Family Dining at Regal Nursing and Rehabilitation Center, Lampasas

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Juannie S. Andrews, L.N.F.A. and Melissa Lancaster, Dietary Manager offered this presentation at one of TxCCC's steering committee meetings. Regal Nursing in Lampasas, TX proves daily that culture change principles in dining benefit the resident, the staff, and the facility. This presentation outlines their journey from institutional to family-style dining.

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Family Dining at Regal Nursing and Rehabilitation Center, Lampasas

  1. 1. Regal Nursing and Rehabilitation Center Family Dining Presented by: Juannie S. Andrews, L.N.F.A. Melissa Lancaster, Dietary Manager
  2. 2. Regal Nursing and Rehabilitation Center <ul><li>Individually owned LTC </li></ul><ul><li>60 Bed Skilled Facility </li></ul><ul><li>Secure Dementia Unit </li></ul><ul><li>Accepts Medicaid and Medicare </li></ul>
  3. 3. Cultural Change <ul><li>In 2007, state announced that Cultural Change was coming for the Dining Experience and 2010 was mentioned as the target year. We had already implemented some small changes in the facility that could be considered part of a cultural change. </li></ul><ul><li>Live house plants through-out the Dining area and throughout the facility. </li></ul><ul><li>House Pets ( Cats, Dog, Parakeet, Fish Tank) </li></ul><ul><li>But we wanted to do more, so this seemed the perfect opportunity to explore alternative options for Dining. </li></ul>
  4. 4. First Strategy Meeting <ul><li>Attendees </li></ul><ul><li>Administrator (Ron Milton) </li></ul><ul><li>Dietary Manager (Melissa Lancaster) </li></ul><ul><li>Consultant Dietician from food vendor (U.S. Foods) </li></ul><ul><li>Dietician from DADS, Lillian Gates </li></ul><ul><li>Of course we are a smaller facility, larger facilities would more than likely have a larger representation of Department Heads. </li></ul>
  5. 5. What are Initial Goals? <ul><li>Decrease weight loss </li></ul><ul><li>Improve nutritional outcomes </li></ul><ul><li>Increase food choices and food consumption </li></ul><ul><li>Decrease waste of food </li></ul><ul><li>Improve survey results </li></ul><ul><li>Improve census/Marketing strategy </li></ul><ul><li>Create a more homelike and pleasant dining experience. </li></ul>
  6. 6. What alternate Dining options are available? <ul><li>Extended hours </li></ul><ul><li>Restaurant style dining </li></ul><ul><li>Buffet style dining </li></ul><ul><li>“ Breakfast in Bed” </li></ul><ul><li>Select menu </li></ul><ul><li>Family dining </li></ul><ul><li>Continental Breakfast </li></ul><ul><li>Brunch </li></ul><ul><li>Five meal plan vs. 3 meals plus snack </li></ul>
  7. 7. More Questions to Answer <ul><li>What alternate Dining option would work best in our nursing facility considering staffing patterns, cost restraints, lay-out of the facility, resident’s dietary needs and levels of acuity? </li></ul><ul><li>How close is the meal service to meals at home? </li></ul><ul><li>Is the plan functional and does it offer more personalized service for the residents? </li></ul><ul><li>How will the residents benefit from the changes to meal service? </li></ul><ul><li>If given a choice would you eat here? </li></ul><ul><li>What can be done to give the residents more choice? </li></ul><ul><li>Do we implement for every meal and every day of the week? </li></ul><ul><li>Once the decision is made regarding which option and how often, then what is the next step? </li></ul>
  8. 8. The Decision <ul><li>Family Dining option was the choice. </li></ul><ul><li>For the lunch meal. </li></ul><ul><li>In the main Dining Room, only. </li></ul><ul><li>On Fridays to begin. </li></ul>
  9. 9. After the Decision <ul><li>Letters to physicians explaining our new Family Dining program with request for orders for liberalized diets for the residents. </li></ul><ul><li>Introduced to staff through in-servicing. </li></ul><ul><li>Introduced to residents to the Family Dining program through the Resident Council meeting. </li></ul><ul><li>Introduced Family Dining program to family members by letter explaining the program and the advantages. </li></ul><ul><li>Residents’ family members were invited to join the resident for our Family Dining meals. </li></ul><ul><li>Educated department heads serving in the dining room regarding the proper diets and meal consistency for each type of diet and thickened liquids. </li></ul>
  10. 10. Initial Cost <ul><li>Table clothes and cloth napkins. </li></ul><ul><li>China, glassware and eating utensils. </li></ul><ul><li>Serving bowls and serving cart. </li></ul><ul><li>Table center pieces. </li></ul><ul><li>Pitchers to serve beverages. </li></ul><ul><li>Cart to serve beverages tableside. </li></ul><ul><li>Condiments for each table. </li></ul><ul><li>The biggest expense was the purchase of the linen and carts. We purchased the china, glassware, eating utensils and serving bowls at the Dollar General. </li></ul>
  11. 11. Time Frame from First Strategy Meeting to First Family Dining Meal Service <ul><li>The First Strategy Meeting was held on the May 17, 2007. </li></ul><ul><li>Our first Family Dining Meal service was served in our Main Dining Room on July 24, 2007. </li></ul>
