Lisa Alexander and Sally Renke
|The project also had strategic level support from:|
|Helen Reilly, Therapy Lead and Professional Lead for Dietetics, Heart of England NHS Foundation Trust|
|Carole Davies, Head of Planned Care, Solihull Community Services, Heart of England NHS Foundation Trust.|
What was the problem you were trying to address?
Aims of the Nutrition Support project:
To review the use and cost effectiveness of sip feeds and prescribable nutritional products.
To support General Practice and Community Health Services to identify and effectively treat service users at risk of malnutrition, ensuring effective nutritional screening, clear treatment pathways and accessible resources, supported by ongoing training.
To widen the range of therapeutic options available to GPs and community staff, giving them the tools to confidently deliver a range of basic dietary approaches, in addition to the option of prescribing sip feeds.
To expand the capacity of the community Nutrition Support Service to provide specialist dietetic expertise to support the management of complex patients requiring oral nutrition support.
To ensure changes to practice are sustainable
Background to the Nutrition Support project:
The project was instigated in discussion with local GPs and commissioners who were concerned about the high and rising cost of sip feeds. Sip feed expenditure in Solihull had been rising by approximately 10% each year. The 12 month cumulative spend for June 2009-June 2010, was calculated at £658,000 (Figures from Solihull Medicines Management) and this was predicted to increase to over £720,000 in 2011.
Previous attempts to control prescribing had made some impact but had not been sustained. GPs were persuaded that a dietetic approach, working closely with the Medicines Management Team would offer different expertise to support them to improve the cost effectiveness and quality of the nutritional support they provided to patients.
Areas to tackle (raised by the GPs) included:
- A heavy reliance on sip feeds as the predominant therapeutic option to manage malnutrition.
- The need for practical guidance to support GPs and community staff to advise on improving nutrient intake using a dietary approach, as an additional option to using sip feeds.
- Initiation of sip feeds in hospital or following a hospital stay without robust plans for review. It was recognised that nutritional advice for hospitalised patients may need to alter once they are discharged home and that even if oral supplements are appropriate on discharge they may not be required longer term. Clear systems for reassessment and follow up were needed to ensure appropriate advice in the community setting to prevent inappropriate prescribing and subsequent wastage.
- An increase in requests for oral supplementation for service users in nursing, residential and care facilities, often without effective screening for malnutrition and without first line advice to improve nutrient intake using normal foods. This applied across NHS, Council-run and private providers.
- The need for specialised dietetic support to help GPs and community staff with the management of complex patients requiring oral nutritional support e.g. those not improving using first line approaches; those progressing towards enteral tube feeding as a result of a deteriorating underlying condition; those with complex dietary needs underlying a need for nutritional support. (A service was already in place to oversee home tube feeds but had very limited capacity to support management of oral nutritional support).
A 3 year project was developed, funded initially for a one year pilot with agreement to extend if it delivered the agreed objectives.
To complete a review of prescribed nutritional supplement use in all 31 GP Surgeries across the Solihull borough (1/3 completion in year 1).
To deliver nutrition support training for all relevant Community Healthcare Professionals to improve identification of malnutrition using nutritional screening and management of malnutrition in at risk patients. Training to be based around each General Practice, tailored to local needs as identified in the practice-based review of nutritional support provision.
To develop a range of easy to use, easy to access resources to support GPs and community staff to deliver simple dietary advice to support patients / carers to improve food intake.
To establish and support sustainability measures across General Practice and Solihull Community Services as an integrated part of the review process to ensure the changes in practice are continued after the review. (incorporating analysis of ongoing training needs, development of pathways for management and follow up etc).
To set up clinics led by Practice staff to deliver first line management and to monitor and review patients on nutritional support
To provide access to specialist dietetic expertise to support GPs with the management of complex patients requiring oral nutritional support.
To reduce sip feed expenditure to achieve a 2 for 1 saving on the project investment.
How did you create your project plan?
