Rhythms of Daily Living Dining & Choice Rhythms of Daily Living © Dining & Choice Aligning Expectations – Resources – Outcomes

Rhythms of Daily Rhythms of Daily LivingLiving© Dining & ChoiceDining & Choice

Aligning Expectations – Resources – Outcomes

April 28, 2004 IAHSA - a celebration of age 2

Why Do 65% Of NH Residents Eat Less Than 75% Of Most Meals* ? Primary Factors That Contribute To Malnutrition In

Nursing Homes 1. An Inappropriate Dining Experience For The Resident.

2. Meal Delivery Methodology and Systems Not Conducive To Eating.

3. Good Nutrition is of no value if it is not consumed

*Excerpted From Ch 14 Of Report To Congress “Appropriateness of Minimum Staffing Ratios In Nursing Homes” Authored By J. F. Schnelle et al, Borun Center For Gerontological Research


Must Rising Acuity Levels Mean Lower Dining Quality ?

©©

Independent Living Assisted Living Memory Enhanced Skilled Nursing

Nutrition Quality Food Quality Service Quality Life Quality


What Are Factors of a Quality Dining Experience? Relaxed service Choice of what, where and when you eat Participation in the definition of generational experience

expectations Reputation – consistency of service Timeliness Presentation & Taste of meal Do not rush me Neighbors, Atmosphere, aroma, friendliness cleanliness Residents eat when hungry & personal eating habits are

accommodated

The Simple Answer Is NoNo!


Skilled Care Dining TodayRestricted Service Times, Too Short For Quality & Assistance

< 20 MinutesFor Dining

0 10 20 30 40 50 60

Minutes

Loading Time

Transport Time

Waiting Time

Service Time

Dining Time

Extra Assistance

Food Quality Zone

Temp. Integrity

The Quality Gap


Bridging The Quality GapServe The Resident, Not The System

The System – Individual Preparation, Bulk Service Prepare Individual Menu Items For Storage Place On A Tray For Transport To Feeding Area Transport and Leave In Cart Distribute and Unwrap At Scheduled Meal Time

The Alternative – Bulk Preparation, Individual Service Prepare Menu Items In Bulk Transport To Dining Room Servery Plate Individually and Serve Upon Request


Rhythms of Daily LivingRhythms of Daily Living

The core of RDL is the opportunity to exercise choice – residents’ for how they choose to live their day and staff choice for care delivery. This creates a collaborative coalition of residents and caregivers working together in a living environment. RDL facilitates the delivery of care, the experience of living and the dignity of self-determination.


RDL is a management principle that aligns the natural rhythms of residents and the support they need. The organizing principle of RDL is that people should be able to make meaningful choices in their daily lives – on their own or with assistance. RDL relies on caregivers to help define and achieve outcomes that balance individual choice and system efficiency.


Balancing the Natural Rhythms of Resident Living and Care Work A “More Normal” Pattern of Living and Work

Residents Eat What And When They Want Over A Longer Meal Service Pre-Meal Medications, Bathing and Other Activities Are Less Pressured Staff Provides Assistance As Required

24 Minutes Is Average Optimal Feeding Assistance Time With A Range From 5 To 70 Minutes Depending On ADL Status*

48% Of Nursing Home Population Require Some Degree of Assistance* A Dining Experience, Not A Feeding Period

Shift Dining Service Focus From Trays To Residents and Quality Collaborative Service Support Aroma Therapy Course Presentation Minimal Distraction Environment

*Excerpts From Ch 14 Of Report To Congress “Appropriateness of Minimum Staffing Ratios In Nursing Homes” Authored By J. F. Schnelle et al, Borun Center For Gerontological Research


What are the Attributes of a Quality Dining Experience? Quality of menu item presentation Appetizing Taste Variety Atmosphere, environment Pleasant service Choice Consistency China/glassware Timely Appropriate temperature & consistency


The Main Thing For Senior Care

Choice


“Some facilities studied, usually the lower turn-over ones, were in the process of thinking about how to increase individualized care. For example, the researcher asked, what are you doing if anything about resident choice. ‘We are looking at it. Ideally, we want them to eat when they want. We encourage them to tell us what care they want, a shower or bath, or to get up when they want.”

Page 5-49 Appropriate of Minimum Nurse Staffing Ratios in Nursing Homes, Phase II Final Report prepared by Abt Associates for the Centers for Medicare and Medicaid Services, December 2001.


Outcomes No complaints Socialization Weight stabilization Improved I/O’s Less plate waste Smiles Reduced staff turnover Improved skin integrity Reduced use of supplements Congenial and pleasant environment – warm & inviting


Benefits better interaction with staff & residents freedom of choice residents more social amongst themselves better presentation Food is hot/cold Better texture POS selection for menu items Better I/O’s Resident choice of time to eat/when hungry

What Are Your Experiences?