  12. 12. Resistance to Change-Staff <ul><li>Staff was extremely resistant to the impending changes. </li></ul><ul><li>Dietary staff was resistant, they said it would take too long to do and would slow everything down and it would back everything up in the kitchen. </li></ul><ul><li>Department Heads were resistant in that they couldn’t take their lunch when they customarily took them. ( At or around noon time). </li></ul><ul><li>They had too much to do. They couldn’t take time out of their already busy day to do the Family Dining. </li></ul><ul><li>Department Heads were concerned that they would give the residents the wrong diet and the wrong consistency. </li></ul>
  13. 13. Resistance to Change - Residents <ul><li>Residents were resistant to the changes. </li></ul><ul><li>In the beginning, we moved all of the tables together and sat everyone at different tables and in different seats from where they were accustomed to sitting. </li></ul><ul><li>They did not like that at all. So we set the tables back to the way they were and sat the residents where they were used to sitting. </li></ul><ul><li>Actually, this was the only complaint from the residents. </li></ul><ul><li>The fact that their family members were invited to join them for lunch was a big factor in gaining acceptance from the residents and their families. We continue to have families join in our lunch meal. </li></ul>
  14. 14. Overcoming resistance <ul><li>Department Heads were in-serviced by the Dietary Supervisor regarding the various diets. The fact that we had changed to Liberalized Diets helped tremendously. </li></ul><ul><li>Once they were in-serviced they felt a bit more comfortable. </li></ul><ul><li>Lunch breaks were reschedule for the Department Heads so they would be available during meal set up and service. </li></ul><ul><li>Dietary staff was in-serviced as to the part of the new process for which they were responsible. </li></ul><ul><li>The biggest piece of advice to all involved, “Don’t make it anymore difficult than it really is.” </li></ul>
  15. 15. Moving through the obstacles <ul><li>In the beginning it did take longer than normal for all parties involved. </li></ul><ul><li>But as we moved through the process it went smoother and faster each time we did it, until it was finally second nature to every one involved. </li></ul><ul><li>Now it takes less time than if we had to serve institutional style. </li></ul><ul><li>Department Heads were able to adjust their work schedules around Family Dining and found that they could still get their work done. It forced better time management. </li></ul>
  16. 16. After the beginning <ul><li>After the first six months of doing Family Dining once a week it was learned: </li></ul><ul><li>Food Costs DID NOT increase. </li></ul><ul><li>Supplement Costs decreased, slightly. </li></ul><ul><li>Labor Cost stayed the same. </li></ul><ul><li>Residents were eating more. </li></ul><ul><li>Less complaints about the food from residents. </li></ul><ul><li>Residents and family members loved it. </li></ul>
  17. 17. So it was decided that <ul><li>Change Family Dining from one day a week to two days a week. </li></ul><ul><li>Begin serving family style on Wednesday and Friday in the first quarter of 2008. </li></ul>
  18. 18. What I inherited! <ul><li>On my first visit on August 20, 2008, when I toured the facility before agreeing to take the Administrator position, this is what I saw: </li></ul><ul><li>A cat lying stretched out on the Front Desk without a care in the world. </li></ul><ul><li>Another cat riding on the housekeeping cart, while the housekeeper went room to room cleaning. </li></ul><ul><li>Tables that were set with cloth table coverings, cloth napkins, china, glassware, table center piece and condiments available on each table. </li></ul><ul><li>Lunch service, where the department heads were actually involved in meals service and served the meal from serving bowls on a cart. </li></ul><ul><li>And residents that actually seemed to be happy and content. </li></ul><ul><li>Even though the facility is 500 miles from my home in Baton Rouge, La., I decided to take the position. </li></ul>
  19. 19. Strange New Environment <ul><li>Where I came from </li></ul><ul><li>Typical plain vanilla LTC Facility. </li></ul><ul><li>Sterile environment </li></ul><ul><li>No outstanding personality to each home all “looked” and all operated the same. </li></ul><ul><li>Resident rooms all look alike </li></ul><ul><li>Meal services extremely structured. </li></ul><ul><li>Animals, relaxed homelike environment, Family Dining, department heads that were involved with the residents! WOW! </li></ul><ul><li>My first question was, “What does the state surveyors say about all of this?” </li></ul><ul><li>To my amazement, our survey team has had no issues with it at all. In fact, at our last two surveys, we were told by one of the team members that our facility is the only facility that they have seen in their region that has no complaints about the food from the residents and or the family members. </li></ul>
