The Malnutrition Task Force

Dr Ailsa BrothertonMember of the National Task Force

The Malnutrition Task ForceIndependent group of experts across health, social care and local

government united to address the problem of preventable malnutrition in older people, with ministerial support.

Our mission

To ensure the prevention and treatment of malnutrition is embedded in all care and community support services and awareness is raised amongst

older people and their families

Malnutrition

• Devastating consequences• Declining mobility - due to

muscle wasting• Decreased resistance /

delayed healing• Dizziness, leading to falls• Depression• Deteriorating quality of life• Death!

3 million people malnourished or at riskOlder people are more vulnerable affecting 1:10 (0ver a million)36% already malnourished or at risk on admission to hospital

Our ageing population20

10

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

2021

2022

2023

2024

2025

2026

2027

2028

2029

2030

100

110

120

130

140

150

160

170

Projection of Increase in UK Older Population

75+

65+

(201

0=10

0)

Commitment to Act: Pledges

Malnutrition Task Force – Salford Pilot Site Background and Introduction

Kirstine FarrerConsultant Dietitian

Salford Royal NHS Foundation Trust

Malnutrition Task Force – Salford Pilot Site Background and Introduction

Kirstine FarrerConsultant Dietitian

Salford Royal NHS Foundation Trust

PHYSICALDisease related malnutrition

Feeding

Swallowing

Low activity

Decreasedorgan reserve

Specificdisease

Multiple drugs(taste)

SOCIAL

Isolation

Poverty

PSYCHOLOGICAL

Depression/bereavement

Dementia

Alcohol

Mobility

Malnutrition in the UK

Vulnerabilit

y

Poor breathing and cough from loss of muscle strength

Psychology – depression & apathy

Poor Immunity and infections

Decreased Cardiac output

Hypothermia – decline in all functions

Renal function – limited ability to excrete salt and water

Loss of muscle and bone strength - falls and fractures

Impaired gut integrity and immunity

Impaired wound healing and susceptibility to pressure ulcers

Liver fatty change, functional declinenecrosis, fibrosis

Consequences of Malnutrition (within days)

Inadequate food intake is common in hospital

• European Nutrition Day survey* found that of patients aged >75 years only1:– 46% ate all of breakfast– 34% ate all of lunch– 35% ate all of dinner

• Older inpatients in a hospital elderly care unit in the UK were judged to be eating inadequately and only 67% had assessments2

*748 units in 25 countries, total n=16455, aged >75 years n=4799.1. Schindler KE, Schuetz E, Schlaffer R, Schuh C, Mouhieddine M, Hiesmayr M. NutritionDay in

European hospitals: risk factors for malnutrition in patients older than 75 years. Clin Nutr 2007; 2:10.2. Patel MD, Martin FC. Why don’t elderly hospital inpatients eat adequately? J Nutr Health Aging 2008;

12(4):227-231.

Prevalence of malnutrition

Hospitals Care Homes Mental Health Units

Centres (n=)

Patients (n=)

Centres (n=)

Residents (n=)

Centres (n=)

Patients (n=)

2007 Autumn

175 9336 173 1610 22 332

2008 Summer

130 5089 75 614 17 185

2010 Winter

185 9668 148 857 20 146

2011 Spring

171 7541 78 523 67 543

Prevalence 25-34% 30-42% 18-20%

Communities - little or no contact with services

Communities in contact with

services

Care Homes

Hospital

93%

5%

2%

3 m

illio

n m

alno

uris

hed

Individuals at risk of malnutrition

The Malnutrition Carousel

HOSPITAL

NURSING HOME

CAREHOME

HOME

Malnutrition

PRIMARY CARE dependency GP visits prescription costs hospital admissions

SECONDARY CARE complications length of stay readmissions mortality

We know what excellent nutritional care looks like

Nutrition support in adults 2006

February 2006

The effectiveness of Nutrition Support

0 10 20 30 40 50 0 5 10 15 20 25 30

30 RCT, n = 3258RR 0.59 (CI 0.48 to 0.72)

10 RCT, n = 494; RR 0.29 (CI 0.18 to 0.47)

Complications % Mortality %

Controls Controls

Treatment Treatment

The Cost of Malnutrition

Public expenditure associated with <3 million individuals in UK who are malnourished or at risk of malnutrition

2003 - >£7.3 billion p.a

2007 - >£13 billion p.a.

2014 - ?? >£15 billion p.a.

