The Background to the Pilot

1. Monitoring and Support of Enterally Fed Residents in Aged Care FacilitiesPilot Study(November 2012- November 2013) Waitemata DHB Community DietitiansTeresa Stanbrook Community Dietitian

2. The Background to the Pilot 5 Otago University Students (2011) Business case “Monitoring & Support for Enterally Fed Patients in Aged Care Facilities within Waitemata District Health Board” Kane J, Lilly G, Oxford H, Stanbrook T, Wilson R, Zhang Z, Undergraduate Business Study – Otago University 2012. Case was prompted by patients admitted to Waitakere Hospital for “Avoidable Hospital Admissions”related to enteral feeding

3. Admissions of Enterally Fed Residents from Residential Care Facilities (2010-2011) * Waitakere site only

4. The Business Proposal… “A major financial strength of our business proposal is the potential reduction in hospital admissions, that have resulted from poor enteral feeding practice, will be reduced. This will result in considerable savings for Waitemata DHB in comparison to the amount of money invested in the service. The potential savings are considerable, as even a modest 6% reduction in hospital admissions will be cost effective. The goal for this proposed service is to achieve an 80% reduction in admissions for this group of patients”.

5. Additional FTE Required • An extension of 0.20 FTE each week to the Waitemata DHB community dietetic service, i.e. 8 hours a week to be shared between 4 Dietitians.

6. Inequality of Home vs. Residential Care In the community: The Waitemata DHB community dietitian is responsible to support enterally fed patients residing in their own home. Aged-care facility: It was the facilities’ responsibility to contract a private dietitian to support enterally fed patients.

7. Community Dietitians- Enteral Feeding • Up-skill and update their knowledge of enteral feeding products and equipment by regular contact with product representatives • Maintain professional competency in enteral feeding by completing a Waitemata DHB e-learning course every 2 years. • Present enteral feeding case studies each year to professional colleagues for reflection and best practice.

8. Pilot of One Year Duration Commenced in November 2012 Letter to Facilities re Pilot Letter/briefing to Private Practice Dietitians Patient consent Form- (Ethics/Māori health/ Quality) RAC consent Form- (Ethics/Māori health/Quality) Enteral feeding Plan for documentation in patient case notes Feeding Plan review to be done regularly and placed in patient notes

9. Aims of The Pilot To provide an equity of care for patients receiving enteral feeding with those patients residing in their own homes To reduce admissions to acute facilities To provide a safe discharge from an acute facility back to the Residential Care Facility. To provide a seamless transfer of care from the residential facility to an acute facility To provide ongoing clinical expertise in enteral feeding To network with other Waitemata DHB clinicians to improve patient outcomes and Quality of Life e.g. SLT, GNS, Geriatricians To liaise with Gastro Nurse specialist and assist with the training of staff in enteral feeding- Annual PEG Workshop

10. Number of Facilities/ Patients in Pilot Rodney District 2 2 North Shore 8 23 Waitakere 8 17

11. Total patients in Pilot study – Initial vs Present

12. Patient Activity During Pilot

13. Patient admissions to an acute facility since pilot began *Dietitian advised facility to admit Patient to Hospital

14. Patients Admitted to Gastro Clinic for First TimePEG Changes Initiated by Dietitian * First time feeding tube change.

15. “Waitemata DHB Community Speech-language therapists support patients with changes in swallowing within residential aged-care facilities..... The introduction of Waitemata DHB dietetic colleagues has resulted in improved interdisciplinary working within the context of residential aged-care facilities and consequently improved outcomes for patients. In particular, the time frames involved in transitioning patients from enteral to oral feeding have reduced as communications within the DHB team have occurred in a more timely manner”.   Kelly Bohot I Speech-language TherapistCommunity WestMedicine and Health of Older People I Waitemata DHB Speech Language Therapy

16. Improved Patient outcomes with SLT /DT working cohesively Improved access to specialist Waitemata DHB care Care facilities contact Dietitian directly Liaison with GNS to improve patient outcomes Improving access of medical information on patient care Improved documentation for facility audit process Improved attendance at Waitemata DHB PEG workshop by RAC carers Reduced hospital admissions (West figures compared to 2011) Facilities have requested ongoing training for their carers The Outcomes so far...

17. The challenges • The Facility GP - developing a partnership • Developing a relationship with facility staff • The Facility Patient notes !!! • Providing comprehensive documentation • Inadequate FTE to meet the ongoing requirements • Private Dietitian practising in the same facility • Best practice often difficult to maintain due to facility driven by costs • Identifying the need to train/up skill staff in enteral feeding in some Residential Aged Care facilities

18. Questionnaire Questionnaire response : 68. 4%

19. Conclusion to Pilot. • The majority of Facilities wished the Community Dietitians to continue providing intervention for their patients who were enterally fed • Facilities requested DT assistance in on going training of staff • There were positive outcomes for some patients due to the networking of Waitemata DHB clinicians • More FTE is required to meet the on going demands of the service. Confirmed increase to 0.30 FTE with onging discssion as to how this is split across the region • The Community Dietitians reported an increase in job satisfaction – entering a different working environment and interacting alongside a new group of clinicians • It is now business as usual

20. Questions?