AGING: An ADA PRIORITY AREA

1
AGING An ADA PRIORITY AREA

• NANCY WELLMAN, PhD, RD, FADA
• National Policy Resource Center on Nutrition
  Aging
• Florida International University

2
ADA AGING Priority Area

• Guiding Knowledge Basic Premises
• Millions of older Americans would benefit from
  nutrition services if they were more broadly
  available.
• There is a nutrition care crisis in long term
  care facilities from skilled nursing to
  assisted living to board care homes.
• Medical Nutrition Therapy in chronic disease
  management reduces health care utilization and
  lessens the need for prescription drugs.

3
ADA AGING Priority Area

• Acknowledges AGING as vital to our profession
• Demographic, ethical, economic issues
• Unmet needs new roles for RDs in AGING
• Strengthen RDs knowledge about aging
• Increase interest in working with older adults
• Educators, CEUs, practicum, mentoring
• Strategic AGING practice policy approaches
• RDs, ADA, DPGs, State Associations
• Federal state legislators agencies
• ADA Task Force on Aging established

4
ADA AGING Priority Area

• Strategies
• Complement current position papers w/ more
  targeted ones on nutrition aging.
• Develop evidence based practice guidelines and
  other tools on nutrition aging.
• Integrate MNT within all health care delivery
  systems serving older adults.
• Update expand university curricula on aging.
• Partner w/ national aging societies advocacy
  organizations to support stronger strategies and
  responses to the needs of older adults.

5
AGING Priority Area

• Americas Longevity Revolution needs a Dietitian
  Revolution!
• We need to be part of the solution, not part of
  the problem!
• Nutrition care crisis LTC, especially nursing
  homes.
• Malnutrition nutrition risk persons in home
  community based systems, eg, ALFs, home health,
  caregivers, etc.
• Its never too late to promote good nutrition!

6
AGING Priority Area

• Health care delivery systems have changed
  dramatically during the past decade.
• Nutrition services venues have not.
• Clinical nutrition has moved out of hospitals
  into communities.
• Hospitals today are yesterdays ICUs.
• Nursing homes today are yesterdays hospitals.
  Where are the full time RDs?
• Assisted living facilities today are yesterdays
  nursing homes. Where are the RDs?
• Home community based care is where its at
  nursing home w/o walls. Where are the RDs?

7
SHORTAGE RD EXPERTISE

• AGING NETWORK
• AoA, AoA Regions, SUAs, AAAs, ENPs
• LONG TERM CARE
• nursing facilities, ALFs, retirement communities,
  personal board care homes, etc, etc.
• HOME COMMUNITY-BASED CARE

8
STATE OF THE PROFESSION

• Are we preparing todays students for tomorrows
  jobs?
• Knowledge attitudes about older adults
  employment preferences of students Kaempfer,
  Wellman, Himburg, JADA, Feb 2002
• Aging content in dietetics nutrition curricula
  Rhee, Wellman, Castellanos, Himburg, JADA in
  press
• Content analysis of aging in textbooks
• Intro Life Cycle Nutrition Gerontol Geriatr
  Educ in press
• Diet Therapy Community Nutr in prep

9
299 SENIOR DIETETICS NUTRITION STUDENTS

• FINDINGS
• Low knowledge about older adults
• Lower than other professions
• Neutral attitudes toward older adults
• Least preferred to work with oldest age groups
• 65-74, 75-84, 85

10
RDs NEED TO KNOW MORE ABOUT AGING

• Increase aging content in curricula in
  undergraduate, graduate, CEU programs.
• Broaden exposure to older adults through
  classroom field experiences.
• Include more information on aging, including
  positive aspects, in textbooks.
• Partner w/ on-campus interdisciplinary resources
  in aging join AGHE in GSA.
• Emphasize aging in core competencies strategic
  planning by health professions.

