutrition Care Policy has links to the following accreditation standards as there is not a separate stand-alone national nutrition standard:1) National Standards for Mental Health

Services2) National Standards for Quality Health

Services 3) EQuIPNational

In terms of EQuIPNational, Standard 12 Criterion 2 refers to the Management of Nutrition - the organisation ensures that the nutritional needs of consumers/patients are met.

Both the National Standards for Mental Health Services and the National Standards for Quality Health Services are mandatory. There are an additional five EQuIP standards, that when combined with the 10 NSQHS are described as EQuIPNational but are only desirable.

Slide 8: Background: Nutrition Care & Accreditation Continued – Links Page There are eight links to the National Standards for Mental Health Services and nine National Standards for Quality Health Services. In addition, the Nutrition Care policy links to all 5 EQuIPNational standards.

Here are a few examples to demonstrate the links to the standards:- The importance of governance and

leadership of implementing and monitoring the nutrition care policy and related documents such as the Nutrition Standards for Consumers of Mental Health Services

- The importance of consumer and/or carer representation on nutrition care committees

- The need for clinical information systems that link clinical data into a menu management system

Slide 9: Background: ACI Nutrition Standards The ACI Nutrition Standards are to be used by dietitians and food service providers as the foundation document for menus designed for hospitals.

Each Nutrition Standard is based on the nutrition requirements for either adult inpatients whom are at risk or malnourished, children and young adolescents or mental health populations who are at risk of enduring conditions (e.g. metabolic syndrome, overweight / obesity).

All the Nutrition Standards include nutrient goals, minimum number of choices to be offered and serve size of food and fluids.

They all align directly to the Element 5 of the Nutrition Care Policy “Planning and Delivery of Food and Fluids”.

Slide 10: Background: ACI Nutrition Standards Continued – 3 Standards PicturesIn 2011, the Nutrition Standards for Adult Inpatients, Nutrition Standards for Paediatric Inpatients in NSW Hospitals, and the Nutrition Care Policy were released.

Clinicians identified that the Nutrition Standards for Adult Inpatients did not meet the needs of the Mental Health Consumers in NSW.

The focus of the Nutrition Standards for Adult Inpatients was on malnutrition and did not factor in

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the high prevalence of chronic disease in mental health populations. In general hospitals there are high rates of malnutrition ~ 30%, consumers have a much shorter length of stay and an older average age. Hence these standards focused on providing food and nutrition that is high in energy and protein.

Consequently a Nutrition & Mental Health working group was established in late 2011.The working group was multidisciplinary, representing metro and regional areas, large and small facilities, from acute, non-acute, subacute, forensic, older persons, and rehab units. The working group had representatives from Food Service, the Official Visitors Program & the NSW Consumer Advocatory Group (Mental Health)

Literature reviews, consultation with consumers, audits and mapping across mental health facilities all provided the information required to develop and release the Nutrition Standards for Consumers of Inpatient Mental Health Services in NSW.

Nutrition Standards for Consumers of Inpatient Mental Health Services in NSW were released in 2013 and provided the guidance to facilities to ensure that the “Food and Fluid” component of the mandatory Nutrition Care Policy can be implemented.

Slide 11: Background: ACI Nutrition Standards Continued – Table Comparison The Nutrition Standards for Consumers of Inpatient Mental Health Services in NSW are not designed to be used for children, but rather for older adolescents, adults and older people. Nor are the standards appropriate for consumers with eating disorders.

The MH standards differ significantly to the general adult standards with the focus on high rates of over-nutrition whilst also acknowledging the presence of under-nutrition, and more specifically the often poor intake of micro-nutrients.

The nutrient targets within the Nutrition Standards are based on the needs of people aged 31-50 years which is reflective of the largest consumer population in mental health facilities.

Slide 12: Nutrition Standards for Mental Health: Overview The Nutrition Standards are evidence-based best practice and developed by the ACI Nutrition & Mental Health Working Group.

Consumers with mental illness are a unique and varied group who needs differ to the general hospital population.

