Food First! Enhancing the Nutritional Value Of Meals with Fortified Food

Food First!

Enhancing the Nutritional

V

alue

Of Meals with Fortified Food

Digna Cassens, MHA, RDN &

Linda S. Eck Mills, MBA, RDN, FADA

First Edition, May 2014 Copyright 2014

Digna Cassens, MHA, RDN

Linda S. Eck Mills, MBA, RDN, FADA

This book provides the tools for implementation of a fortified food program using real food, not commercially manufactured medical nutritionals. It is available as a stand-alone copy or with the option of obtaining 6 continuing education units option available for purchase separately.

This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the publishers. To request permission please submit a written request to Cassens Associates or Dynamic Communication Services.

Published by:

Cassens Associates – Diversified Nutrition Management Systems PO Box 581

La Habra, CA 90633 dignacassens@gmail.com

&

Dynamic Communication Services 20 Worman Lane

Bernville, PA 19506 Linda@DyComServ.com ISBN-10: 978-0692-208240 ISBN-13: 978-0692-20824-3

Printed and manufactured in the United States of America First Printing: 2014 Cassens Associates

What Others are Saying

I have completed my review of … Food First! Enhancing the Nutritional Value

of Meals with Fortified Food. As you know, I was an early adopter of the

Pioneer Dining Standards so this is a topic near and dear to my heart. … Your

program is exactly what is needed to impact a change in the practice… Your

implementation materials provide the participant with all the necessary tools to

bring this program to fruition in their community. It is inclusive and very

thorough. I look forward to having it available in the long-term-care

communities I work with.

Janice Raymond, MS, RDN, CSG, Director of Clinical Nutrition Services,

Thomas Cuisine, Co-Editor, Krause Nutrition 13

_{& 14}

_ed.

It was a pleasure to review your book, Food First! Enhancing the Nutritional

Value of Meals with Fortified Food. The following are points of interest for this

review:

