The 4Ps of Nutrition: performance, power, policy and position Sandra Capra AM,PhD,FDAA Professor of Nutrition, Univers

1. The 4Ps of Nutrition: performance, power, policy and position Sandra Capra AM,PhD,FDAA Professor of Nutrition, University of Queensland Chair, International Confederation of Dietetic Associations HNEH Quality Exposition

2. Nutrition is not just a pretty extra • I want to argue that nutrition is a fundamental to quality health care • I want to pose the argument that nutrition has been a “cinderella” in the health system for too long • I want to claim that errors in nutritional management through lack of resources and policies are heavy costs to the system and to the people. HNEH Quality Exposition

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4. Nutrition is a core foundation of health • Underpins good health • Underpins reduction of chronic disease • Underpins quality services • Underpins quality of life • Is multidisciplinary • Is cheap • Is effective HNEH Quality Exposition

5. Performance – nutrition delivers! • Nutrition as a strong performer in health and health care systems • Medical nutrition therapy • Functional nutrition therapy • Food service • Public interest in nutrition • But performance is perceived to be affected by • Invasion of the field by underqualified persons clouding the ‘truth’ and the evidence • Trivialising nutrition HNEH Quality Exposition

6. Reducing stress – increasing stress- nutrition blog.iqmatrix.com HNEH Quality Exposition

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9. The proportion of same-day separations increased between 1998–99 (47.9%) and 2007–08 (56.3%). • The average length of stay (including same-day separations) in hospitals was 3.3 days in 2006–07 and 2007–08. • Between 1998–99 and 2007–08, for patients staying at least one night: • average length of stay varied between 6.2 days and 6.5 days for public acute hospitals • average length of stay decreased from 5.9 days in 1998–99 to 5.4 days in 2007–08 for private hospitals HNEH Quality Exposition

10. But….. • Those who enter with malnutrition stay longer – much longer. • Average LoS for those with malnutrition at entry is about double that of those who entry well nourished. HNEH Quality Exposition

11. http://www.aihw.gov.au/publications/hwe/pahced03-33/estimates.htmlhttp://www.aihw.gov.au/publications/hwe/pahced03-33/estimates.html HNEH Quality Exposition

12. Functional and Medical NutritionTherapies http://www.feinberg.northwestern.edu/nutrition/images/AppleCutout.jpg HNEH Quality Exposition

13. Anti-inflammatory HNEH Quality Exposition

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15. Power • Nutrition as a powerful tool for health • Poor nutrition costs money HNEH Quality Exposition

16. WHO HNEH Quality Exposition

17. http://siteresources.worldbank.org/INTPHAAG/Images/Nutrition-Image1.gifhttp://siteresources.worldbank.org/INTPHAAG/Images/Nutrition-Image1.gif HNEH Quality Exposition

18. Policy • Setting systems that will deliver benefits • Nutrition on the policy agenda • The ACHS EquiP4 revisions under standard 1.5 “Organisation providing safe and care and services” includes a new standard 1.5.7 that concerns ensuring that nutritional needs are met, introducing screening and including nutrition in the care plans among other specified activities. These are currently under discussion. HNEH Quality Exposition

19. A Healthier Future for All AustraliansNational Health and Hospitals Reform Commission Final Report June 2009 HNEH Quality Exposition

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21. Malnutrition now updated in DRGs • Malnutrition is the silent epidemic- 35%+ in health facilities, (www.daa.asn.au), 15% in HACC clients in community (Leggo et al 2008), 50% in RAC • The kind of malnutrition we see most is now recognised in the classification system – • disease induced malnutrition, • malnutrition in a land of plenty • Malnourished overweight persons • As a co-morbidity it affects the casemix weighting and therefore reimbursement systems. • The diagnosis must be by an APD HNEH Quality Exposition

22. Position • Positioning nutrition as a core health concern • Having the policy is not enough – it must be actioned HNEH Quality Exposition

23. Primary Health Care Reform in Australia Report to support Australia’s first national primary health care strategy • DoHA, 2009 Very little comfort here These are poor HNEH Quality Exposition

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25. Source: Splett P. 1996 HNEH Quality Exposition

26. Have we the workforce to deliver? • We can do a good job and reduce errors mostly if there are enough qualified nutrition staff available • Nutrition is everyone’s business and is multidisciplinary • The professional nutrition staff should hold nationally recognised credentials. For nutrition this is the APD credential for any work that requires competence in medical nutrition therapy and foodservices in any form and in any setting. HNEH Quality Exposition

27. Source; Brown Capra and Williams ; Profile of the Australian dietetic workforce 1991-2005 Nutrition and Dietetics; 2006;63:166-178 HNEH Quality Exposition

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29. Standardised Terminology • Errors relate to miscommunication in diagnoses and treatments • Electronic medical records are here/coming by 2012 • They will • Facilitate information sharing • Provide nformation to measure desired outcomes • Document outcomes and therefore drive the evidence base and standards of practice. • We need to adopt the International Dietetics and Nutrition Terminology (IDNT) HNEH Quality Exposition

30. The lack of a standardized approach in nutrition language and terminology can lead to an inaccurate diagnosis which may then lead to inappropriate or ineffective nutrition interventions and lower quality. • When nutrition and dietetics interventions are solely based or described by a medical diagnosis, there can be ambiguity in both the cause of any nutrition issues and nutrition management HNEH Quality Exposition

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32. This contrasts with the “IFI” approach of the National Allied Health Classification Committee, which does not include sufficient terms or details to clearly identify what practitioners actually do. It adopts a functional approach, which groups many separate issues under single codes, leading to an inability to compare outcomes. HNEH Quality Exposition

33. b 530 Weight maintenance functions – Functions of maintenance of acceptable body mass index (BMI); impairments such as underweight, cachexia, wasting, overweight, emaciation and such as primary and secondary obesity Source: IFI coding Manual for Pilot Project 2007 HNEH Quality Exposition

34. Food as the tool to deliver nutrition HNEH Quality Exposition

35. Food in health care is a treatment • Calling foodservice a “hotel” service means that it can be forgotten • Treated as less important • Subjected to cost cutting at times HNEH Quality Exposition

36. Would you eat these? HNEH Quality Exposition

37. My challenge • http://www.youtube.com/watch?v=dqdYxy7kHns Make the services as good as this!! HNEH Quality Exposition

38. Nutrition –the 4Ps • Recognise the performance of nutrition in healthcare • Recognise the power of nutrition to make a difference to quality services • Adopt policies to make a difference • Position nutrition services so they can deliver quality and excellence • Be a leader HNEH Quality Exposition