The new standards apply to all situations were food and fluids are provided to mental health consumers.

Slide 13: Nutrition Standards for Mental Health: Importance of Nutrition Adequate nutritional intake is extremely important for consumers with mental illness.

Adequate nutrition is of benefit to both the consumer and the health system. In terms of consumers it has the following benefits:1) Improved clinical outcomes and metabolic

profiles2) Prevention of malnutrition: There is a risk of

both over-nutrition and under-nutrition in this group of consumers that may manifest as malnutrition. Protein Energy Malnutrition is less than 8% in mental health facilities, and is generally more prevalent in older age groups.

3) Improved skin integrity and wound healing: Adequate nutrition contributes to reducing the risk of pressure injuries and improve wound healing. This results in better outcomes for the consumer and health system

4) Improved satisfaction: Providing a menu that will offer food choices that are appetising, appealing and enjoyable whilst also meeting their clinical, psychosocial, cultural and religious preferences will ensure an improved satisfaction, and consequently improved nutritional intake.

5) Improved life expectancy: Consumers with mental illness are dying at a rate of 25 years younger than the general population. This is primarily due to treatable physical co-morbidities. Improving the consumer’s nutritional intake that reflects the Australian dietary guidelines will aid in improving life expectancy.

6) Normalising eating behaviours: The menu should aim to ensure that the environment is as normalised as possible. Meals should be appetising and culturally appropriate, with variety and flexibility to reflect the characteristics and demographics of the people admitted to the mental health facility as well as their length of stay. The meal service should enable access to adequate quantities of appropriate foods and fluids to meet the individuals’ nutritional needs and to ensure satiety. Adequate food needs to be available 24 hours a day.

7) Reducing falls risk.In terms of the Health System, good nutritional intake results in improved immune function, improved muscle strength and function, improved rates of healing, less risk of depression, less rates of physical co-morbidities such as diabetes, heart disease and obesity. This consequently results in

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decreased cost of treatment, decreased length of stay and decreased metabolic complications.

Slide 14: Nutrition Standards for Mental Health: Overarching Principles & GoalThe overarching principles support the goal and focus on the right of consumers to be provided with safe, nutritious and appetising high-quality meals of sufficient variety to meet their needs and expectations, and which offer a model of best nutritional practice.

Foods should be offered in a supportive environment where eating is normalised, in all situations and considering all aspects of nutrition.

Principles include:1) NSW Health acknowledges a duty of care to

ensure access to safe, appropriate and adequate food and fluid as an essential component of care and treatment.

2) The menu will offer food choices that are appetising, appealing and enjoyable - psychosocial, cultural and religious preferences. This is extremely important to support food intake, quality of life and consumer satisfaction.

3) Menu design will be based on the needs of the consumers of the inpatient mental health facility (length of stay), and apply best-practice principles in menu planning.

4) Variety with respect to food colour, texture, taste, aroma and appearance.

5) The menu design and choices offered will maximise opportunities for consumers to choose at least the minimum number of serves from each of the main food groups recommended in the Australian Dietary Guidelines (ADG).

6) The National Health and Medical Research Council’s Nutrient Reference Values for Australia and New Zealand will be the basis for developing menu standards that are adequate in nourishment and hydration.

7) The meal service will enable access to adequate quantities of appropriate foods and fluids to meet the individuals’ nutritional needs and to ensure satiety. Adequate food needs to be available 24 hours a day.

8) Where possible, a person’s nutritional requirements should be provided from food.

Overall improved nutrition will contribute to reduced morbidity, mortality and increased life expectancy.

Slide 15: Nutrition Standards for Mental Health: Why the Standards are needed

Mental Health consumers in NSW inpatient mental health services have the following characteristics: 1) Younger than the reference person used in

the adult hospital nutrition standards. The majority of consumers in MH beds were aged between 25 and 54 years old (63%). However, nearly 20% of Mental Health Consumers are aged over 55 years (this compares to 51% in general hospitals).