  20. 20. First things First! <ul><li>First thing that I did when I started working at Regal in Lampasas was to bring my 13 year old beagle to work with me everyday. </li></ul><ul><li>He absolutely loved it, the residents loved it and the staff spoiled him rotten. </li></ul><ul><li>And to my amazement, the surveyors loved him, too. </li></ul><ul><li>In fact he was with us everyday until this past May, when he passed at the age of 15 ½ years old. </li></ul><ul><li>I (We) now have a little Shiatsu that I bring to work. In fact, one of the resident’s family members thought about me after I lost Buddy and brought her up to the facility one day to visit. We all fell in love with her. So she is our new Mascot. </li></ul>
  21. 21. The Next Step: Reassess Family Dining <ul><li>Again, it was noted </li></ul><ul><li>Dietary Labor Costs stayed the same. </li></ul><ul><li>Food costs did not increase, in fact they had decreased. </li></ul><ul><li>Less food was left uneaten which translated to less food waste, especially on Wednesday and Friday when we did Family Dining. </li></ul><ul><li>Supplement costs continued to decreased. </li></ul><ul><li>Began to see a decrease in weight loss. </li></ul><ul><li>Resident and family members continued to enjoy and look forward to the lunch meals on the days that we had Family Dining. </li></ul><ul><li>No resident or family complaints about the food or food service. </li></ul>
  22. 22. Can we improve and or expand on the current Dining Experience? <ul><li>Refresh the dining area with new more updated color scheme by painting and providing new art work on the walls. </li></ul><ul><li>Brighten the area by removing the old curtains and blinds to let the natural light in through the windows. </li></ul><ul><li>Purchase more table clothes and napkins in a variety of colors to change the look each day. </li></ul><ul><li>Reduce the noise level and create more ambiance by providing soft music at each meal. </li></ul><ul><li>Add live plants throughout the Dining area to decrease noise levels and soften the decor. </li></ul><ul><li>Increase Family Dining for the lunch meal from just two days a week to five days a week, Monday through Friday. </li></ul>
  23. 23. The Easy Part <ul><li>Painted the Dining Room changing the color scheme. </li></ul><ul><li>Replaced the art work. </li></ul><ul><li>Removed the curtains and blinds. </li></ul><ul><li>Purchased a CD Player/Radio system and CD’s with easy listening music from the 40’s and 50’s. </li></ul><ul><li>Purchased a variety of colors of linen for the tables. </li></ul><ul><li>Situated live plants and hanging ivy in the windows to soften the lighting. </li></ul>
  24. 24. Now, for the hard part! <ul><li>Convince the Dietary Manager and the Department Heads to increase Family Dining from two days a week to five days a week. </li></ul><ul><li>After a few months of cajoling, arguing, threats of mutiny from the department heads and the Dietary Supervisor, the choice was finally made to begin Family Dining five days a week, Monday through Friday. </li></ul><ul><li>Toward the end of the first quarter of 2009 we began Family Dining. </li></ul><ul><li>Now better than two years later, the staff wouldn’t have it any other way! </li></ul>
  25. 25. We can use all the help that we can get. <ul><li>During an audit by the Quality Assurance Monitor, she identified that the food served to the residents might not be hot enough for the residents, particularly at the end of service, as we were using only one cart to pass the food. </li></ul><ul><li>Our census had grown by at least 16 in the main dining room since we began Family Dining. </li></ul><ul><li>Increased carts to three carts and purchased more serving bowls for the two carts that were added. </li></ul>
  26. 26. Details of Family Dining – as it looks today <ul><li>The Dietary Manager and assigned Department Head prepare the Dining Room tables just prior to the noon meal service. </li></ul><ul><li>Each table is set with cloth table cloth, cloth napkin, condiments and table center piece. </li></ul><ul><li>Each place setting is set with china, glassware and eating utensils. The meal ticket for each resident is placed by the respective place setting. </li></ul><ul><li>As residents are brought to the Dining Room, the assigned department head brings a cart with damp rolled washcloths that have been moistened with spearmint water for each resident to wash their hands. Spearmint enhances appetite. </li></ul><ul><li>Next the beverage cart is passed to each table, where the department head offers a choice of drink. Supplements are passed at this time. </li></ul>
  27. 27. Details of Family Dining – as it looks today <ul><li>After beverages are passed, the appetizer carts, which includes homemade soup of the day, cottage cheese, yogurt, choice of crackers are brought to each table. </li></ul><ul><li>While the appetizer carts and beverage carts are being passed the dietary aide and cook are placing the food from the steam table into the serving bowls. The serving bowls are placed on each serving cart and the department heads that are assigned to the Dining Room begin serving the meals at table side. The meal tickets are on the table at each residents’ place setting. </li></ul><ul><li>Pureed are served individually directly from the steam table. Prior to service, residents that are on pureed diets, who are able to respond are asked their preference. </li></ul><ul><li>As the plates are served the C.N.A. and Nurse follow behind to double check service and help with set up. </li></ul><ul><li>Close to the end of the meal, the dessert carts go out and the residents are served. </li></ul>