• Thorough review of the population and need for the Food First! program

• Very informative with easy-to-use examples for implementing this

program

• Wonderful tools to use for this program implementation and monitoring

• Easy to use recipes for any individual to use for this program

implementation

Table of Contents

Definition of the Food First! Program 17

Practical Applications 18

Skilled Nursing, Rehabilitation, Sub-Acute and Long Term Care 19

Group and Congregate Homes 19

Senior Assisted Living Centers 20

Home Health Care 20

Pressure Ulcers Prevention and Treatment 21

Hospice Care 21

Oncology 22

Pregnancy and Hyperemesis Gravidarum 22

Oral Maxillofacial Conditions 22

Athletes in Training 23

Regulations and Guidelines 24

Dining Standards and Observation 24

Quality Assessment and Process Improvement 33

Dining Initiative 36

Recommended Course of Practice 41

Relevant Research Trends 42

CHAPTER II 44

Planning 44

Critical Planning Steps 44

Scope of the Project and Budget Available 44

Internal and External Resources 45

Timeline and Work Plan 45

Project Procedures 48

Project Evaluation 48

Assessment of Assets and Risks 49

Staff Assessment 49

Physical Plant, Equipment and Supplies Assessment 50

Ingredients Needed 51

Assessment of Individuals to Include 52

Table of Contents

Communication with Staff and Planning Meetings 55

Communicating with your Customers and their Families 57

Communicating with Physicians 59

Policies and Procedures 61

Clinical Analysis and Supplementation Decision Tree 63

Protocol for Food Fortification Program Using Food First! 63

CHAPTER III 66

Implementation 66

Implementation Steps 66

Staff Training 68

Foods to Include in the Program 72

Sample Menus 72

Problem Solving Exercise 1 74

Problem Solving Exercise 2 75

Problem Solving Exercise 3 76

Sample Inventory 77

Sample Recipes 78

Breakfast Recipes 78

Dairy Free Recipes 79

Lunch or Dinner Recipes 79

Dairy Free Recipes 79

Snacks 82

Observations and Data Gathering 83

Additional Considerations 88

Cost Conrol 88

Food Sanitation and Safety 88

Customer Health and Safety 89

Quality of Life and Care 89

Conclusion 92

References And Resources 93

Tables

TABLE

NAME

PAGE

Table I-1 2013 Memorandum Summary 25

Table I-2 Dining Standards Goals 26

Table I-3(a) Dining Standards Observation 26

Table I-3(b) CMS-20053 Dining Standards Observation 27

Table I-4 12 Action Steps to QAPI 34

Table I-5 Five Elements of QAPI 35

Table I-6 Creating Home II Workshop Recommendations 38

Table I-7 Dining Standards Recommendation 41

Table I-8 Relevant Research Trends 42

Table II-9 Sample Gantt Chart for Program Implementation 47

Table II-10 Nutritional Risk Identification Form 53

Table II-11 Sample Meeting Schedule 55

Table II-12 Meeting Minutes Template 56

Table II-13 Sample Letter to Clients and Families 58

Table II-14 Sample Letter to Physicians 60

Table II-15 Food First! Policy and Procedure 62

Table II-16 Supplementation Decision Tree for Weight Loss Prevention

62

Table II-17 Food Fortification Protocol 65

Tables

TABLE

NAME

PAGE

Table III-19 Training the Trainer Lesson Plan: Food First!

Supplement Program 69

Table III-20 Lesson Plan: Food First! Fortified Food Preparation 70

Table III-21 Competency Observation 71

Table III-22 Sample Fortified Menu 73

Table III-23 Sample Fortified Breakfast Menu 74

Table III-24 Sample Fortified Lunch Menu 75

Table III-25 Sample Fortified Dinner Menu 76

Table III-26 Sample Fortified Breakfast Recipes 78

Table III-27 Sample Fortified Dairy-Free Recipes 79

Table III-28 Sample Fortified Lunch or Dinner Recipes 79

Table III-29 Chocolate Almond Milkshake 80

Table III-30 Fortified Milk 81

Table III-31 Sample Quality Assessment Form: Fortified Food Process

84 Table III-32 Sample Quality Assessment Form: Identification of

Residents at Risk of Unplanned Weight Loss

85

Table III-33 Fortified Foods QAPI Plan 86

12

-“Let food be thy medicine and medicine be thy food” ― Hippocrates

INTRODUCTION

How would you feel if you were not able to eat enough calories to maintain weight? There are many factors affecting the amount and type of food that some individuals are able to eat. There are also times regardless of the amount of food a person eats they just cannot gain any weight. The struggle often seems never ending, and it is discouraging as well as risky to be seriously underweight.

Seeking medical attention is always the right course of action and should be done the first to step out the possibility of a physiological or health factor. In the meantime balancing calorie intake and energy output is essential to stop weight loss and achieve weight goals. Individuals who are chronically underweight and who have difficulty ingesting sufficient amounts of food to maintain their weight will benefit from eating calorie dense foods. Calorie dense foods that provide high calories and protein either naturally or because they are enhanced or fortified during food preparation with additional nutrient dense ingredients.

Many factors may contribute to a decreased appetite or the ability to eat enough food. Chewing or swallowing problems sometimes keep the individual from eating enough, resulting in decreased intake and subsequent unwanted weight loss. Alterations in taste and smell are often associated with and the side effects of

medications, a disease or the aging process can affect the ability or desire to eat adequate amounts of food and fluids. Hyperactivity caused by neurobehavioral

Food First!

13

-conditions such as Attention Deficit Hyperactivity Disorder and Autistic disorder may cause texture or taste biases that prevent those individuals from eating sufficient calories and protein. There are various options available to provide enough nutrition to prevent decline and avoid unwanted weight loss without the use of commercially manufactured food supplements, also known as medical nutritionals or nutritional foods.

Advances in food technology made readily available commercially

manufactured nutritional products that enhance nutrients, increasing calories and protein and are easy to use. Many of these products are expensive and lack the palatability of those that are house prepared. Providing fortified food in smaller

portions should be considered for individuals at high nutritional risk that are unable to eat enough food to meet nutrient needs. By using fortified food at meals and snack time in lieu of commercially prepared supplements you will be able to satisfy the most demanding palate, improve acceptance and consumption, and save money. Fortified foods have more nutrients per portion than their original counterparts, so they can be served in smaller quantities. Individuals with poor appetite can ingest sufficient calories and protein without being overwhelmed with bigger portions. What better way to meet individual’s nutrient needs than being able to offer them delicious, well prepared food that they will look forward to eating?