2) Longer average length of stay (average non-acute admission 126 days, average acute average length of stay was 14 days)

3) The Aboriginal and Torres Strait Islander population represented at a higher rate in mental health beds: 7% as compared with 2% in general hospital beds

4) Diverse population with children and adolescent mental health consumers through to the older person

5) As discussed previously, both under and over-nutrition are prevalent, particularly micronutrient malnutrition.

6) Higher risk of obesity and cardio-metabolic chronic diseases and lower risk of protein-energy malnutrition than in general consumers.

7) There are a variety of factors which impact on the nutritional status of Mental Health consumers: - Effects of common psychotropic

medications (often leading to weight gain, increased risk of diabetes, constipation, increased risk of choking, lethargy and amotivation)

- People with mental health illnesses often demonstrate unhealthy eating patterns compared with the general population (more fat, sugar, skipping meals, more takeaway, food hoarding, low fibre diets)

- Less physical activity in people with depression and psychosis and as a result of reduced opportunity to exercise in hospital

- Trauma can effect nutritional intake- People with mental health illnesses are

more like to engage in high-risk behaviours such as drug and alcohol misuse, smoking and caffeine overconsumption

- Amotivation and impaired cognition all effect a person’s nutritional intake

- Socialisation will improve food intake.

8) Food service systems are different. More commonly meals are eaten in dining room settings, and there is greater access to food from external sources.

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Slide 16: Nutrition Standards for Mental Health: FormatThe Nutrition Standards outline the key macro- and micronutrient goals such as energy, protein vitamins and minerals. The new menu developed should meet these goals. This will enable most consumers to meet their individual nutrient requirements. These Standards only include recommended daily intakes (RDIs) for nutrients likely to be important to people admitted to inpatient mental health facilities. If menus are designed to meet these specified nutrient goals, it is likely the requirements for other essential nutrients (e.g. thiamin, vitamin A or potassium) will also be met.

All of the nutrition standards (Adult Inpatients, Paediatrics and MH consumers) are presented in the same format.

This is an example of the structure of the nutrition standards. This example is looking at energy as the nutrient. The goal is to ensure that the consumer has access to 8000 kJ a day which is the recommended daily energy requirement. The strategies acknowledge that individual requirements will vary, with a need for choice on the menu that will enable the consumer to meet their individual goals. The strategies provide practical ideas on how we can adapt these standards to meet the needs of individual consumers.

The rationale provides the background evidence behind the goal and strategies.

Slide 17: Nutrition Standards for Mental Health: Minimum Menu Choices Choice is a key factor affecting food intake and satisfaction.

A minimum standard for menu choice helps to ensure people in mental health facilities are provided with a range of foods consistent with dietary guideline recommendations, consistency of service provision across the State, and equity of access.

Minimum Menu Choice Standards outline minimum number of choices, serving size and comments. It is divided into foods provided at main meals and those at mid-meals.

The actual number of main meals and menu patterns are not specified, to allow flexibility in menu planning and implementation.

The traditional meal pattern in hospitals has been: breakfast, lunch and dinner, plus three mid-meals. However, it is recognised that other models could also be used to meet the nutrient goals and the

minimum menu choice standard; for example, four or five smaller meals a day.

Slide 18: Nutrition Standards for Mental Health: Format: Banding The standards also include ‘Bands’. The ‘Bands’ classify menu items with respect to nutritional content and density. These Bands define nutritional profile with each menu item category – soup, main dishes, salads, sandwiches, vegetables and desserts.

The Bands attempt to reflect foods typically used in the Australian diet to ensure a range of menu items are able to be offered to all inpatient groups, including acute, sub-acute residents and those who have frequent admissions.

The Bands address energy content, nutrient density and consumer expectations. For example, a consumer choosing fish from the menu would receive a minimum of 110 gm fish with a maximum fat content of 10 grams and maximum sodium content of 161 mg. A wet dish such as a beef stroganoff needs to be at least 120 grams of cooked weight, with a maximum of 1500 kJ, minimum 20 grams of protein, maximum 15 grams of fat and maximum of 460 mg of sodium.