  28. 28. Expanding Family Dining to the Secure Unit. <ul><li>About six months ago one of the family members for a resident on our Secure Unit, asked why don’t we do Family Dining on the Secure Unit? There was no particular reason why not, the simple truth of the matter is that we never even considered it. </li></ul><ul><li>We were serving the meals for the unit in the traditional way. Compartmentalized plastic hot trays served in the kitchen, put on a tray rack and then transported to the Secure Unit dining room, where the trays were served to the residents by the aides on the unit. </li></ul>
  29. 29. The Meeting to discuss Family Dining for Secure Unit <ul><li>Attendees </li></ul><ul><li>Administrator </li></ul><ul><li>Director of Nursing </li></ul><ul><li>Assistant Director of Nursing </li></ul><ul><li>Dietary Manager </li></ul>
  30. 30. Things to Consider <ul><li>We already knew what the advantages would be for the residents on the secure unit. The advantages would be the same as we had experienced for the residents in our Main Dining area. </li></ul><ul><li>What would need to be changed in our current process to accommodate Family Dining in an area apart from the kitchen? </li></ul><ul><li>Could we use the same set up for the tables as in the Main Dining area? </li></ul><ul><li>If not, what can we do? </li></ul><ul><li>Who would serve the plates, if we did the Family Dining? </li></ul>
  31. 31. Game Plan <ul><li>Purchase more serving bowls. </li></ul><ul><li>Purchase more plates and glassware. </li></ul><ul><li>Decide who might need to continue with the divided plates. </li></ul><ul><li>Use CD player from unit’s activity room to play music at lunch. </li></ul><ul><li>Dress tables with table clothes, cloth napkins, China and glassware. Two residents use the divided plate, which are set on their table. </li></ul><ul><li>No center pieces or condiments on tables. </li></ul><ul><li>Eating utensils would be passed as the food is served. </li></ul><ul><li>Meals tickets would be kept on cart and would be used as plates are served. </li></ul><ul><li>Use the same rack that we were using to deliver food and beverages from kitchen. </li></ul><ul><li>C. N. A.’s and Nurse assigned to the Secure Unit would serve each resident’s plate. </li></ul><ul><li>In-service C.N.A.’ and Nurse on the unit regarding each diet and the set up for the dining tables on the unit. </li></ul>
  32. 32. Final Product <ul><li>Just prior to service, the aides on the Secure Unit set the tables with the table clothes and the cloth napkins. </li></ul><ul><li>Followed by the plates and the glassware. </li></ul><ul><li>Ice is put into each glass. </li></ul><ul><li>Back in the Kitchen </li></ul><ul><li>Beverages are placed in pitchers on transport cart. </li></ul><ul><li>Rolled silverware is placed on the transport cart, as well. </li></ul><ul><li>The last thing, Food is put in serving bowls from the steam table, to include all items offered (Main course and all alternates). Each bowl is covered prior to transport. </li></ul><ul><li>From the kitchen to the Unit </li></ul><ul><li>The hall monitor then transports the food transport rack to the unit were the aides and nurse begin serving the residents. </li></ul><ul><li>Condiments are kept in a locked service area on A-Hall. The aides take them out just prior to lunch and pass each out to each resident as they serve each plate as indicated on the meal ticket and/or per resident’s request. </li></ul>
  33. 33. Success! <ul><li>We have been doing Family Dining on the Unit for six months now and we have had the same success for the residents on the unit as we have had for the residents in the Main Dining room. </li></ul><ul><li>And most importantly the residents and the residents family members enjoy it. </li></ul><ul><li>We even have two resident’s whose families come every day for lunch and enjoy the meal with their family member. </li></ul>
  34. 34. <ul><li>During our 2009 annual survey, a resident told the surveyor that we were getting her up way too early for breakfast. Of course, as it goes, she had not shared that with the staff at all! </li></ul><ul><li>Something positive did come out of that situation. We identified three other residents that had the same problem. </li></ul><ul><li>In response to that we extended our breakfast hours, which allows those residents that wish to sleep in to do so. </li></ul><ul><li>In addition, we discovered that several more residents would rather a small, less heavy meal for breakfast. </li></ul><ul><li>Our response to that was to include the choice of a variety of dry cereal, fruit, sweet rolls and pastries every morning for those residents who did not wish to have the traditional eggs, bacon, sausage toast, etc. for breakfast. </li></ul><ul><li>At the same time we expanded the choices for our traditional breakfast in that we offer scrambled, boiled or fried eggs, crème of wheat and/or oatmeal, sausage patties, bacon and/or sausage links, wheat or white bread toast and/or biscuits. </li></ul>Again, we can use all the help that we can get.