Strategic level planning:
The project plan was formulated in consultation with commissioners, GPs and Medicines Management leads. This engagement was crucial to achieve a shared understanding of the goals of the project and to harness support for the funding and delivery. The initial ‘hook’ was to achieve cost savings while improving quality of provision.
The formulated project was presented at the GP Commissioning Boards for their approval and to gain their support to go into Practices to carry out the local reviews.
A rapid improvement focus was essential to build support, demonstrating that the project could deliver its goals. The dietitian therefore targeted the GP Practices with the highest sip feed expenditure initially, where there was most scope to have a noticeable impact.
Local planning for each practice:
Practices were reviewed one by one. Links with the Medicines Management Team were invaluable. The dietitian worked with the local Prescribing Support Pharmacists to support introduction and development of a project plan for each Practice. An initial discussion was held in the Practice with the Prescribing Support Pharmacist, the Practice Manager and the GP’s to establish a plan of action specific to that individual Practice.
A review of all patients currently receiving sip feeds was carried out by the dietitian in conjunction with Practice staff. This was undertaken by a combination of telephone reviews, clinics and home visits. The review took place within each Practice, this was essential to actively review the patient case load and to achieve engagement of practice staff, rather than a more distant review.
Following the review, a feedback meeting was arranged and again a Practice-specific plan was established built around education needs to improve nutrition support provision; the scope to establish first line clinics; arrangements for review audits and follow up review.
For those Practices with a nursing home in the catchment area, the dietitian conducted a sip feed review within the home, followed by a ‘whole home’ training approach, with the establishment of key nutrition leads within the home and the initialisation of monthly Focus Groups to enable on-going monitoring.
Actions have been carried out as cross cutting background work and in each individual Practice.
- Promote effective nutritional screening at all levels to identify patients at risk of malnutrition using ‘MUST’
- Update local guidelines for management of malnutrition with the inclusion of care pathways and care plans to help to identify and treat malnutrition and to enable the on-going management of complex and chronic oral nutrition support patients.
- Provide access to resources (patient advice leaflets) to support a first line ‘food first’ approach within GP Practices, Primary Care settings, residential and care settings and amongst Practice Nurses, District Nurses and Community Pharmacists.
- Work with Medicines Management to identify high priority Practices based on high sip feed expenditure
- Provide support for Practices to review existing patients on sip feeds and move those who are able onto a nutritionally adequate diet without sip feeds.
- Provide guidance on ‘end points’ for sip feed prescribing.
- Provide dietetic support with nutritional management of complex patients.
- Review repeat prescribing. Review of patients who are currently taking prescribable nutritional products, who have either not been assessed in the community or have no plan for monitoring in place - often this happens as a result of a discharge on sip feeds from acute services where follow-up is passed back to the GP.
- Work with the acute setting to manage the different approaches for discharging patients on sip feeds, streamlining information provided across the acute and community settings to ensure GPs are given clear guidance on nutritional screening and ongoing management of malnutrition, especially following discharge from hospital.
- Provide expert advice on product selection where sip feeds are genuinely needed - most cost effective product, assessing patient preferences and compliance (use of starter packs) maximise rebate.
- Feedback and identify ongoing training needs and delivery plan individualised to each Practice and any local nursing / care homes.
- Work with nursing homes/care homes from all sectors to promote a ‘food first’ approach. Promoting the use of regular, nourishing foods and drinks and appropriate feeding strategies to prevent and treat malnutrition without prescribable sip feeds - this is particularly relevant to care facilities where inappropriate use of prescribable sip feeds was commonly encountered.
- Provide regular updates to GPs and commissioners on the progress and outcomes of the project
- Idenitify a proportion of the cost savings to cover the cost of dietetic provision and to make the case to commissioners to appoint additional dietetic staff (a band 4 Dietetic Assistant Practitioner) to increase capacity to sustain the changes in practice with regular audit and ongoing training.
