More-2-Eat Phase 2: Spread/Scaling Up Improved Nutri>on Care

CFNSept21,2018

HeatherKellerRDPhDFDCSchlegelResearchChairNutri<on&Aging,UniversityofWaterloo

The Problem…

•  Meal<memanagement•  Ea<ngassistance•  Nutrientdensefood•  Oralnutri<onalsupplements•  Die<<ancounseling

•  (Baldwin&Weekes,2011;Cheungetal.,2103;Kimberetal.,2015;StraTon&Elia,2007)

Treatmentworks

The Solu>on: The Integrated Nutri>on Pathway for Acute Care (INPAC)

Kelleretal,2015;CFNCatalyst2014-2015

The ‘More-2-Eat’ Project Phase 1

Objec&ves:

1)  Testandevaluateimplementa<onprocessin5diversehospitalsin4provinces

2)  Todevelopavirtualtoolkittosupportimplementa&onofINPAC

Funding:CanadianFrailtyNetwork(2015-17)

Kelleretal.2017

CFNSIG2015-2017

Co-inves>gators/Collaborators for Implementa>on Study

Co-inves&gators•  BarbaraLiu•  JackBell•  PauleBernier•  CarlotaBasualdo-Hammond•  LeahGramlich•  ManonLaporte•  DonaldDuerksen•  SumantraRay•  PaulineDouglas•  LoriCur<s

Collaborators•  BridgetDavidson•  JoelDubin•  MarinaMourtzakis•  RichardSawatzky•  AliesMaybee•  KhursheedJeejeebhoy•  SarahRobbins•  LindaDietrich•  HeatherTruber

8

INPAC Care Ac>vi>es Implemented Ac&vity Implemented?

Nutri&onscreeningatadmission(withCNST) ✓(Allsites)

UsingSGAtotriagepa&ents ✓(Allsites)

MedPassused ✓(Allsites)

Foodintakemonitoringandfollowinguplowintake ✓(Mostsites)

Volunteersavailableduringmeal&mes ✓(Mostsites)

Weightstakenonadmission ✓(Somesites)

Regularweightstaken ✓(Somesites)

Morefoodavailableforpa<entsontheunit ✓(Somesites)

Dischargeplanning ✓(Somesites)

Implementa>on of Screening at Admission

Implementa>on of Malnutri>on Diagnosis with Subjec>ve Global Assessment

Pa&entCareProcessesandTreatmentImproved

Propor&onofPa&ents(%)Treatment/Care

ProcessBaseline Follow-up

Treatment(advancedcare)

31 63

Medpass(oralnutri<onsupplement)

2 15

Weeklyweight 3 21Foodintakemonitoring

1 32

(Kelleretal.,ClinNutr2018)

Note:Thisisacrossthe5sites.Notallsitesfocusedonweeklyweightsorfoodintakemonitoring.

Pa&entoutcomes?

LengthofStay(days)Site Baseline Follow-UpA 9 6B 12 8C 7 5.5D 8 9E 11 9

Meal&mebarrierstofoodintake

(Kelleretal.,submiTed2018)

AyearacerM2ESite Screening SGA1 region region2 hospital hospital3 region region4 region region5 hospital hospital

SpreadPostM2EPhase1

M2EChampions:MeiTom,MarlisAtkins,RoseannNasser,DonnaBuTerworth,BrendaHotson,MarileeS<ckles-White,SuzanneObiorahM2EResearchAssociates:JosephMurphy,AndreaDigweed,LinaVescio,ChelsaMarcell,StephanieBarnes,ShannonCowan,SheilaDoering,MichelleBooth

Trainees

•  CeliaLaur•  RenataValai<s•  TaraMcNicholl•  SabrinaIuglio

The Knowledge To Ac>on Cycle

Capability

•  Educa<on:buildskill•  Enablement:considerexis<ngskillsandopportuni<es

Opportunity

•  Environmentalrestructuring:makeiteasytodotherightthing• Modeling:createaculturalexpecta<onforthebehavior

Mo<va<on

•  Persuasion:makethebehavioura‘goodthingtodo’•  Incen<visa<on:makeitdesirabletodothebehavior

Behaviour Change Wheel: Behaviour Change Techniques

Michieetal,2011

Accoun<ngforClimate

InvolvingRelevantPeopleintheChange

ProcessBuildingaReasontoChange

ImprovingNutri<onCareforPa<ents

BuildingStrong

Rela<onshipsWithintheHospitalTeam

EmbeddingChangeintoCurrentPrac<ce

Hospital Staff/Management Opinions About Making Change

Lauretal,2017

Key Actors

ChampionSiteImplementa<onTeamExternalcoachCo-champions

•  Buildteamengagement•  Staffdiscussiongroups•  SurveytounderstandKAP,barriers•  Lunchandlearns

