Nutrition in care homes and home care - From recommendations to action

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Undernutrition remains a considerable problem in health-care settings and policies throughout Europe. In 2002, the Council of Europe published a report on food and nutritional care in hospitals, which contained over 100 recommendations for improvement. The current report explores the prevalence, causes and specific consequences of undernutrition in care homes and home care. It builds upon the work of the Belgian National Food and Health Plan and the international workshop on undernutrition in care homes and home care, which was organised in Brussels on 22 and 23 November 2007 by the Belgian Federal Public Service of Health, Food Chain Safety and Environment. The report examines the major barriers to proper nutritional care in these health-care settings and explores the roles and responsibilities of all actors involved. Detailed recommendations for action on different levels have been elaborated by experts from several Council of Europe member states to improve awareness, screening and management of undernutrition.
  23 Executive summary Undernutrition is a deficiency of energy, protein and other nutrientsimpairing the body and its functioning, jeopardising clinical outcomes.Undernutrition causes hospital stays to double and increases complicationsand mortality with the elderly across Europe. Among the causes of undernutrition are decreased metabolic rate, weaknesses and illnesses.Complicating factors common with the elderly are loss of appetite,dementia, social isolation, reduced oral health, financial problems andabsence of feeding assistance – making this group particularly vulnerable toundernutrition.Treating undernutrition costs around €10.95 billion per year in the case of the UK, thus making it as costly as, for example, obesity. Although most of the expenditure on disease-related malnutrition involves people over 65, or15% of the population, it remains largely unrecognised as a major healthcare problem. About half the cost of undernutrition occurs outsidehospitals, mainly in long-term residential care for older people. Care costscan be reduced through preventive medicine, observing social justice andfair equity-efficiency trade-offs. Undernutrition can be prevented throughpromoting better nutrition in hospitals and care homes and oral hygiene, byinstalling screening routines, by educating caregivers, and by making mealsa social event. Reimbursement should be expanded for dietary counsellingand supplemental foods.Proper screening routines are of particular importance for early detectionof undernutrition, which can be concealed. Health care facilities need toadopt scientifically and technically established diagnosis tools and criteria,and should continue screening after discharge from hospital. Collaborationwith dieticians should be increased. To successfully tackle malnutrition amultidisciplinary, multilevel approach is important, informing, educatingand training stakeholders, patients and residents, family, caregivers andpolicy makers. Awareness of undernutrition issues should be improved withcare home management and kitchen staff through continued education.Dieticians should be given a central role in this regard. In the light of theabove, policy makers should create legal frameworks to confrontundernutrition as the public health concern that it is. Governments shouldset and enforce standards for nutritional care and screening, assessmentand follow-up and make undernutrition part of national food and healthplans. Dietetic follow-up and specialised nutrition should be included forreimbursement. Support should be given to research on best practices, andevidence-based approaches. National platforms for the transfer of   24nutritional patient information between care settings should be organised.Nutritional education should be included in physicians’, nurses’ andcaregivers’ training. Finally, government policies aimed at combatingundernutrition should include assigning political responsibility for elderlypeople and putting undernutrition on the political agenda.  25 1. Introduction In 2002, the Council of Europe published a report on food and nutritionalcare in hospitals, i which contained over 100 recommendations forimprovement. In this report, the Council of Europe confirms that early andproactive screening, combined with the monitoring of dietary habits, cancontribute to a faster socio-economic reintegration of the patient and to animprovement of his/her quality of life. In 2003, the Council of EuropeCommittee of ministers adopted a resolution ii and formulatedrecommendations on the situation in hospitals. These recommendationsinclude: − a clear definition of the responsibilities of health care staff andhospital management with regard to nutritional care; − implementation of scientific standards for assessing, evaluatingand supervising diet and the risks of patients in relation toundernutrition; − extension of an institution’s liability with regards to nutritionalcare after hospitalisation; − improving the training level of health care staff; − promotion of individualised and flexible offer of meals with thepossibility for the patient to ask for additional servings; − patients’ input into drafting their meal-taking schedule; − promotion of co-operation and communication amongst hospitalstaff members to guarantee an optimal level of nutritional care,including better communication between the hospital and front-line health care staff; − the notion that far from being a hotel service, nutrition is anessential element of patient treatment; it must therefore beconsidered as such by the hospital management; − the idea that management must acknowledge responsibility fordispensing nutritional care and must give priority to an internalpolicy on nutrition; − taking into account the costs incurred by complications andprolongation of hospital stays due to undernutrition whenallocating the food budget.  26In 2006, as an example of national activities, the Belgian National Food andHealth Plan iii was initiated to address nutritional and health issues andformulate related recommendations. It focuses on three different settings:hospitals, care homes and home care. The plan considered undernutritionas an important issue, which led to the establishment of a dedicated policyoption and the creation of several expert working groups. Their mainobjective was to identify the main causes of undernutrition and develop anaction plan. This resulted in the identification of eight fields of action. Atwo-day international workshop on the topic of undernutrition in carehomes and home care was organised on 22 and 23 November 2007 andallowed European experts to present and debate the various aspects of thisspecific problem in Europe.These activities together with the Council of Europe Committee of Ministersresolution have been the basis for the recommendations and evaluations inthis report. It focuses on the importance of early and adequate nutritionalrisk screening, the prevalence and causes of undernutrition, the differenttypes of nutritional support, the distribution of responsibilities and theimportance of continuing education on (clinical) nutrition in the threesettings. At the end of this report, we will outline the responsibilities of allthe actors involved in resolving this important European-wide issue, as wellas suggesting possible actions in each of the settings.The following have served as sources of information for this report: − the report and recommendations of the Committee of Experts onNutrition, Food Safety and Consumer Protection, Food and nutritional care in hospitals: how to prevent undernutrition , 2003; − papers and the report prepared by speakers at the internationalworkshop on undernutrition in care homes and home care,Brussels, November 2007; iv − the recommendations and outcomes of the different workinggroups in the framework of the Belgian National Food and HealthPlan (NFHP-B), 2006-08; iii − the final report of the STAVO project conducted by the BelgianMinistry of Social Affairs and Public Health, 2006; v − the evaluation report of a project on undernutrition in geriatricwards, conducted by the Belgian Ministry of Social Affairs andPublic Health, 2007. vi
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