In the first 12 months, dietetic review of patients who are currently taking prescribable nutritional products has been carried out in 13 GP surgeries across Solihull, reviewing an average of one surgery each month.
For each patient the review has included an assessment of current dietary needs and the implementation of a care plan with on-going review for those with more specialist needs. This dietetic input has supported on average 40 patients per Practice in recovery from episodes of ill health or hospital treatment, ultimately serving to enhance quality of life and wellbeing for those with long term conditions by improving nutritional status.
Use of nutritional screening has increased
A food first approach is becoming embedded at Practice level and in care and residential settings.
The 2 for 1 savings target was exceeded in the first 5 months of the project. Actual prescribing data/performance for 5 practices supported April – September June 2011 shows a two quarter year on year reduction in spend of £22.1K for those practices directly supported (some of those practices did not receive a full 6 months input from the dietician). However in addition as a result of significant sip feeds prescribing awareness by the dietician and already receiving referrals from non-targeted practices the wider benefits of the dietitian’s work can be seen in a further reduction of £20.0K across the remaining Solihull practices for Q1-2 based on a pre-pilot baseline (and not accounting for +10% growth in spend in the previous two years). Therefore the gross savings for Q1-2 have been £42.1K which pro-rata to 1 year and 10 practices is in line with target savings of at least £85K and probably in excess of that. These savings are in addition to any reduction in costs due to reduced dietetics direct access to the Heart of England Foundation Trust acute service and dietetics therapy outpatients as a result of the capacity and availability of a Community-based Nutrition Support Dietitian providing a specialist service for GPs and Community Health Professionals to refer complex oral nutrition support patients to.
There has been a high level of satisfaction with the service delivered with a very positive reception and feedback.
The service has raised awareness of the benefits of high quality nutritional care and has raised the profile of the dietetic service across Solihull.
National and Local Health Outcomes:
The improvements in the quality of nutrition support provided in the community setting helps to deliver improvements in line with the following national outcome domains;
- Preventing people from dying prematurely as a result of unrecognised and untreated malnutrition
- Enhancing quality of life for people with long-term conditions
- Helping people to recover from episodes of ill health or following injury
- Ensuring that people have a positive experience of care
These outcomes also support the following local outcomes:
- More people have good health
- More people are supported to remain in their community for treatment and for recovery.
- More people with health problems are recovering
- More people have improved physical and mental health
- More people have a positive experience of care and support
All of the above lead to cost savings due to fewer hospital admissions, fewer GP visits, reduced inappropriate supplement prescriptions, reduced dependency on primary care services and fewer referrals dietetic outpatient services.
How are you going to maintain the improvement?
The success of the project in its first year has secured agreement for funding for a further two years.
A business case is also currently being developed with the support of the commissioning lead to use a further proportion of the savings to fund a Dietetic Assistant Practitioner to build the capacity of the team to deliver ongoing training, support and expertise.
There is recognition that sustaining the improvements will require long term dietetic leadership and support.
The project has been taken up for roll out across the Birmingham and Solihull Commissioning Cluster.
The dietetic consultations have focused on promoting the use of regular, nourishing foods and drinks and appropriate feeding strategies to prevent and treat malnutrition without prescribable sip feeds - this has been particularly relevant to the care facilities visited.
Care pathways have been developed to identify and treat malnutrition, including the next steps after first line advice and on-going management of complex and chronic oral nutrition support patients.
Written literature and resources have also been developed to support this advice and has been piloted with patients, within care facilities and in General practice.
The initial reviews are being followed up by educational sessions for GP practice staff and for staff in care facilities to enable the changes made to be sustained in the long term.
Training is currently being rolled out in a number of nursing homes and includes sessions for the catering team, trained nurses and care staff.
Nursing home Nutrition leads have also been established and they are meeting with the dietitian in monthly Nutrition Focus Groups, to discuss and coordinate care for those residents highlighted as being at risk of malnutrition. These groups also serve to identify any current gaps in knowledge and practice within the home, which can be addressed by further training and workshops.