  35. 35. Ever changing process <ul><li>We are constantly reassessing and evaluating our progress and outcomes. </li></ul><ul><li>With each re-visit we identify something that we may need to change and/or find another idea, we may want to implement. </li></ul><ul><li>For instance, at about the same time we began our Family Dining in our Secure Unit, we explored the possibility of improving the quality and preparation of our food. </li></ul><ul><li>Most all of our food is now truly homemade, prepared from scratch. </li></ul><ul><li>We use as many fresh fruits and vegetables as we can. </li></ul><ul><li>We use a variety of fresh potatoes. </li></ul><ul><li>No longer use frozen, dehydrated, canned or powdered potatoes. </li></ul>
  36. 36. Ideas come from every where! <ul><li>A couple of months ago we had a newly admitted resident, who wanted nothing but soup, soup and more soup for her meals. </li></ul><ul><li>This gave us the idea to offer a “soup of the day” for the residents. </li></ul><ul><li>We now offer a different soup each day as “the soup of the day.” It is available from 10:00 a.m. until the kitchen closes at 7:30 p.m. </li></ul><ul><li>It is offered at lunch on the appetizer cart and at the supper meal. </li></ul><ul><li>If a resident wants soup at mid-morning or mid-afternoon, it is available. </li></ul><ul><li>We are even using recipes submitted by the residents. </li></ul><ul><li>It is a big hit! </li></ul>
  37. 37. Activities as an ally <ul><li>In our therapy department we have a cook top and stove that is used by our Activity Department. </li></ul><ul><li>Residents are involved in preparing and baking their own recipes. Homemade cookies are at the top of the list. </li></ul><ul><li>The homemade goodies are served at hydration and snack time. </li></ul><ul><li>Activity Director serves a variety of goodies each day at 10:00 a.m. and again at 2:00p.m. </li></ul><ul><li>Smoothies, root beer floats, lemonade, juice, ice cream, watermelon (in season), cantaloupe (in season), strawberry crush, tea, and etc. </li></ul>
  38. 38. Other ideas for hydration <ul><li>Family of a former resident donated a crushed ice and water machine that is set up in the dining area for residents to get ice and or water when ever they wish. </li></ul><ul><li>A coffee station is, also, available in another area of the dining room where coffee is available from 6:00a.m. until bed time. Dietary fills last pump carafe with coffee at about 7:30p.m. for those residents that want coffee after the kitchen is closed. </li></ul><ul><li>In the evening after supper, we have a group of residents that like to gather and have their gourmet coffee and tea. We leave a carafe of hot water for their convenience and snacks from the snack cart are available to them. </li></ul>
  39. 39. After everything is said and done. <ul><li>Weight loss decreased </li></ul><ul><li>Less food waste </li></ul><ul><li>Less supplement use/cost decrease </li></ul><ul><li>Census increase from 32-34 average to 52-54 average. Got up to 60 at a point. </li></ul><ul><li>With three Long Term Care Facilities in a community of 7,000, our new strategies have definitely given us the edge. </li></ul><ul><li>No complaints from residents and/or family members regarding food! </li></ul><ul><li>No increase at all in labor costs. Find better use of time. </li></ul><ul><li>Raw food cost – little if any increase due to implemented changes. </li></ul><ul><ul><li>Raw Food Cost (average) 2008 - $4.47 </li></ul></ul><ul><ul><li>Raw Food Cost (average) 2009 - $4.05 </li></ul></ul><ul><ul><li>Raw Food Cost (average) 2010 - $4.21 </li></ul></ul><ul><ul><li>Raw Food Cost (average) 2011 - $4.30 </li></ul></ul>
  40. 40. Homelike environment <ul><li>Two cats </li></ul><ul><li>A dog </li></ul><ul><li>Parakeet </li></ul><ul><li>Fish </li></ul><ul><li>Live Plants </li></ul><ul><li>Family Dining </li></ul><ul><li>Extended hours for breakfast </li></ul><ul><li>An organic garden tended by the residents. </li></ul><ul><li>Inquiries and/or new residents, I tell them that we will completely empty out the resident room, if they wish. They can bring whatever furniture, knick-knacks, pictures, wall hangings from home that they want. If they want to set the room up like their bedroom at home, that is fine. </li></ul>
  41. 41. With each change <ul><li>Throughout the past four years with each change that we have implemented we were met with resistance. Some times the resistance was greater than others. </li></ul><ul><li>But the lesson here is to keep moving through the resistance and obstacles, whether real or imagined, with a can do and positive attitude. </li></ul><ul><li>We are blessed to have Melissa. She is always positive in her attitude and has that can do attitude that is essential to our success. </li></ul><ul><li>Eventually the soothsayers are silenced and they finally understand that this is not about them, but about the residents and the residents, only. </li></ul><ul><li>It is about providing a place for the resident that is as near as being in their own home, as we can make it, which is our intent. </li></ul><ul><li>It’s about the little things! </li></ul>