This course will focus on the advantages of using house prepared fortified food as the first defense to improve nutrient intake and prevent unwanted weight loss, and provide methods to prepare it for various textures and tastes in a survey friendly, time efficient and economical way. You will learn how a Food First! program using fortified

Introduction

14

-food is aligned with the Dining Practices Standards and the CMS directive for person directed care. In this manual the terms Food First! and fortified food will be used instead of calorie dense food.

This program has been in development since 1985, developing recipes, tracking results, trending and recording outcomes. In 2009 I started selecting the recipes for publication, planning to test and quantify in 10 and 25 portions for institutional use. Recipe development is a long process, and revisions often take even longer. In the summer of 2011, I was invited to do a presentation at the Idaho Health Care

Association by friend and colleague Monica Perry, RND, LDN on the topic Creative and Survey Friendly Food Fortification Program. Years before Monica had collaborated with Rita Deary, CDM, developing a food fortification program they called Food First widely used in the state. It was in Idaho that I first became acquainted with the term Food First!, a term I have used since then. To my surprise and delight CMS also has used this term in the regulatory guidelines.

In 2011, I also had a chance “meeting” on the Dietetics in Health Care Communities (DHCC) Dietetic Practice Group (DPG) electronic mail list of the Academy of Nutrition and Dietetics with Linda S. Eck Mills, MBA, RDN, LDN, FADA. Linda had developed and used her own recipes in her hospice practice, and in her usual generous nature she offered to let me use them in my book. This led to a partnership that resulted in the 2012 publication of Flavorful Fortified Food – Recipes to Enrich Life.

Since then there have been many requests for additional information on how to implement the program. Some of the seminars I have had the opportunity to conduct

Food First!

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-are for groups such as Consultant Dietitians of California (CDC), members of DHCC, the Association of Nutrition and Foodservice Professionals (ANPF), and the

Washington State DHCC and ANPF Annual Meeting and Exhibition. The questions about implementation and a study course for continuing education kept coming up during each of these.

This book is a compilation of everything I’ve done to implement a Food First! program for companies I have worked with in the past and communities to which I currently provide consulting services independently. It is my firm belief that by implementing a Food First! program you too will be able to:

• Use real food instead of commercially manufactured products • Improve and maintain nutrition, weight and skin integrity • Honor individual food preferences

• Prevent or delay the need for invasive nutrition interventions • Control food, supplies and labor costs

• Improve customer satisfaction

Due to regulatory requirements and custom, in the various healthcare settings, we refer to our individuals using different terms. Some of the commonly used terms include patient, resident, client, consumer, customer, person or individual. All of these words have the same meaning and are correct depending on the setting, geographic location and license under which each institution or organization operates. In this book, the word individual refers to all persons that have placed their trust in us as their healthcare providers. The Key Terms included lists the various terms and acronyms commonly used.

Introduction

16

-KEY TERMS

ANFP Association of Nutrition & Foodservice Professionals

CDA California Dietetic Association

CDC Consultant Dietitians of California

CDM Certified Dietary Manager

CMS Centers for Medicare & Medicaid

DHCC Dietetics in Healthcare Communities

Dietary Department Dining Services Dining Services Dietary Department

DM Dietary Manager, Dining Manager, Department Manager

DPG Dietetic Practice Group

DSM Dietary Services Manager

DSS Dietary Services Supervisor

DTR Dietetic Assistant Registered

Gantt Chart

A chart in which a series of horizontal lines shows the amount of work done or production completed in certain periods of time in relation to the amount planned for those periods. (Oxford Dictionaries)

IDT Interdisciplinary Team

IHCA Idaho Health Care Association

QAPI Quality Assessment & Process Improvement

RD Registered Dietitian

17

-“One cannot think well, love well, sleep well, if one has not dined well.” Virginia Woolf, A Room of One's Own

CHAPTER I

COURSE OBJECTIVES

Throughout this course the participants will meet the following learning objectives, and by the end of the session will be able to:

1. Define a Food First! program

2. List five goals of a Food First! program

3. List six steps to implement a Food First! program

Definition of the Food First! Program

The Food First! program is a non-invasive nutrition program for weight loss prevention and pressure ulcer prevention and treatment that meets individual nutritional needs in small volumes. It is based on using real food that is fortified to increase calories and protein. It respects person directed care and personal

preferences. Because of its versatility and ease of use it is appropriate for all stages of life and conditions that cause loss of appetite and decreased intake. Implementing this program helps decrease, or eliminates completely the indiscriminate use of commercial supplements, controlling or reducing the costs of expensive commercial nutritional supplements. By preventing or delaying the need for invasive

interventions, quality of care and life are improved. Using real food that is well prepared provides comfort, and improves satisfaction with meals.