NICE Cost Saving Guidance places effective treatment of malnutrition as 3rd in ranking of potential biggest cost savers to the NHS

Making it happen

‘’This guide is easy to use since we have defined the top three priority actions for each level of the caresystem. Simply go to the part that relates to your organisation and take action’’

Reliable systems of nutritional care

IDENTIFYDesign systems to screen all patients using a validated

screening toolUse local CQUINs

TREATDevelop personal nutritional care

plans

EDUCATION& TRAINING

STRUCTURES AND PATHWAYS

Continuity across

boundariesSenior

Leadership

PREVENTWork with Public

Health, Local Government and

Social Services

Good nutritional care for every individual, in every setting, on every day

Salford Integrated Care Programme: Malnutrition Launch Event, May 2014

Jack SharpExecutive Director Service Strategy and DevelopmentSalford Royal NHS Foundation Trust

Promote independence for older people, delivering:

1. Better health and social care outcomes

2. Improved experience for services users and carers

3. Reduced health and social care costs

Integrated Care for Older People

“Integrated health and social care for older people has demonstrated the potential to decrease hospital use, achieve high levels of patient satisfaction, and improve quality of life and physical functioning”Curry and Ham, Clinical and Service Integration – The Route to Improved OutcomesKing’s Fund, 2010

High levels of need

National and international evidence

Significant populationgrowth

Significant cost of care

Poor experience of care

Service duplication

27

WORK IN PROGRESS - DRAFT 14/11/13

28

Salford’s approach

• System shift from reacting to anticipating

• Personalised, shared care planning; ‘Sally’ at the centre

• Tell your story once, one assessment, one key worker, supported by one integrated system

• Outcomes driven support

2020 improvement measuresEmergency admissions and readmissions

• 19.7% reduction in NEL admissions (from 315 to 253 per 1000 ppn) • Reduce readmissions from baseline • Cash-ability will be effected by a variety of factors

Permanent admissions to residential and nursing care• 26% reduction in care home admissions (from 946 to 699 per 100,000 ppn) • Savings directly cashable but need to be offset by cost of alternative care (especially

increased domiciliary care)

Quality of Life, Managing own Condition, Satisfaction• Maintain or improve position in upper quartile for global measures• Use of a variety of individual reported outcome measures

Flu vaccine uptake for Older People• Increase flu uptake rate to 85% (from baseline of 77.2%)

Proportion of Older People that are able to die at home• Increase to 50% (from baseline of 41%)

30

Partnership approach*

Age UK Care Homes (multiple) Chamber of Commerce Citizens Advice Bureau City West Housing Trust Community Pharmacy Domiciliary Care Providers General Practice Helping Hands

* includes, but not limited to

Inspiring Communities Together

Mature persons group Salford Community Leisure Salford CVS Salford Multi-Faith Forum Unlimited Potential Your Housing Group Other third sector

organisations

• Summer 2012 Sign up by partners and formation of ICP

• October 2012 Engagement events and co-design

• February 2013 Launch of Neighbourhood Collaborative

• December 2013 Salford Chosen to be one of the national pilot sites to tackle malnutrition under the auspices of Age UK on behalf of the Malnutrition Task Force

• January 2014 City-wide roll-out of ICP agreed

• March 2014 Summit Event to celebrate success so far and forward planning including MTF aims

Journey so far

33

What will be different for Sally Ford and her family?

• Greater independence Able to live at home longer

• Reduced isolation Increased opportunities to participate in community groups and local activities

• Confidence in managing own condition and care

Sign-off own care plan and agree who it should be shared with

Support to monitor own health

• Know who to contact when necessary

One main telephone contact number for advice and support

• Increased community support, specialist care when necessary

Access to a named individual to coordinate care and support

• Support to plan for later stages in life

Agreed plan for last year in life

• Sally Friendly City: raising awareness across the city to, both the public and food and beverage providers, about malnutrition and where to go for help

• Centre of Contact: signpost people who identify themselves as at risk of Malnutrition to get appropriate help

• Multidisciplinary Groups: discussing people who are malnourished or are at risk and supporting them with food and drink diaries, supplements, and onwards referral if required

• Wellbeing/Care Plan: will contain best guidance on supporting good nutrition and hydration

• Integrated Care Standards: that all service providers will sign up to, will include requirements around education, training an monitoring of malnutrition, by GPs, health and social care practitioners and care homes

Opportunities to align with MTF priorities

Do you think it’s normal for people to lose weight as they get older?

More than half thought losing weight in older age was normal

106

83

31

YesNoDont KnowDepends

Over the winter do you think you may have lost weight without intending to?

A quarter said they had lost weight over the winter without intending to

46

131

41

YesNoDont KnowDepends

Over the past week do you think you have been eating enough?16% felt they had not been eating enough over the previous week

160

32 11

YesNoDont KnowDepends

Have you had a smaller appetite lately?32% said they had a smaller appetite lately

67

135

4

YesNoDont Know

Reasons people gave for not eating enough

Illness / medical conditionEats less now on own - loss of meal providerLess hungry /no motivation/ lost enjoyment in food/no reason to keep to regular mealtimesToo busyOther

What people said they’d do if they found themselves losing weight without intending to

Go To DoctorsEat MoreAsk FamilyNothing / Wouldn't be worriedDont KnowOther - see nurse/chemist/other help

GROUP EXERCISE 1

• On your Table is an extract from the Malnutrition Task Force Guides

• This shows the 5 Principles and some important interventions needed to ‘reduce preventable malnutrition and dehydration in older people’

• We would like you to help us better understand how we are currently doing in Salford

• Please share your views on what you think is happening now, where there are gaps, and what more we need to do.