  42. 42. Questions and Answers October 25, 2011 Webinar <ul><li>Budgeting and Meal Planning </li></ul><ul><li>Q1: What is the food cost per person per day? </li></ul><ul><li>A1: Regal - P.P.D. is approximately $5.25, which includes supplements. </li></ul><ul><li>TRISUN - The food cost varies based on location, census, acuity etc., but runs from $4.30-5.00 in most 100-bed facilities. </li></ul><ul><li>Q2: Many of my facilities are struggling with reductions in food costs as a result of the Medicare reimbursement changes.  Does TRISUN’s dietary program increase the baseline food costs?  What's the average food cost for TRISUN facilities? </li></ul><ul><li>A2. There was an initial increase in food cost but as the newness of the choices wore off TRISUN costs stabilized.  The food cost varies based on location, census, acuity etc., but runs from $4.30-5.00 in most 100-bed facilities.  </li></ul><ul><li>Q3: What is the raw food cost for each of the facility presenters: Lampasas and TRISUN? </li></ul><ul><li>A3: TRISUN - Raw Food cost average for 2011 is 4.3 PPD </li></ul><ul><li>A3: Regal Nursing & Rehab. – Raw food cost average so far in 2011 is $4.3 PPD </li></ul>
  43. 43. Questions and Answers October 25, 2011 Webinar <ul><li>Q4: Are some of the food vendor organizations attuned to culture change and able to offer support and guidance toward revising dining strategies? </li></ul><ul><li>A4: Regal-Lampasas: When we first started with the culture change in 2007, we were using U.S. Foods and they were extremely helpful. In fact, their Dietician was on the panel to help us get started. We are using Sysco at this time and it is my understanding that they have a Dietician available, as well. </li></ul><ul><li>Q5: Is there a particular meal service (breakfast, lunch or dinner) that you find to be most difficult in offering a dining program that offers flexibility in time as well as food choices? If so, what made it so difficult to offer choices in time and food selection? </li></ul><ul><li>A5: Regal-Lampasas: I would say that lunch is for us, with Family Dining, the easiest meal to do as Family Dining. But breakfast and supper are not a problem in that we are offering more choices for those meals. </li></ul>
  44. 44. <ul><li>Q6: Has there been a barrier to liberalized diets? For example, have you found resistance from physicians, families, dietician, staff, etc...? If so, how did you overcome these barriers? </li></ul><ul><li>A6: Regal-Lampasas: When we shared with everyone what we were trying to accomplish, we received no resistance at all. </li></ul><ul><li>DADS: You can share the position paper from the American Dietetic Association, &quot;Individualized Nutrition Approaches for Older Adults in Health Care Communities&quot; w/ families, physicians or other staff, which explains liberalizing diets. Your consultant dietitian should be able to retrieve this information for you. </li></ul><ul><li>Q7: This question refers to the &quot;regular&quot; dishes that are being purchased in local stores. Have you found that the commercial dishwashers are &quot;tough&quot; on residential plates and glasses and that they need to be replaced more often than a commercial plates and glassware? </li></ul><ul><li>A7: Regal-Lampasas: No, not at all. </li></ul>Questions and Answers October 25, 2011 Webinar
  45. 45. <ul><li>Q8: What about reusing food that may return to the kitchen.  How is this done to prevent infection control issues and ensuring freshness of the re-served meals? </li></ul><ul><li>A8: TRISUN - Per our policy we do not re-use food that has been served or left the kitchen. We base our selective menus on items that can be prepped ‘In Advance’, like chef salad or cottage cheese and fruit plates, OR short order items like burgers, grilled cheese or chicken tenders. For the dessert and beverage carts we send out small quantities and send out additional as requested. We do use items leftover on the steam table to make homemade soups, stews, desserts, etc.  </li></ul><ul><li>Q9: Is this a program that's in several of your facilities or how many?  Are there other consultant RD's doing the same thing for their TRISUN homes? </li></ul><ul><li>A9: TRISUN implemented dietary changes in all 41 of its facilities. They use a combination of regional Registered Dietitians (RDs) who cover multiple locations or consultant RDs.  </li></ul>Questions and Answers October 25, 2011 Webinar
