Mo More- e-2- 2-Eat Phase 2: Spr t Phase 2: Spread/ ead/Sc - PowerPoint PPT Presentation

Mo More- e-2- 2-Eat Phase 2: Spr t Phase 2: Spread/ ead/Sc Scaling Up aling Up Imp Improved ed Nu Nutri> tri>on on Car Care CFN Sept 21, 2018 Heather Keller RD PhD FDC Schlegel Research Chair Nutri<on & Aging, University of Waterloo

Th The P e Prob oblem em…

Treatment works • Meal<me management • Ea<ng assistance • Nutrient dense food • Oral nutri<onal supplements • Die<<an counseling • (Baldwin & Weekes, 2011; Cheung et al.,2103 ; Kimber et al., 2015; StraTon & Elia, 2007)

Th The S e Sol olu>on on: Th The In e Integ egrated ed Nu Nutri>on on Pa Pathway for Acute Care (INPAC) Keller et al, 2015; CFN Catalyst 2014-2015

Th The ‘Mor e ‘More-2-E e-2-Eat’ Pr ’ Project Ph oject Phase 1 ase 1 Objec&ves: 1) Test and evaluate implementa<on process in 5 diverse hospitals in 4 provinces 2) To develop a virtual toolkit to support implementa&on of INPAC Funding: Canadian Frailty Network (2015-17) Keller et al. 2017

CFN SIG 2015- 2017

Co-i Co-inves es>gator ors/Col /Collabor orator ors for Imp or Implemen lementa> a>on on Stu Study y Co-inves&gators Collaborators • Barbara Liu • Bridget Davidson • Jack Bell • Joel Dubin • Paule Bernier • Marina Mourtzakis • Carlota Basualdo-Hammond • Richard Sawatzky • Leah Gramlich • Alies Maybee • Manon Laporte • Khursheed Jeejeebhoy • Donald Duerksen • Sarah Robbins • Sumantra Ray • Linda Dietrich • Pauline Douglas • Heather Truber • Lori Cur<s 8

INP INPAC Car C Care Ac> e Ac>vi> vi>es Imp es Implemen lemented ed Ac&vity Implemented? Nutri&on screening at admission (with CNST) ✓ (All sites) Using SGA to triage pa&ents ✓ (All sites) MedPass used ✓ (All sites) Food intake monitoring and following up low ✓ (Most sites) intake Volunteers available during meal&mes ✓ (Most sites) Weights taken on admission ✓ (Some sites) Regular weights taken ✓ (Some sites) More food available for pa<ents on the unit ✓ (Some sites) Discharge planning ✓ (Some sites)

Imp Implemen lementa> a>on on of Scr of Screen eenin ing a g at t Ad Admission mission

Imp Implemen lementa> a>on on of Maln of Malnutri> tri>on on Diagn Diagnosis with osis with Su Subjec> jec>ve Glob e Global Assessmen al Assessment t

Pa&ent Care Processes and Treatment Improved Propor&on of Pa&ents (%) Treatment/Care Baseline Follow -up Process Treatment 31 63 (advanced care) Medpass (oral 2 15 nutri<on supplement) Weekly weight 3 21 Food intake 1 32 monitoring Note: This is across the 5 sites. Not all sites focused on weekly weights or food intake monitoring. (Keller et al., Clin Nutr 2018)

Pa&ent outcomes? Meal&me barriers to food intake Length of Stay (days) Site Baseline Follow-Up A 9 6 B 12 8 C 7 5.5 D 8 9 E 11 9 ( Keller et al., submiTed 2018)

Spread Post M2E Phase 1 A year acer M2E Site Screening SGA 1 region region 2 hospital hospital 3 region region 4 region region 5 hospital hospital

M2E Champions: Mei Trainees Tom, Marlis Atkins, Roseann Nasser, Donna BuTerworth, Brenda • Celia Laur Hotson, Marilee S<ckles-White, Suzanne • Renata Valai<s Obiorah • Tara McNicholl M2E Research Associates: Joseph • Sabrina Iuglio Murphy, Andrea Digweed, Lina Vescio, Chelsa Marcell, Stephanie Barnes, Shannon Cowan, Sheila Doering, Michelle Booth

Th The K e Knowled edge T e To Ac> o Ac>on on Cy Cycl cle e

Beh Behavi viou our Ch Chan ange Wh e Wheel: eel: Beh Behavi viou our Change T Ch e Tech echniques es • Educa<on: build skill • Enablement: consider exis<ng skills and opportuni<es Capability • Environmental restructuring: make it easy to do the right thing • Modeling: create a cultural expecta<on for the behavior Opportunity • Persuasion: make the behaviour a ‘good thing to do’ • Incen<visa<on: make it desirable to do the behavior Mo<va<on Michie et al, 2011

Hospit Hosp ital St al Staff/Man aff/Manag agemen ement Op t Opin inion ions Ab s Abou out Makin t Making Ch g Chan ange e Accoun<ng for Climate Embedding Change into Current Prac<ce Involving Relevant Building People in the Change Strong Process Rela<onships Within the Building a Hospital Team Reason to Change Improving Nutri<on Care for Pa<ents Laur et al, 2017