44

-“The only real stumbling block is fear of failure. In cooking you've got to have a what-the-hell attitude.”Julia Child

CHAPTER II

PLANNING

To ensure success of the Food First!in the healthcare settings program it is necessary to have an orderly and systematic implementation plan. Devoting sufficient time to the planning processes and obtaining accurate data will make the planning and implementation go smoother.

Critical Planning Steps

Whenever projects of this scope are planned, it is important to develop a

planning checklist and implementation timeline. This helps ensure that important steps are not missed and that implementation remains on target. The checklist should include these simple steps.

Scope of the Project and Budget Available

1. The goals of the Food First! program are to: • Increase the caloric density of foods

• Use real food instead of commercial products 2. List of deliverables:

• Tasks

 List of tasks required to complete the project  Establish responsibilities and assign positions

Chapter II

45

- Write procedures for work to be performed  Write monitoring process and assign monitors • Costs

 Planning, training and implementation costs

 Cost of materials, supplies, equipment, changes and delays • Deadlines

 Develop timeline using a calendar

 Generate project Gantt chart to keep everyone on-task

Internal and External Resources

1. Internal resources

• List the departments participating • List staff selected for participation 2. External resources

• Physicians • Menu sources • Consultants

Timeline and Work Plan

Developing a timeline is the only way to ensure a project remains on schedule. Simple, short-term projects requiring few steps and one or two departments can be managed using a simple calendar and lists. Planning and implementing a Food First! program has multiple components and involves all departments. List tasks, timelines, due dates and responsible disciplines by position. It is to everyone’s advantage,

Food First!

46

-especially the project manager, to be able to see the project steps and progress at a glance:

• Tasks or activities scheduled • Start and end date for each task • Length of time allocated for each task • Overlapping of tasks or activities • Start and end date of the entire project

A sample Gantt chart (Table I-9) is provided in this section, or you can create your own. Free and for purchase Gantt charts in Excel are available on the Internet. Here are a few URL addresses for your convenience.

• http://office.microsoft.com/en-us/excel-help/create-a-gantt-chart-in-excel • http://try.quickbase.intuit.com/gpm/Learn-More-110CB-1491DF.html • http://try.quickbase.intuit.com/gpm/Learn-More-110CB-1491DF.html • http://www.vertex42.com/ExcelTemplates/excel-gantt-chart.html • https://www.smartsheet.com/c/smarter-gantt

66

-“Training is everything. The peach was once a bitter almond; cauliflower is nothing but cabbage with a college education.” Mark Twain

CHAPTER III

IMPLEMENTATION

The redundancy of the thorough planning process is your best asset towards a flawless start-up. By completing the preliminary steps correctly and allowing sufficient time for planning before launching the new process, success is ensured. Conduct a final check for any loose ends that may lead to later difficulties. Review the implementation steps below for completion and check off every line of the project timeline to ensure no steps were forgotten. Review the work plan timeline chart, notes and checklists to ensure all systems are ready. If there were any weaknesses in the plan, verify they were corrected and obstacles have been removed. Now you’re ready to implement the program. Let’s review some of the steps for implementation. See Table III-18.

Implementation Steps

1. Plan development and implementation strategy 2. Develop timeline

3. Plan and provide education and training 4. Assign team members and responsibilities 5. Establish information flow

6. Develop and implement formal data gathering tools 7. Collect and analyze data

Food First!