11
OPPORTUNITIES FOR NUTRITION INTERVENTION
NURSING HOME CARE
HOSPICE CARE
SUPPORTIVE
DAY SERVICE RESIDENTIAL
SUB-ACUTE CARE
LINKAGES / REFERRALS
ACUTE CARE
HOME CARE
Continuity of Care Multidisciplinary
COMMUNITY CARE
AMBULATORY CARE
MEDICAL
12
THE NUTRITION GAP
INDIVIDUAL

• Supportive Medical / Health
• Services Services
• Food Nutrition Food Nutrition
• nurturing, emotional, therapeutic tx for
• quality of life, social role medical condition
• 2 SEPARATE, PARALLEL SYSTEMS
• LITTLE CONTINUITY OF CARE

13
WHAT IS LONG TERM CARE?

• A wide range of assistance, services, or devices
  provided over an extended period of time and
  designed to meet medical, personal and social
  needs in a variety of settings or locations to
  enable an individual to live as independently as
  possible.
• New federal objective Rebalance LTC

14
WHERE IS LTC PROVIDED?

• Community sites
• Senior centers, HCBC
• Adult day care
• Home
• Home Health
• In home, Caregivers, HCBC, Med. Waiver
• Hospice

• Residential
• Assisted Living Facilities
• Continuing Care Communities
• Adult homes/personal care homes
• Nursing homes
• Sub-acute
• Short Term /or Rehab
• Long Term
• Hospice

15
COMMON SERVICES SUPPORTS IN HCBC

• Adaptive aids/equipment
• Adult companion
• Adult day health
• Case management
• Caregiver support
• Chore
• Congregate meals

• Consumer protection
• Counseling
• Benefits
• Nutrition
• Retirement
• Elder abuse/neglect
• Exercise programs

16
COMMON SERVICES SUPPORTS IN HCBC

• Home modifications
• Homemaker services
• Home modifications
• Information and assistance/referral
• Medication management

• Education
• Health
• Nutrition
• Guardianship
• Habilitation
• Health monitoring
• Home-delivered meals

17
COMMON SERVICES SUPPORTS IN HCBC

• Therapies
• Occupational
• Physical
• Speech
• MNT
• Training
• Family
• Transportation
• Volunteer opportunities

• Personal emergency response
• Psychological counseling
• Respite care
• Skilled nursing care
• Social Activities

18
HOW IS LTC PAID FOR?

• Local community funds
• Medicare
• Medicaid
• Out of pocket
• Older Americans Act funds

• Private charitable funds
• Private insurance
• State funds
• Veterans Administration

19
HOW IS LTC REGULATED?

• FOLLOW THE MONEY who pays
• Home health nursing homes
• Medicare Medicaid
• Most LTC services
• Assisted living facilities
• Continuing care communities
• Adult day care
• Adult or personal care homes
• Self-regulated some natl association standards
• Accredited by organizations (CARF)
• Regulated by state entities

20
WHERE ARE NUTRITION SERVICES and RDs?

• Older Americans Act
• State/local agencies must solicit advice of
  dietitian or individual of comparable expertise
• No requirement
• Assisted living facilities
• Adult care homes
• Continuing care communities
• Adult day care

• 1915 (c) Medicaid Waiver-Fed/State funded
  Nursing home without walls
• List of 20 services
• Definitions for homemaker, chore, home health
  aid, various therapies, etc.
• NO mention of nutrition, meals, RD
• Nutrition services NOT IDENTIFIED AS NECESSARY to
  keep people in home or independent

21
IOM RECOMMENDATIONSRole of NutritionElderly,
1999

• HCFA, accreditation, licensing groups should
  reevaluate existing reimbursement systems
  regulations for nutrition services along the
  continuum of care (acute, ambulatory, home,
  skilled nursing LT care) to determine adequacy
  of care

22
IOM RECOMMENDATIONSRole of NutritionElderly,
1999

• RECOMMENDATIONS
• Validate nutrition screening methodology in acute
  care, as well as optimal timing of nutrition
  screening
• Provide nutrition services, including basic
  nutrition education nutrition therapy, in home
  care settings
• Review requirements standards for food
  nutrition services in skilled nursing LTC
  facilities