What Are Your Experiences?Obstacles

structure of ordering staff resistance to change inadequate staffing training of staff to new tasks Management of change (Fair Process) Need to educate the staff in the process of change Clear explanations of the reasons/outcomes of changes How changes will impact staff security and knowledge

of job tasks and resident served


40% of Residents Gain Weight In The First Few Program Months

50% Reduction In The Number Of Residents Losing Weight. Consistent Improvement In Resident Satisfaction $0.18 – $0.21 Reduction In Food Cost Per Meal From Less

waste. 85% Decrease In Use of Supplements Higher Job Satisfaction Improved Hydration Outcomes Exceed Regulatory Requirements

RDL Is RealReported Results From Ten Communities That Have Implemented RDL


PLAN & DEVELOP

Organize

Alter

Codify

Train

Improve

Choice Dining AlignmentProcess Overview

Plan

Evaluate

Define

Assess

Implement


Plan Transition Process and Commit ResourcesWrite Program Transition Budget and Operating Narrative

Organize

Codify

Organize For Culture Change Establish “Experience” Alignment Teams To Define/Implement Transition

Codify Policies/Procedures and Training By Function Write & Task Procedures/Training Using RDL© Base

Choice Dining AlignmentPlan and Develop

Plan

Evaluate “Readiness” With Leadership, Managers & Residents/FamiliesDefine Outcomes Baseline and Expectations

Evaluate

Define Define Service Functions and Outcomes For Each ExperienceIdentify Beneficiaries/Benefits and Diagram Service Functions


Program Intersects Grid

PROJECT COMMUNITY OF DISTINCTION

FINANCIAL ENHANCEMENT

QUALITY OF LIVING

QUALITY OF WORK

OPERATIONAL EFFECITVENESS

COMMUNITY

POS System Improved management of production controls, improved tracking of billable supplies

Ability to implement DBP

MOW Increase presentation of McLean Brand into the community

Increased revenues and improved efficiencies of the existing resources

Improve QoL for MOW clients Increased operational effectiveness for facilities

Campus Dining Program Continuity of standards throughout the community

Increased cost efficiencies Improved QoL for all residents and work environment for staff

Increased effectiveness in all appropriate operational areas


Program Intersects Grid

PROJECT COMMUNITY OF DISTINCTION

FINANCIAL ENHANCEMENT

QUALITY OF LIVING

QUALITY OF WORK

OPERATIONAL EFFECITVENESS

HEALTH CARE CENTER

3 & 4 Modification RDL

Creates a signature service for the Memory Support neighborhood

Reduce costs with the implementation of RDL

Improved resident QoL and improved staff working environment

Operational benefits of RDL

RDL Dining Creates a signature model of resident service for the HCC

Reduce costs with the implementation of RDL

Improved resident QoL and improved staff working environment

Operational benefits of RDL

MDR Service Modifications Compliment service model of RDL, grille options and service venues

Increased accessibility to dining program increasing revenue options

Increased selection and choice improving QoL

Increased productivity while increasing services reducing neighborhood service requirements.

MOW Capacity Increase Increase presentation of McLean Brand into the community

Increased revenues and improved efficiencies of the existing resources

Improve QoL for MOW clients Increased operational effectiveness for facilities


Assessment Points for RDL ImplementationStages are defined against the requirements of: Administration: fiscal, management and leadership

considerations Regulatory: compliance criteria (grouped by clinical and

operational considerations) Systems: software programs, forms, policy & procedures,

protocols Personnel: staffing requirements, training, HR. The impact

on each care disciplines is identified by department PP&E: Property, Plant & Equipment necessary to perform

the tasks and functions


STAGES of RDL Readiness GAP Analysis

Establish clear understanding among all constituents (residents, staff and administration) as to the program impact on 6 principle areas.

Culinary Capacity Establish a servery on the resident floor where all meals can be finished, plated and served.

Individualized Service Establish a service program without the tray system. Meals are plated in the servery when the resident is in the

dining room. Choice is based on pre-ordered menu items, however time of service is not flexible. Point of Service Menu Choice

Establish the opportunity for the resident to choose alternate items from a menu during meal service. Schedule Choice I[1]

Establish the opportunity for residents who are self-sufficient and independent to dine at a time of their choosing, within established service times.

Schedule Choice II Establish the opportunity for residents who require assistance with dining but are able to determine when they

would like to dine to do so within established service times. 7. Venue Choice (If Appropriate)

Establish the opportunity for residents to choose alternate places to dine.

[1] Schedule choice is the last and most difficult stage to implement because it affects the scheduling of all resident activities from bathing to medication and activities.


Choice Dining Alignment Continuous QualATIsm Alignment

Improve

Train

Alter

Assess

EffectivePractices

Documents

Rhythms of Daily Living Dining & Choice Rhythms of Daily Living © Dining & Choice Aligning Expectations – Resources – Outcomes