76

-Table III-25. Sample Fortified Dinner Menu

Fortified Portion Regular Modified Textures

Recipe Size No Added Salt Mech Puree

6 oz. Tomato Soup X X

56 8oz Jiffy Enriched Soup X X

1 pk Crackers X Pureed

48 1 ea. Tuna Salad Sandwich grd filling pureed filling

2 ea. Lettuce & Tomato Chopped pureed

Parsley Sprig Garnish pureed bread

1/2c Cucumber Salad chopped pureed

4 oz. Sherbet X X

4 oz. Milk X X

18 8oz Fortified Milk X X

Alternate

½ Sandwich on Banana Bread X X

½ c Fruit Plate chopped pureed

1 Lettuce Leaf shredded pureed

12 8 oz. Cottage Cheese Smoothie X pureed

(Reproduced from Cassens Associates DNMS 2011www.nutritionmanagementsystems.org)

Problem Solving Exercise 3

There is one individual that does not eat fish including tuna, or drink milk, and is allergic to tomatoes. Try any of these alternatives.

• Substitute the Egg Salad recipe for Tuna Salad

• Change the soup to another vegetable flavor without tomatoes, such as cream of celery, carrot, or broccoli. Omit tomato slice from sandwich, add a pickle slice, grated carrots or spinach to sandwich

• Give Dairy Free Coffee Latté (fortified coffee) with meals

“I don't know what it is about food your mother makes for you, especially when it's something that anyone can make - pancakes, meat loaf, tuna salad - but it carries a certain taste of

Chapter III

77

-Sample Inventory

One of the many advantages of this program is its flexibility. Any foods in your cupboard or inventory can be used to increase calories and protein in the menu.

Individual preferences can easily be met and dietary, ethnic and religious requirements complied with. You can add your own options to the samples below.

 Cheese – cottage cheese, Cheddar, Jack, Mozzarella, Swiss, American cheese, cheese sauce

 Coconut milk or coconut cream

 Soups - condensed , frozen, fresh prepared, soup mixes, instant

 Cream half & half, liquid nondairy creamer, sour cream, cream cheese, Eggs -liquid pasteurized or fresh shell

 Flavorings for smoothies, shakes and desserts

 Fruits - canned, fresh or frozen, juices or fruit desserts such as pie fillings  Legumes, pasta, rice, potatoes of any variety

 Meat, fish, poultry - fresh, canned, frozen or cooked

 Milk -fresh homogenized, soy, evaporated, condensed, non-fat dry  Powdered breakfast mix, whey protein powder, non-dairy protein powder  Pudding mixes and fillings

 Sugar, honey, molasses, agave

 Syrups and sauces for additional calories and flavoring variations  Vegetables - canned, fresh, frozen

Food First!

78

-Sample Recipes

These recipes can be used as written, or with slight variations increase calories and protein or change flavors. Tables III-26 to III-28 list some examples from the book

Flavorful Fortified Food – Recipes to Enrich Life. You will find two sample recipes on Tables III-29 and III-30.

Breakfast Recipes

Table III-26. Sample Fortified Breakfast Recipes

Recipe Name Nutrition facts per 1 cup serving

Calories Protein CHO Fat

Banana Nut Milkshake 543 kcal 13 g 69 g 25 g

Breakfast Bread Pudding 370 kcal 12 g 34 g 21 g

Coffee Milkshake 496 kcal 12 g 56 g 25 g

Super Topping (1/4 cup) 270 kcal 5 g 24 g 17 g

(Reproduced with permission from Cassens and Eck Mills 2012www.flavorfulfortifiedfood.com)

Chapter III

79

-Dairy-free Recipes

These dairy free recipes can be used as written, or with slight variations. To increase protein may use tofu, whey free protein powder or liquid.

Table III-27. Fortified Dairy-Free Recipes

Recipe Name Nutrition facts per 1 cup serving

Calories Protein CHO Fat

Dairy-Free Citrus Cream 207 kcal 1 g 25 g 12 g

Dairy-Free Super Cereal 409 kcal 5 g 29 g 31 g

Dairy-Free Eggnog 357 kcal 7 g 48 g 15 g

Dairy-Free Coffee Latté 234 kcal 1 g 23 g 15 g

(Reproduced with permission from Cassens and Eck Mills 2012 www.flavorfulfortifiedfood.com)

Lunch or Dinner Recipes

These recipes can be used as written, or with slight variations increase calories and protein or change flavors.