23
THE NUTRITION CARE CRISIS

• 35-85 LTC residents at risk for malnutrition
  dehydration
• 70 NH residents fail to finish 75 of food,
  major determinant of mortality (UCLA Borun Ctr
  Aging)
• 15-25 of residents admitted to NH have pressure
  ulcers (Geriatric Med, Mayo website)
• clear association w/ protein energy
  undernutrition (PEU)
• 208,000 gt65y admitted to acute care w/ 1 dx of
  dehydration (CDC/NCHS 1998)
• 5.8 day average length of stay
• 50 of elderly Medicare beneficiaries
  hospitalized w/ dehydration died within 1 year
  (AJPH 1994)

24
ASSISTED LIVING

• Only State Regulations, e.g., Florida regs
• Weights semi-annually
• wt loss evaluated at survey
• Provide therapeutic diet or offer selections that
  meet diet requirements
• Monitor quality quantity of therapeutic diets
• Person designated in charge of food service
• Must perform duties in safe sanitary manner

25
ASSISTED LIVING

• Florida regs, cont.
• Menus must meet RDA via Food Guide Pyramid
• Minimum portions defined (explicitly)
• Adapted to habits, preferences physical
  abilities of residents
• Reviewed annually by RD
• Meal timing defined
• Facility must employ or contract an RD if Class
  I, Class II, or uncorrected Class III deficiency

26
ASSISTED LIVING

• No regulations for assessment
• No regulations for education training
• For ALF w/ special license for higher level of
  nursing services
• ie, Limited Nursing Services, Extended
  Congregate Care (No tube-feeders or Stage 3 or 4
  ulcers)
• No additional dietary regs re nutrition staffing

27
ASSISTED LIVING

• CASE STUDY
• Problems w/ weight loss _at_ survey
• Consultant RD contracted
• Interviewed M resident w/ signif. wt loss
• Swallowing problem 2? esophageal stricture
• Staff couldnt make adequate mechanical
  modifications
• Resident was mashing meals in his room.

28
ASSISTED LIVING

• Roles for RDs
• Food Service
• Menus (adequacy, therapeutic, cultural)
• Sanitation
• Production
• Nutrition Care (dynamic population)
• Nutritional screening/assessment
• Mechanical consistencies
• Adaptive devices
• Diet orders/therapeutics
• Individualize feeding per resident needs
• Overweight, underweight, poor appetite,
  food/medication interactions, dehydration

29
PERSONAL CARE/ADULT HOMES

• Fewer than 10 residents
• Only state regulations, eg, Florida regs
• Staff
• 21, read write, pass background check
• receive training in food safety w/in 30 days
  of hiring if relevant to duties
• Assistance
• Provide help with cutting food, pouring
  beverages, hand feeding, etc., as required

30
PERSONAL CARE/ADULT HOMES

• Staff should observe, record report
  significant change in weight, Stage 2 ulcer, to
  care provider case worker
• Food Service
• Meals planned on Food Guide Pyramid
• Nutrition retained easy to consume
• At least 3 meals/day, nutritious snacks
• Provider should assist resident w/adaptive
  equipment
• Food prepared should follow diet orders
• Consideration to ethnic preferences

31
PERSONAL CARE/ADULT HOMES

• Roles for RDs
• Write menus, cultural considerations
• Educate staff about food cooking
• Knowledge may be quite limited
• Training technical assistance
• Mechanical consistencies
• Adaptive devices
• Diet orders/therapeutics
• Individualize feeding per resident needs
• Overweight, underweight, poor appetite,
  food/medication interactions

32
HOME HEALTH

• Mid-1990s Home Enteral Nutrition
• 75 HEN for gt65 y
• 1400 Medicare beneficiaries
• Growing 25 per year
• Medicare 6M/y on tube feed supplies
• No mention of nutrition professional Code of
  Federal Regulations for home health agencies
• JCAHO standards for nutrition eval not specif.
• Medicare reimbursement policy restricts nutrition
  services in home nutrition therapy
• Only 2 Dx diabetes renal disease, to date

33
HOME HEALTH

• 77 technology-dependent home care managed by
  family caregiver
• 59-88 family caregivers receive no formal
  instruction
• May lead to mistakes contribute to serious
  complications, poor outcomes
• 20 tube feed complications require MD or ER
  visit
• 9-15 result in hospital admission