Key KT ac<vi<es Key Actors • Build team engagement • Staff discussion groups • Survey to understand KAP, barriers Champion • Lunch and learns Site • Tailor INPAC to specific unit Implementa<on processes/context Team • Collect data to evaluate and s<mulate change External coach • Learn about change management Co-champions • Use diverse behaviour change techniques • Ready-to-use resources • Build on early success

INP INPAC Au C Audit it

Implementa<on Sustainability Developmental Period 1 Period 2 Period 3 Period 4 Period 5 Period 6 Sept – Dec Jan – Mar Apr – June July – Sept Oct – Dec Jan – Mar 2015 2016 2016 2016 2016 2017 N=546 N=867 N=848 N=837 N=832 N=1100 4 Audits/site 6 Audits/site 6 Audits/site 6 Audits/site 6 Audits/site 8 Audits/site Overview of the More-2-Eat Study Time Frames and INPAC Audit Data Collec<on (n=5036 pa<ents).

INP INPAC Imp C Implemen lementa> a>on on T Toolkit oolkit m2e.nutri&oncareincanada.ca

Wha What w t we think help e think helps sus s sustain/ ain/ spr spread ead (Laur et al, submiZed)

Phase 2… Phase 2… (K (Keller eller, Lau , Laur, V , Vali> ali>s, Du s, Dublin lin, Ch , Chen en, Cu , Cur> r>s, Bell, Ra s, Bell, Ray, Gr , Gramlich amlich, , Morriso Mo rrison) n) • Can implementa&on be done within current resources? - 10 hospitals, 6 provinces - Phase 1 sites expand to 2+ further units - Sustain and replicate? - Phase 2 hospitals, 1 unit - RedCAP Registry for data entry and templates for reports - self managed - INPAC toolkit and resources - Training on behaviour change - Monthly telephone coaching - Community of Prac<ce Listserv Outcome data: LOS, readmission, in –hospital mortality CFN KT Funding 2018-2019

Publica>ons from M2E to date 1. McNicholl T et al., Handgrip strength, but not 5m walk, is a useful func<onal measure to add to clinical nutri<on Assessment. Nutr Clin Pra<ce (accepted Aug 2018). 2. Cur<s L, et al., Low food intake in hospital: pa<ent, ins<tu<onal, and clinical factors. Appl Physiol Nutr Metab. 2018. doi 10.1139/apnm-2018-0064 3. Keller H, et al., Mul<-site implementa<on of nutri<on screening and diagnosis in medical care units: success of the project More-2-Eat. Clin Nutr. 2018: 1-9 doi 10.1016/j.clnu.2018.02.009 4. Laur C, e al., Nutri<on care acer discharge from hospital: an exploratory analysis from the More-2-Eat study. Healthcare. 2018; 6(1): 9. doi 10.3390/healthcare6010009 5. Keller H etl al., Update on the Integrated Nutri<on Pathway for Acute Care (INPAC): Post implementa<on tailoring and toolkit to support prac<ce improvements. BMC Nutr. 2018; 17: 2. doi 10.1186/ s12937-017-0310-1. 6. Laur CV, et al. Comparing hospital staff nutri<on knowledge, aqtudes, and prac<ces before and 1 year acer improving nutri<on care: results from the More-2-Eat Implementa<on Project. J Parenter Enteral Nutr. 2018; 42(4): 786-796. doi 10.1177/0148607117718493 7. Valai<s R et al., Need for the Integrated Nutri<on Pathway for Acute Care (INPAC): gaps in current nutri<on care in five Canadian hospitals. BMC Nutr. 2017; 3: 60. doi 10.1186/s40795-017-0177-8 8. Laur C, et al., Changing nutri<on care prac<ces in hospital: a thema<c analysis of hospital staff perspec<ves. BMC Health Serv Res. 2017; 17(1): 498 doi 10.1186/s12913-017-2409- 9. Laur C , Keller H. Making the case for nutri<on screening in older adults in primary care. Nutr Today. 2017; 52(3) :129-136. doi 10.1097/NT.0000000000000218 10. Laur C, et al.,. Malnutri<on or frailty? Overlap and evidence gaps in the diagnosis and treatment of frailty and malnutri<on. Appl Physiol Nutr Metab. 2017; 42(5): 449-458. doi 10.1139/apnm-2016-0652 11. Keller H et al., . More-2-Eat: evalua<on protocol of a mul<-site implementa<on of the Integrated Nutri<on Pathway for Acute Care. BMC Nutr. 2017; 3: 13. doi 10.1186/s40795-017-0127-5

Ackn Acknowled wledgemen ements ts This research is funded by Canadian Frailty Network (known previously as Technology Evalua<on in the Elderly Network, TVN), supported by Government of Canada through Networks of Centres of Excellence (NCE) Program In-kind Support: Die<<ans of Canada Canadian Society of Nutri<on Management Canadian Nutri<on Society NNEdPro Global Centre for Nutri<on and Health Regional Geriatric Program of Toronto

Ques<ons?