Good nutritional care is now a matter of quality. Organisations must now ensure a high quality of nutritional care if they are to meet the national minimum standards as set out by the Care Quality Commission (CQC). Training for all staff within nursing and residential care facilities will serve to meet these standards and improve the quality of nutritional care.
Links have been developed with Solihull Council which has commissioned a rolling training programme for council-funded care facilities. The council is also planning to extend this provision to the private and voluntary sector. The training includes an overview of the Care Quality Commission Outcome 5: ‘Meeting Nutritional needs’ and how it can be achieved through screening using the MUST screening tool, implementing appropriate care plans and providing appropriate first line advice.
Nutrition and hydration are identified as one of the SHA Chief Nurse’s eight ‘high impact’ clinical areas. A nutrition support education program has been initiated for the Community Nurse teams in Solihull Community Services to help to achieve both the nutritional assessment element of the Community Nursing CQUIN and appropriate care planning and sustainability as part of the Solihull Oral Nutrition project. To ensure that this standard is maintained, a rolling training program will need to be completed on an annual basis.
A rolling training program has also been developed for other teams within the community setting, to meet the nutritional outcomes set out in the NICE 2006 Clinical Guideline ‘CG32: Nutrition Support in Adults’. Training is being provided for those Community Professionals that come into contact with vulnerable patient groups, to include The Virtual Wards, Speech and Language Therapists, Hospice staff and the Macmillan Nursing service.
All of the training programmes include education around malnutrition screening using MUST, with the aim of improving the identification of those at risk of malnutrition within General Practice, in care facilities and service users in the community.
Medical Practices have agreed for review sip feed audits to be conducted on a 3 to 4 monthly basis and for the dietitian to conduct a ‘remote’ assessment of appropriate usage. This allows the dietitian to take on a ‘sip feed consultancy role’ and to ensure that malnutrition is being appropriately identified and managed within the practice, following the initial sip feed review and associated education.
A number of Medical Practices have expressed an interest in setting up a Health Care Assistant or Practice Nurse led clinic in house, to provide first line dietary advice to those identified at risk of malnutrition. Training and support are being provided by the Dietitian to enable this to be set up and a Dietetic clinic has also been put in place to provide a service for the more complex patients identified through screening and assessment.
Continued training and dissemination of local guidance and care pathways with the ongoing support of the Nutrition Support dietitians will also serve to deliver a cost saving; NICE has identified better nutritional care as the fourth largest potential source of cost saving to the NHS.
Because of the cost savings generated by the project funding for a Band 4 Dietetic Assistant has been approved by the Commissioners to help support the ongoing training and evaluation required to maintain the improvements that has been made so far.
Tips for others planning similar projects
- Engagement! Work collaboratively to build ownership, ‘buy in’ and support of stakeholders.
- Define clear outcomes. Be very clear about what you will deliver from the start and make sure it is built around what stakeholders feel is important.
- Key messages are: large numbers of patients require nutritional support, effective nutritional screening is key to identify those at risk, nutritional support is vital to improve patient outcomes and quality of care, there are a range of options to deliver the nutritional support required.
- But also listen to what the GPs, commissioners and any other stakeholders are concerned about; make it clear how these areas will be addressed and demonstrate impact on these areas of concern
- Make sure it is clear that the savings resulting from more cost effective use of sip feeds are a by- product of the improved nutritional support practice. The potential savings are an effective ‘hook’ to engage the interest of GPs and commissioners but simply capping sip feed expenditure will not be sustainable. The savings go hand in hand with the investment in dietetic time to deliver the improved nutritional support provision and support long term changes in practice.
- To achieve immediate outcomes and cost savings, it is helpful if the initial sip feeds reviews can be led by a dietitian to ensure the tools and techniques for delivering high quality nutritional care are built into practice.