•  TailorINPACtospecificunitprocesses/context

•  Collectdatatoevaluateands<mulatechange

•  Learnaboutchangemanagement•  Usediversebehaviourchangetechniques

•  Ready-to-useresources•  Buildonearlysuccess

KeyKTac<vi<es

INPAC Audit

Period1Sept–Dec

2015

N=546

4Audits/site

Period2Jan–Mar2016

N=867

6Audits/site

Period3Apr–June

2016

N=848

6Audits/site

Period4July–Sept

2016

N=837

6Audits/site

Period5Oct–Dec2016

N=832

6Audits/site

Period6Jan–Mar2017

N=1100

8Audits/site

Developmental Implementa<on Sustainability

OverviewoftheMore-2-EatStudyTimeFramesandINPACAuditDataCollec<on(n=5036pa<ents).

INPAC Implementa>on Toolkit

m2e.nutri&oncareincanada.ca

What we think helps sustain/spread(Laur et al, submiZed)

Phase 2… (Keller, Laur, Vali>s, Dublin, Chen, Cur>s, Bell, Ray, Gramlich, Morrison) •  Canimplementa&onbedonewithincurrentresources?-  10hospitals,6provinces-  Phase1sitesexpandto2+furtherunits

-  Sustainandreplicate?-  Phase2hospitals,1unit-  RedCAPRegistryfordataentryandtemplatesforreports

-  selfmanaged-  INPACtoolkitandresources-  Trainingonbehaviourchange-  Monthlytelephonecoaching-  CommunityofPrac<ceListservOutcomedata:LOS,readmission,in–hospitalmortality

CFNKTFunding2018-2019

Publica>ons from M2E to date 1.McNichollTetal.,Handgripstrength,butnot5mwalk,isausefulfunc<onalmeasuretoaddtoclinicalnutri<onAssessment.NutrClinPra<ce(acceptedAug2018).2.Cur<sL,etal.,Lowfoodintakeinhospital:pa<ent,ins<tu<onal,andclinicalfactors.ApplPhysiolNutrMetab.2018.doi10.1139/apnm-2018-00643.KellerH,etal.,Mul<-siteimplementa<onofnutri<onscreeninganddiagnosisinmedicalcareunits:successoftheprojectMore-2-Eat.ClinNutr.2018:1-9doi10.1016/j.clnu.2018.02.0094.LaurC,eal.,Nutri<oncareacerdischargefromhospital:anexploratoryanalysisfromtheMore-2-Eatstudy.Healthcare.2018;6(1):9.doi10.3390/healthcare60100095.KellerHetlal.,UpdateontheIntegratedNutri<onPathwayforAcuteCare(INPAC):Postimplementa<ontailoringandtoolkittosupportprac<ceimprovements.BMCNutr.2018;17:2.doi10.1186/s12937-017-0310-1.6.LaurCV,etal.Comparinghospitalstaffnutri<onknowledge,aqtudes,andprac<cesbeforeand1yearacerimprovingnutri<oncare:resultsfromtheMore-2-EatImplementa<onProject.JParenterEnteralNutr.2018;42(4):786-796.doi10.1177/01486071177184937.Valai<sRetal.,NeedfortheIntegratedNutri<onPathwayforAcuteCare(INPAC):gapsincurrentnutri<oncareinfiveCanadianhospitals.BMCNutr.2017;3:60.doi10.1186/s40795-017-0177-88.LaurC,etal.,Changingnutri<oncareprac<cesinhospital:athema<canalysisofhospitalstaffperspec<ves.BMCHealthServRes.2017;17(1):498doi10.1186/s12913-017-2409-9.LaurC,KellerH.Makingthecasefornutri<onscreeninginolderadultsinprimarycare.NutrToday.2017;52(3):129-136.doi10.1097/NT.000000000000021810.LaurC,etal.,.Malnutri<onorfrailty?Overlapandevidencegapsinthediagnosisandtreatmentoffrailtyandmalnutri<on.ApplPhysiolNutrMetab.2017;42(5):449-458.doi10.1139/apnm-2016-065211.KellerHetal.,.More-2-Eat:evalua<onprotocolofamul<-siteimplementa<onoftheIntegratedNutri<onPathwayforAcuteCare.BMCNutr.2017;3:13.doi10.1186/s40795-017-0127-5

Acknowledgements

In-kindSupport:Die<<ansofCanadaCanadianSocietyofNutri<onManagementCanadianNutri<onSocietyNNEdProGlobalCentreforNutri<onandHealthRegionalGeriatricProgramofToronto

ThisresearchisfundedbyCanadianFrailtyNetwork(knownpreviouslyasTechnologyEvalua<onintheElderlyNetwork,TVN),supportedbyGovernment

ofCanadathroughNetworksofCentresofExcellence(NCE)Program

Ques<ons?