  46. 46. <ul><li>Q10: Can this style of dining work in facilities that hold 125-150 residents and have more than 3 dining rooms? </li></ul><ul><li>A10: I would say “Yes”, that Family Style Dining could work. You may need to utilize more of your department heads, C.N.A and Nurses’, but I think it definitely can be done. </li></ul><ul><li>Q11: Please provide more on implementation steps, especially for facility lay outs that are not kitchen/dining room adjacent. </li></ul><ul><li>A11: For our Secure Unit, the tables are set for dining by the C.N.A.’s that are on that hall. The kitchen staff fills the serving bowls with the food directly from the steam table. The serving bowls are all covered with saran wrap and taken immediately to the secure unit via the meal tray rack. Once on the unit, the plates are served by the C.N.A’s and the Nurse assigned to that lunch room. </li></ul>Questions and Answers October 25, 2011 Webinar
  47. 47. <ul><li>Q12: Would like more information as to the corporation and the road blocks there. How to overcome the idea of ‘cost too much to do’. </li></ul><ul><li>A12: The best response that I could give would be the increase in census. We went from 32/34 average census to 53/55 average within four months or less. I would attribute part of that increase was due to the Family oriented and Homelike environment which the Culture Change movement embraces, that sets us apart from the other facilities in town. Also, our supplement costs decreased, weigh loss decreased and our residents DO NOT complain about the food. As, I stated at the seminar, the state surveyor who surveys our facility, stated that this is the only facility in his area where the residents do not have complaints about the food. I have been here for better than three years now and the residents have not had a complaint regarding our food since I have been Administrator. So, I would say that you may argue that the residents are happier regarding the Dining Experience and that may relate directly to less complaints thus possibly resulting in less deficiencies for your dietary department and nursing (decrease in weight loss). </li></ul>Questions and Answers October 25, 2011 Webinar
  48. 48. <ul><li>Special Diets </li></ul><ul><li>Q1: Why do people on a puree diet not receive choices at the family dining? </li></ul><ul><li>A1: Regal-Lampasas: We have few pureed diets and the ones that we do have are not able to make a conscious decision as to what they would like to eat. In situations where a specific resident needs a pureed diet and can choose the food, staff ask what selection the person prefers prior to service. </li></ul><ul><li>Q2: How to you ensure residents with altered diets do not feel left out when wanting to select items that are inappropriate (puree, msoft)? </li></ul><ul><li>A2: Regal-Lampasas: All diets are available to be served from the carts by the department heads. For individuals needing a mechanical soft diet, staff prepare and put the meal in a serving bowl, just as the regular consistency diets. See the previous question for pureed diets. </li></ul>Questions and Answers October 25, 2011 Webinar
  49. 49. <ul><li>Q3: By doing the dinning experience, how can you ensure special diets are provided, such as low salt, diabetic, etc.? </li></ul><ul><li>A3: Regal-Lampasas: The specific diet for each resident is on the meal ticket that is placed on the table for the server to know what each resident’s needs are. The servers (department Heads) have all been in-serviced by the Dietician and Dietary Manager. There is a nurse in the Dining Room at all times during lunch to ensure that the appropriate meals are served. If the resident should request something that in not indicated on the diet ticket, they (the server) has been instructed not to serve it without receiving confirmation from the nurse. The biggest thing that helped us was liberalizing the diets for all of the residents. </li></ul><ul><li>DADS: Research has repeatedly demonstrated that special diets may not be the best choice for the elderly. Quality of life and improved nutritional status can be enhanced by less-restrictive diets. A therapeutic diet that limits seasoning options and food choices can lead to under-nutrition and negative health effects. A diet cannot be effective if it is not eaten! Significant weight loss (because food is not eaten) is more likely to cause death than the disease that a special diet may treat. In the elderly, medical conditions should be treated medically. Older adults should always be individually assessed before liberalizing diet orders. </li></ul>Questions and Answers October 25, 2011 Webinar