34
HOME HEALTH

• Roles for RDs nutrition support
• Discharge planning by RD skilled in home
  nutrition support Team effort w/ RNs
• 60 enteral Rx by MD, 40 by RD (n30)
• 78 nutritional requirement
• Water Rx via Tube, 1-2000 ml
• On average, 53 fluid requirement
• Develop educational materials for caregivers
• Prevent physical, technical, nutrition
  complications
• 14-73 of tube fed older adults (n30)
• RDs in ambulatory care develop evidence-based
  protocols follow-up, monitoring, reassessment
• Water intake as of need 7-201
• HJ Silver,
  Dissertation, 2001

35
HOME HEALTH

• Roles for RDs nutrition care
• Educate caregiver on basics of nutrition
  hydration
• Training technical assistance
• Mechanical consistencies
• Adaptive devices
• Diet orders/therapeutics
• Individualize feeding per client needs
• Overweight, underweight, poor appetite,
  food/medication interactions
• Problem solving/simplification
• Easier for both care receiver caregiver
• Nutrition screening for care receiver giver

36
SKILLED CARE/NURSING HOME

• Federal State Regulations
• More extensive nutrition regulations
• Consultant RD minimum reqd by fed law
• No minimum qualifications to chart
• Nursing Home A
• 120-bed, 60 skilled
• Hospital district affiliation, govt ownership
• 99 Press-Ganey Customer Satisfaction
• Nutrition Staffing
• 1 FT DTR
• Consultant RD 5 hrs/week

37
SKILLED CARE/NURSING HOME

• CASE STUDY 76y B F, cared at home by niece
• Indigent case (our tax dollars)
• Admitted hospital w/dehydration
• 2? eating drinking problem
• IV fluids, discharged home over concerns of
  niece
• Presented hospital w/ dehydration, severe
  malnutrition, pressure ulcers
• 11 wounds, all areas of body
• Albumin too low to measure on std lab tests
• Stabilized with IV fluids

38
SKILLED CARE/NURSING HOME

• CASE STUDY, cont.
• Discharged to NH w/o addressing PO problem
• Admission wt 80 lb
• Several days for NH assessment
• Needs cant be met PO
• Hospital note say family wont accept tube, but
  niece open to PEG when approached
• Readmitted to hospital for PEG
• Back in NH, has gained 5 lbs, but
• NH A averages 20-24 tube feeders
• Remember FT staff 1 DTR

39
STAFFING GUIDELINES

• Clinical Care
• Assessment 45-60 min/resident
• 120 min/first 14 days
• On-going risk documentation 20 min/res
• Communication with nursing 30 min
• Care Plan Conferences 60 min/wk
• Vogelzang Womack, CD-HCF 1999
• Cant just count beds
• admissions
• Acuity skilled beds

40
RESEARCH LTC Institute

• Victoria Hammer Castellanos, PhD, RD
• Beyond Clinical Care
• Adequate nutrition care is neither simple nor
  uni-dimensional
• Full time RD for on-going coordination of
  resident feeding assistance
• Appropriate staffing ratios
• Organizational plans for mealtime assistance
• Paradigm shift re Licensed Nurses
• Involvement of nurses is essential for success
• RDs need to facilitate systems communication

41
RESEARCH LTC Institute

• Risk Management/Prevention
• State of Florida RDs CANNOT be Licensed Risk
  Managers (but EMTs can)
• Valid systems for resident assessment
• Food Intake, Fluid Intake, Body Weight
• Systems approaches for optimizing food fluid
  intake
• 60 residents drank gt10 oz at snack
• Med Pass 140 cc when 8 oz offered
• www.fiu.edu/nutreldr

42
SKILLED CARE/NURSING HOME

• Nursing Home B
• 180-bed, for profit partnership
• 120 skilled beds
• 80-85 admissions/month
• Hx Nutrition Staffing
• 2.5 FT DTRs
• Consultant RD 4 hours/week
• Recently ? skilled beds from 60 to 120
• Consultant RD finally convinced them they need
  full-time RD

43
SKILLED CARE/NURSING HOME

• Roles for RD
• Clinical Care
• 42 hr/wk new admission assessments alone
• 40 hr/wk reassessments/ongoing care/care plan
  meetings
• Currently, anybody (CDM, DTR, Diet Clerk) can
  (AND DO) provide this service chart in medical
  record as long as facility employs Consultant RD.
• WE ARE GIVING AWAY OUR JOBS
• Would Licensed Nurses let CNAs or orderlies give
  medications, assess wounds, chart progress
  notes in the medical record?