Slide 19: Nutrition Standards for Mental Health: New Features The major features of the Nutrition Standards which differ from the general adult standards include:

1) Consumer-centred and recovery-focussed language

2) Consumers are often hungry due to the appetite stimulating effects of psychotropic medications. So the time lapse between supper and breakfast should not exceed 12 hours

3) A minimum variety to be offered on menus is featured due to the long length of stay and goal to normalise eating

4) Limits on the amount of energy of main meals and mid meals due to the higher rates of obesity, overweight, diabetes, and cardiovascular disease

5) Deficiency in magnesium and long-chain omega-3 fatty acids have been linked to depression. The standards include goals for magnesium and omega 3 fatty acids. The standards have a magnesium nutrient goal of 420mg/day from vegetables, legumes, nots and wholegrain cereals

6) High fibre bread and breakfast cereal choices due to high rates of constipation and excessive hunger with MH consumers. The nutrient goal is 30 gram of fibre a day

7) Low glycaemic index foods choices at each meal due to higher rates of diabetes,

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metabolic syndrome and hunger. Low glycaemic foods offer higher rates of satiety.

8) Omega-3 content which has been linked with improving depressive symptoms. The omega 3 fatty acids goal of 430mg/day can be met from fish three times a week in main dishes, sandwiches or salads preferably oily fish such as tuna, salmon, sardines

9) Information on nutritional issues for particular groups and nutrition-related conditions (e.g. eating disorders, older people, metabolic syndrome, coeliac disease)

10) Advice on the availability of caffeinated beverages due to the various impacts that caffeine can have on the body including acting as a central nervous system stimulant, which can increase blood pressure and levels of catecholamines.

Slide 20: Nutrition Standards for Mental Health: New Features Menus and food provision practices that meet the Nutrition Standards should be implemented by mid 2016.

LHDs/Networks are responsible for implementing the standards in collaboration with their Food Service Provider.

To assist with implementation the ACI Nutrition & Mental Health Working Group has developed a Toolkit.

The Toolkit provides guidance, tools and resources for LHD / Networks and Facility Nutrition Care Committees.

The Toolkit is divided into 4 parts:Part 1 is the Nutrition Standards Implementation ChecklistPart 2 is on Governance and LeadershipPart 3 is Nutrition Standards Education & Resources and the final part is on Menu Development.

Slide 21: Nutrition Standards for Mental Health: Toolkit The Toolkit resources include: - An implementation checklist to be used in

conjunction with the Nutrition Care Policy checklist

- Templates for Agendas and terms of reference for LHD / network meetings and Facilities

- Nutrition Care Policy Accreditation Mapping document to the above mentions standards e.g. National Standards for Quality Health Services

- This presentation as well as other educational handouts

- Menu design package that includes minimum menu choice checklist, site information data collection tool, example menu and banding ready reckoner.

Slide 22: Nutrition Standards for Mental Health: Evaluation of the Standards In nutritional standards evaluation will include the following:1) Evaluation of implementation 2) Achievement of its goals in terms of consumer

focuses, clinical practice and overall nutrition care policy compliance i.e. governance, patient / consumer satisfaction survey

3) The Nutrition Standards will be reviewed to ensure they remain evidenced-based and reflect best practice.

Slide 23: So what to do next?

Mental health facilities could consider the following:1) Form a Local Health District / Network

Nutrition Care Committee, if not commenced already

2) Form Local / Facility Nutrition Care Committee's or include Nutrition Care on an existing meeting agenda e.g. Clinical Quality & Patient Safety to form a local governance structure

3) Check each site’s compliance with the Mental Health Nutrition Standards Implementation Checklist – Part 1

4) Develop and action plan

Slide 24: Resources and Reference For more information please see the following resources for more details.

Slide 25: ACI Contact If you have any questions and/or would like more information please contract Tanya Hazlewood, the ACI Nutrition Network Manager.

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