  50. 50. <ul><li>Q4: How do you identify the residents on special diets, when they are sitting in the dinning table? How can you distinguish them? </li></ul><ul><li>A4: Regal-Lampasas: The meal tickets are placed on the table next to the place setting where each resident is sitting as the tables are being set. </li></ul><ul><li>Q5: Are there issues with residents requesting items of consistencies not allowed on their diets? </li></ul><ul><li>A5: Regal-Lampasas: Sometimes. If the resident and or families are insistent, the resident and/or family member are informed of the risks and the conversation regarding education is recorded in the medical record. It is re-visited at each Care Plan meeting. In addition, the resident and/or the family member sign a waiver, which is put in the chart. </li></ul><ul><li>DADS: Resident Rights plays a role here. It is important to always document that education was given regarding the consistency issue. If the resident/family still insist, this should also be documented. Waivers may not be upheld in a legal action, so always document discussions. </li></ul>Questions and Answers October 25, 2011 Webinar
  51. 51. <ul><li>Dignity </li></ul><ul><li>Q1: Please comment on extending dining hours (e.g. dinner from 5 to 7 pm) and the impact this can have on preserving dignity and decreasing mealtime interruptions with regard to medication passes? It seems like this would be a great solution. </li></ul><ul><li>A1: DADS: Extended hours allows choice in times of dining, therefore, granting dignity and decreasing mealtime interruptions. </li></ul>Questions and Answers October 25, 2011 Webinar
  52. 52. <ul><li>Staff Participation and Training </li></ul><ul><li>Q1: Which locations of TRISUN (Texas) currently offer this fantastic service? </li></ul><ul><li>A1: TRISUN: All 41 locations offer this dining service. </li></ul><ul><li>Q5: How many staff members served in Lampasas? </li></ul><ul><li>A5: Regal-Lampasas: In the main Dining Room we have three Department Heads that serve from the carts. We serve the beverages first with the appetizers (soup of the day, cottage cheese, yogurt, etc., then the main meal. Then we have a dessert cart that is brought around table to table at the end of the meal. </li></ul><ul><li>Q6: Will this presentation be available on line (visual and audio) after today? Also, will the presentation slides be available to download to be used as a training/educational tool for providers? </li></ul><ul><li>A6: DADS note: Yes, the webinar version of the presentation is available on line (visual and audio) beginning October 27, 2011. To comply with state and federal accessibility laws, PDF versions of the PowerPoint and handout were posted to DADS Culture Change website. However, a trainer can request a free copy of the PPT version by sending e-mail to [email_address] . </li></ul><ul><li>Q7: How many dietary staff are needed to serve all these items TRISUN staff described in the presentation?  Did the facilities have to increase their labor hours? </li></ul><ul><li>A7: TRISUN did not have any increase in labor. The average is 0.45 ppd for dietary labor not counting the dietary manager. There are some locations that are budgeted slightly higher because they have multiple serving kitchens.  </li></ul>Questions and Answers October 25, 2011 Webinar
  53. 53. <ul><li>Regulations </li></ul><ul><li>Q1: I keep hearing things, including during this seminar, where the DADS surveyors are not backing the facility in this aspect of culture change. When is DADS going to catch up here and allow the facilities to do this and remain compliant at the same time? </li></ul><ul><li>A1: Regal-Lampasas: Our experience has been that the surveyors have been supportive. We have only had one deficiency in dietary since 2008. As I mentioned during the seminar, the head surveyor said that this is the only facility in all of the facilities that they visit where they do not get complaints from the residents regarding food. </li></ul><ul><li>DADS note: Nursing homes are encouraged to discuss concerns with the visiting surveyor. If a deficiency is still proposed that the nursing home management believes discourages culture change planning and initiatives, the home’s representative is invited to contact its regional director or regional liaison for assistance. Contact information can be found at: </li></ul><ul><li>Regional Directors - http://www.dads.state.tx.us/culturechange/experts/regulatoryservices.html . </li></ul><ul><li>Regional Liaisons – http://www.dads.state.tx.us/culturechange/experts/liaisons.html </li></ul>Questions and Answers October 25, 2011 Webinar

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