44
SKILLED CARE/NURSING HOME

• Roles for RD, cont.
• Managerial (more experienced RD)
• Risk Management (licensed /or facility role)
• Dining Program
• Staffing
• Seating plan (remember 80 admissions)
• Systems Management Quality Assurance
• Obtaining accurate assessment data
• Interdisciplinary communication cooperation
• Staff Hiring Training

45
SKILLED CARE/NURSING HOME

• Nursing Home B cont.
• Piecing together clinical coverage
• Cant find RD willing to work full-time
• Moonlighting DTRs (working 50-60 hrs)
• Part-time RD
• NH looking to steal RDs from other facility
• Consultants reluctant b/c ? liability
• Piece-meal approach cant achieve quality care
• Some RDs are getting out of NH consulting

46
SKILLED CARE/NURSING HOME

• RD SALARIES
• experience, facility type, medical acuity, mgmt
  responsibilities, location
• Clinical at one facility 35-60K
• Food Service Director 40-60K
• Multi-facility responsibilities 45-65K
• Consultants
• DTR SALARIES
• 25-40K
• Median RD earnings (all) 1998 35K
• Dietitians Edge, 2001

47
SKILLED CARE/NURSING HOME

• Nursing Home C
• Not-for-profit, continuing care/life-care
  retirement community (CCRC)
• 177-bed, w/60-bed Alzheimers unit
• Also 66-bed Assisted Living Facility
• 750 independent living (apts)
• Nutrition staff serves at all levels of care
• After acute illness, often rehab to lower level
  or apt
• 1 FT RD 3 DTRs
• 7 NH residents have ulcers (11 FL)
• Mostly admissions to NH from outside CCRC
• 0 residents w/ wt loss or gain

48
MORE RDs IN AGING STRATEGIES

• Revamp curricula to include more aging
• Information in courses UG Graduate
• LTC experience clinical, foodservice,
  administration, care management
• Mentor students newcomers to aging
• Broaden continuing education in Aging
• Holistic approach, multidisciplinary
• Nutrition as 1o, 2o, 3o prevention
• Gerontology Geriatrics
• Eliminate ageism

49
MORE RDs IN AGING STRATEGIES

• Partner with decision makers
• Improve access to nutrition care
• Improve quality of nutrition care
• Establish aging committees, subcommittees
• State District Associations, DPGs
• Merge CDHCF GN DPGs
• Rename Dietitians in LTC or Nutritionists in
  Aging
• Form aging task forces coalitions
• Federal, state, local
• ADA, DPGs, RDs,
• Other health professionals advocacy groups

50
MORE RDs IN AGING STRATEGIES

• Make room for more RDs from inside
• Mentor students newcomers to aging
• Modify use care standards
• Consultation protocols
• Home Care Practice Report
• GN Standards of Practice
• Negotiate more hours in fewer LTC facilities
• Create FT positions to meet ? acuity needs
• Explore other LTC venues beyond nursing homes

51
MORE RDs IN AGING STRATEGIES

• Advocate against nutrition-related abuse,
  neglect, exploitation of older adults
• Protective services, Ombudsman, media
• Adequate financing for quality services
• Partner w/ health colleagues advocacy groups
  AMDA, NCNNR, etc., etc.
• Show cost-effectiveness
• LTC administrators
• Insurance industry
• Federal state legislators

52
AGING Priority Area

• RDs INVISIBLE IN AGING CARE
• NO LONGER ACCEPTABLE
• PROFESSIONAL MANDATE
• ETHICAL ECONOMIC REASONS