- Involve GP practices as much as possible to engage them in the process. Allow them to have ownership of the intervention in their own practice, for example, asking them to send an initial letter to all patients prescribed sip feeds, to advise them that they are to be reviewed. The dietitian is there to support but not to do it all for them. Participation of practice staff is crucial to ensure they have an understanding of the processes that will make a difference to their future management of nutritional support and to empower them to make changes to their own practice.
- Links with the Medicines Management Team were invaluable. The dietitian worked closely with the local Prescribing Support Pharmacists, this supported introduction to the practices and enabled the dietitian to individualise the approach.
- Develop rolling training programmes from the very beginning. Integrate the initial training into the practice by practice review and tailor it to the individual needs of each practice. Plan for refreshers and updates to sustain improved practice.
- Establishing Nutrition Leads and Focus Groups has worked very well in Nursing homes as a means of facilitating improved care and for identifying any gaps in knowledge and training needs.
- Build in sustainability measures such as a review audit process with regular feedback that enables the improvements to be monitored and maintained long term. It has worked well for the dietitian to move into a ‘sip feed consultancy’ role for those practices that have already received input. This raises the profile of the profession and ensures continued good practice and adherence to guidelines.
- As initial reviews are completed, the dietitian’s role is to coordinate, oversee, empower, monitor and train to make the changes sustainable. Also to offer specialised clinical expertise to support the management of the more complex patients.
- Publicise what has been achieved. Show stakeholders that you have done what was agreed, make sure this information gets to the key people who influenced the set up of the project so they know it was worthwhile. Go and tell them!
- Share the success, it’s their success, some supported the funding and set up of the project, others worked with you and allowed you to change their approach, working differently to deliver the changes that deliver results. Every person who feels they have succeeded is an advocate and will be more likely to sustain the changes.
‘Carry on doing what you are doing, my GPs are thoroughly engaged with this project’ (Quote from a commissioner)
‘It's been such a help having you involved. I think initiating & prescribing via a focus group is very sensible. It will stop nurses & doctors from prescribing without thinking. It will probably lessen our workload too which has to be good! ‘ (Quote from a GP)
‘I'll discuss the list with the GPs, and let you know what they say. They are very pleased with what you have done here’ (Quote from a Prescribing Support Pharmacist)
‘Many thanks for the information and feedback. I am sure the GP’s will be thrilled to know how much work has gone on’ (Quote from a Prescribing Support Pharmacist)
‘Here’s the data for Jul – Sept. Fantastic stuff! Well done’ (Quote from Medicines Management lead following 12 month data)
‘I thought your presentation on Friday was very comprehensive and hit all of the right notes so well done on that and your work to date’ (Quote from Commissioning Manager)
‘It was really good to hear you talk yesterday. The focus groups in particular are something I'm going to talk to our community nutrition support colleagues about so I may be in touch for more ideas!!!’ (Quote from a dietetic project lead from another trust)
‘Thanks for all your help so far with this. Its pleasing that we have done better than expected’ (Quote from a Practice Manager following a review audit)
‘That would be very useful for the Virtual Wards teams. Within the team are HCAs, Staff Nurses, Community Matrons, Pharmacists, Social workers, and Physio’s so it would be of real benefit for us all – recognising and appropriate treatment’ (Quote from Virtual Wards Lead regarding training)
I’ve see two patients this week who have gained several pounds in weight on the dietary advice I gave them. It has worked really well. (Quote from a GP using the new dietary resources)
‘I am pleased that the project is going beyond 12 months, I feel that there is so much more that can be done in the Community’ (Quote from Professional Nursing Advisor)
‘The work you’re doing is very interesting and I really hope providers take it on as it can only improve outcomes for people using services’ (Compliance Manager CQC)
‘They were all really complimentary about Community Services and the work that you and your Teams are doing within Solihull’ (Feedback from Consultants at Solihull Hospital)
‘We have been fighting to get places for this training and it has been worth it!’ (Quote form one of the managers from a privately owned Care Home with regards to the training delivered for the Council)