Table III-28. Fortified Lunch or Dinner Recipes

Recipe Name Nutrition facts per 1 cup serving

Calories Protein CHO Fat

Egg Salad 141 kcal 7 g 5 g 10 g

Hearty Meat Stew 324 kcal 26 g 11 g 19 g

Rich Gravy (1/3 cup) 227 kcal 7 g 17 g 15 g

Cheddar Cheese Soup 402 kcal 17 g 13 g 31 g

Cottage Cheese Smoothie 243 kcal 12 g 28 g 28 g

(Reproduced with permission from Cassens and Eck Mills 2012www.flavorfulfortifiedfood.com)

Food First!

- 92 -

“...nothing is too much trouble if it turns out the way it should.” Julia Child, My Life in France

CONCLUSION

Why use Food First!?

It is better and more enjoyable to eat real food, be able to savor the different flavors and textures, and experience the pleasure of eating Food First! Eating real food provides a dining experience that cannot be equaled.

Resources and References

93

-ADA Position Paper. (2005) Liberalization of the Diet Prescription Improves Quality of Life for Older Adults in Long_{‐Term Care.}

Bernstein, M, Munoz, N. (2012) Position of the Academy of Nutrition and Dietetics: Food and nutrition for older adults: promoting health and wellness. Journal of the Academy of Nutrition and Dietetics. 112(8):1255-1277.

Cassens, D. Mills Eck, LS. (2012) Flavorful Fortified Food – Recipes to Enrich Life. Center for Medicare and Medicaid Services, State Operations Manual Appendix PP –

Guidance to Surveyors for Long Term Care Facilities. 483.25(i)Tag F325 Nutrition 2008 Revised Guidance. Baltimore, MD: Center for Medicare and Medicaid Services.

http://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads.

Center for Medicare and Medicaid Services. Surveyor Training Video

http://surveyortraining.cms.hhs.gov/pubs/VideoInformation.aspx?cid=1101. Dorner, B, Posthauer, ME, Thomas D. (2009)The role of Nutrition in Pressure Ulcer

Prevention and Treatment. National Pressure Ulcer Advisory Panel White Paper. Advances in Skin and Wound Care. 22(5): 212-221.

Dorner, B, Thomas, D. (2009) National Pressure Ulcer Advisory Panel, The Role of Nutrition in Pressure Ulcer prevention and Treatment. National Pressure Ulcer Advisory Panel White Paper. Washington, DC: National Pressure Ulcer Advisory Panel.

Ferraro, K, Winter, C. (2014) Diet Therapy in Advanced Practice Nursing: Nutrition Prescriptions for Improved Patient Outcomes. McGraw Hill Medical, NY. Handy, L. (2010) Culture Change in Dining and Regulatory Compliance. Handy

Resources and References

94

-Handy, L. (2013) Dietary Services: Mastering Survey & Mastering QAPI. Handy Dietary Consulting. www.handydietaryconsulting.com.

Litchford, MD. (2010) The Advanced Practitioners Guide to Nutrition & Wounds. CASE Software. Greensboro, NC.

Memorandum to the State Agency Directors March 2013.The Centers for Medicare and Medicaid Services.

http://surveyortraining.cms.hhs.gov/pubs/VideoInformation.aspx?cid=1101. Munoz, N. (2013) Nutrition: An Intrinsic Factor of pressure-Ulcer Healing. Healthy

Living Winter. The Spectrum.

QAPI Tools Process: Five Elements of QAPI.CMS Process Tool.

www.cms.gov/Medicare/Provider-Enrollment-and.../QAPI/NHQAPI.html. Simmons SF, Patel AV, (2006) Nursing home staff delivery of oral liquid

nutritional supplements to residents at risk for unintentional weight loss. Journal of the American Geriatrics Society. 54(9):1372_‐1376.

OCS Outcome Concepts Systems. (2004) Strategic Marketing: Using Information to Grow your Business. White Paper 04-001.

www.ocshomecare.com/OCSHomeCare/media/.../WP_QAPI07-001.pdf. Pioneer Network Food and Dining Standards Task Force. Pioneer Network, The

Hulda B. & Maurice L. Rothchild Foundation. (2011). The New Dining Practice Standards.

http://www.pioneernetwork.net/data/documents/newdiningpracticestandards.pdf. Accessed October 2013.

Food First!

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