What a Difference a Decade Makes…Transformation of Dietetics in Long-Term Care

As the new millennium dawned, the household model introduced resident-directed dining. Visionaries in the field began to promote new approaches to dining in long-term care as part of the shift from institution to home, by focusing on relationship instead of task and offering point-of-service choice instead of tray service.

Supported in 2005 by the position paper of the American Dietetic Association “Liberalization of the Diet Prescription Improves Quality of Life for Older Adults in Long-Term Care,” and encouraged by positive outcomes in both clinical care and resident satisfaction, the pendulum began to shift. However, the norm for most facilities continued to be prescriptive therapeutic diets and restrictive tray tickets, both standing in the way of resident-directed dining.

The 2007 Pioneer Conference in Minnesota pre-conference intensive  “The Way to the Heart of the Home – Through the Kitchen” introduced the principles of resident-directed dining to participants exploring culture change. But, clinical nutrition, medical nutrition therapy and the role of nutrition in the management of acute and chronic disease still appeared to be the primary focuses of the RD and DTR. Participants of the intensive were reminded of the challenges of the journey when two registered dietitians abruptly left the presentation, loudly registering their concern that they “did not go to college to let people choose what they wanted to eat when their choices might not be in their best interest.”

The focus began to radically change in 2008-2009 as the Center for Medicaid and Medicare Services (CMS) and the Pioneer Network began planning initiatives for the 2009 conference, Creating Home II:  Dining.  The accompanying background papers began to give public voice to leaders in the field.

“Our practice needs to focus on the science of wellness in elder care from a psychosocial aspect.  What resident rights really address are rights to all choices, good and bad.  We need to focus on quality of life from all angles, and redefine wellness or wellbeing as dining with control and choices, community, friends socializing, dignity and respect.” Lori Madalone RD, former Pinon Nutrition Quality Improvement Specialist, 2009

Following the 2010 Creating Home II National Symposium on the Food and Dining Requirements and Culture Change, a workgroup drafted new professional dining standards. These standards aimed to “change what it is like to live in a nursing home in America,” in the words of Carmen Bowman, CMS Conference Consultant and program facilitator. They were supported by the position and practice paper of the American Dietetic Association, “Individualized Nutrition Approaches for Older Adults in Health Care Communities.” The resulting New Dining Practice Standards were supported in 2011 by 11 professional organizations and introduced for surveyor and practitioner training and implementation.

And now, in 2012, the new professional standards are being embraced and adopted by registered dietitians across the country, forming a firm foundation for dietitian advocacy for resident choice, resident rights and quality of life in long-term care.  What a world away from using weight, albumin, BMI, RDI, BUN, HgA1C, Stage IV, mg, mEq, gm, kcal and all the traditional measures of successful nutritional intervention. Dietitians are now advocating aggressively and working tirelessly to champion the residents’ domains of well-being, (identity, growth, autonomy, security, connectedness, meaning and joy) as defined by Fox et al, in “Well-Being:  Beyond Quality of Life…The Metamorphosis of Eldercare.” What a personal and professional joy to be practicing in this new world of resident advocacy.

Linda Bump, MPH is a Registered Dietitian and Licensed Nursing Home Administrator with a passion for resident choice and quality of life with a particular focus on the kitchen as the heart of the home.  As an administrator, she has guided four organizations through transformations to a social model of care.  She has extensive experience as a consultant on the Household Model and has provided education on culture change to 60+ nursing homes through her work with Action Pact since 1999.

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