Transcript Corrina Grimes - Delivering Success Working Smarter

Delivering Success
Working Smarter- Not Harder
in the area of Malnutrition
Corrina Grimes
AHP Consultant
Public Health Agency
A Public Health Problem …

Malnutrition originates in the community
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Malnutrition affected 29% of Adults admitted to hospital (BAPEN
2014)
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Malnutrition contribute to and also occurs as a result of illness
Malnutrition…. At first glance
However there are many elements….
Identify Your Dolls
Malnutrition
Malnutrition Dietary Intervention
Approach
Regional Medicine Management
Dietetic Initiative…
Working Smarter- Not Harder
Identify the Dolls we could affect
change
Drivers…….

Pharmaceutical Clinical Effectiveness Programme
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NICE Guidance CG32 Nutritional Support For Adults & QIPP

Promoting Good Nutrition Strategy
The Pharmaceutical Clinical
Effectiveness Programme (PCE)

(PCE) Programme is an umbrella term for a suite of medicines
management initiatives, initiated by DHSSPS and now implemented
by the HSC Board which include:

The PCE Programme's initiatives continue to contribute to the
Department's efficiency strategy

It is based upon the principle that IMPROVEMENT IN THE QUALITY
AND SAFETY OF SERVICES WILL LEAD TO HEALTH GAINS AND
ASSOCIATED EFFICIENCIES.
Oral nutrition
UK regions: spend per head
12
10
8
6
4
England
Wales
Scotland
Oral nutrition
NI
2011
2010
2009
2011/12
2010/11
2009/10
2011
2010
2009
2011
2010
0
2009
2
NICE CG32
Nutrition support in adults:
Oral nutrition support,
Enteral tube feeding &
Parenteral nutrition & QIPP

Nutritional support to reduce or prevent malnutrition

Utilised skills of a Dietitian to ensure appropriate use of Oral
nutritional supplements with a food first approach
Promoting Good Nutrition Strategy
Scope:

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Strategy relates to adults in all health and social care settings
“Every carefulinobserver
of the
sick will
including individuals
their own
home.
agree in this, that thousands of patients are
starved in the midst of plenty, from want of
attention to the ways which make it
possible for them to take food.”
(Florence Nightingale)
For the purpose of this strategy malnutrition will be considered
as under-nutrition and does not cover obesity or eating disorders
Synergy and Symbiosis..
Work Smarter – Not Harder
A joint Initiative
Synergy
The interaction or cooperation
of two or more organizations,
substances, or other agents to
produce a combined effect
greater than the sum of their
separate effects:
Working Harder - Not Smarter…
Demonstrating Symbiosis and Synergy
Utilisation of:

Dietetic skills and competencies to ensure appropriate clinical
assessment and intervention

Medicines Management (pharmacy) Team’s process and practice
experience in other therapeutic areas and their operational and
strategic support for this initiative

Data analysis, Informatics,Health Intelligence

Organisation and professional networks
Initiative Structure

Medicines Management Dietitians employed as part of Medicines
Management team, professionally responsible to AHP Public Health
Agency

Five Dietitians working across Northern Ireland integrated within the
HSCB Medicines Management Team

Supported by four prescribing support assistants

Regional Medicines Management Dietitian Initiative Steering Group with
key stakeholder membership
Initiative Overview
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Dietetic assessment of patients in identified cohort
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Implement prescribing change where appropriate

Provide training resource for primary care healthcare
professionals

Evaluate the impact
Patient Cohort


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Patients are identified within each practice who are prescribed Oral
Nutritional Supplements (ONS)
Exclusions – patients under the care of a Trust Dietetic Department or last
days of life
These patients are offered an appointment with the Medicines Management
Dietitian :
 within the practice (Clinic)
Care
 in the care home
home
28%
Clinic
 domiciliary setting
48%
Home
24%
Prescribing Cost of ONS/1000NIPUs for each practice in N.Ireland
Prescribing indicators for ONS for individual GP practices
across N.Ireland
Outcomes ……
Inappropriate Prescribing
Criteria used by London Procurement Partnership (LPP) to classify a
prescription as appropriate:
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Patient is at risk of malnutrition (MUST ≥2)
ACBS Indication
Trial of food first has failed
Applying this criteria to these 150 patients in the initial cohort
96% of ONS inappropriately prescribed
LPP data = 75% inappropriately prescribed
Productivity: April 2014

Total number of practices contacted = 47 across Northern Ireland
 27 complete

Total number of patients offered an appointment = 946
– 506 complete
Prescribing changes
Following assessment and tailored dietary advice by the medicines
management dietitian the following prescribing changes were
recommended:

56% of ONS discontinued

8% ONS amended

36% ONS continued
Food First Approach…….
“agree in this, that thousands of patients are starved in the
midst of plenty, from want of attention to the ways which
make it possible for them to take food.”
(Florence Nightingale)
Annual efficiencies
Annual efficiencies of £315k to date
£
– This will be a rolling figure moving forward
1000000
900000
800000
700000
600000
500000
400000
300000
200000
100000
0
Total cost
Exclusions
Inclusions
Efficiencies
Practice Feedback
‘The GPs want me to pass on their appreciation with this initiative.
They have found it really worthwhile’
Practice Manager E-mail
Patient Perceptions of ONS
Settles the stomach when having acid reflux (1 milkshake ONS)
Thought it was a vitamin/mineral drink, patient didn’t realise kcal content
and didn’t want to gain weight (ONS was calogen)
Appetite stimulant
Patient Perceptions of ONS
Examples of how patients are using their ONS:

Calogen (a calorie supplement) being used as an emollient

Ensure Plus Juce used as a laxative

Thought GP gave it to her as she is not drinking enough fluids and
doesn’t like water. Thought it was like Ribena (juice style ONS)

Pro-Cal perceived to be a calcium supplement as opposed to a
calorie and protein supplement
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Build up/tonic
The Rubik’s Cube Effect

Change on one size
will have an impact
on the others

Be mindful of the
impact
The Rubik’s Cube Effect

Regional Medicine
Management Dietetic
Steering Group

Key stakeholder to
share learning and
identify solutions
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Linkages with other
local and regional
initiatives
In Summary

Identify your dolls
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Find your nemo and
synergise
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Remember the Rubik’s
Cube effect……
Thank you