the 4ps of nutrition: performance, power, policy and position sandra capra am,phd,fdaa professor of...

The 4Ps of Nutrition:

performance, power, policy and position

Sandra Capra AM,PhD,FDAAProfessor of Nutrition, University of Queensland

Chair, International Confederation of Dietetic AssociationsSeptember 2009 HNEH Quality Exposition

Nutrition is not just a pretty extra

• I want to argue that nutrition is a fundamental to quality health care

• I want to pose the argument that nutrition has been a “cinderella” in the health system for too long

• I want to claim that errors in nutritional management through lack of resources and policies are heavy costs to the system and to the people.

September 2009 HNEH Quality Exposition

Nutrition is a core foundation of health• Underpins good health• Underpins reduction of chronic disease• Underpins quality services• Underpins quality of life• Is multidisciplinary• Is cheap• Is effective


Performance – nutrition delivers!

• Nutrition as a strong performer in health and health care systems

• Medical nutrition therapy• Functional nutrition therapy• Food service• Public interest in nutrition• But performance is perceived to be affected by

– Invasion of the field by underqualified persons clouding the ‘truth’ and the evidence

– Trivialising nutritionSeptember 2009 HNEH Quality Exposition

Reducing stress – increasing stress- nutrition blog.iqmatrix.com


• The proportion of same-day separations increased between 1998–99 (47.9%) and 2007–08 (56.3%).

• The average length of stay (including same-day separations) in hospitals was 3.3 days in 2006–07 and 2007–08.

• Between 1998–99 and 2007–08, for patients staying at least one night:– average length of stay varied between 6.2 days and 6.5 days for

public acute hospitals– average length of stay decreased from 5.9 days in 1998–99 to 5.4

days in 2007–08 for private hospitals


But…..

• Those who enter with malnutrition stay longer – much longer.

• Average LoS for those with malnutrition at entry is about double that of those who entry well nourished.


Table 1: Estimated change in projected health and residential aged care expenditure due to selected NHHRC reform proposals Expenditure (millions of 2006–07 dollars)

2002-03 2022-23 2032-33

Original projected health and residential aged care (high care) expenditure ($m)

85,063 167,729 246,056

Total health and (high care) aged care expenditure as per cent of GDP 9.3 10.6 12.4 Less net savings due to proposed interventions Improved availability of sub-acute care –127 –190

Reduced rate of increase in obesity –624 –2,566

Faster decline in smoking rates –363 –262 Patient enrolment with a primary health care service (Medical home) –380 –635 Reforms to aged care –519 1,412 Improved access to basic dental care –73 –110 Improved treatment of diabetes –125 –188 Implementation of personal electronic health records –430 –627 Improved safety and quality of care –660 –976

Total net savings –3,301 –4,142

Total health and residential aged care expenditure after net savings from selected NHHRC reforms ($m)

85,063 164,428 241,914

Total as per cent of GDP 9.3 10.4 12.2

http://www.aihw.gov.au/publications/hwe/pahced03-33/estimates.html


Functional and Medical NutritionTherapies

http://www.feinberg.northwestern.edu/nutrition/images/AppleCutout.jpg


Anti-inflammatory


Power

• Nutrition as a powerful tool for health• Poor nutrition costs money


WHO


http://siteresources.worldbank.org/INTPHAAG/Images/Nutrition-Image1.gif


Policy

• Setting systems that will deliver benefits• Nutrition on the policy agenda• The ACHS EquiP4 revisions under standard 1.5

“Organisation providing safe and care and services” includes a new standard 1.5.7 that concerns ensuring that nutritional needs are met, introducing screening and including nutrition in the care plans among other specified activities. These are currently under discussion.


A Healthier Future for All AustraliansNational Health and Hospitals Reform Commission Final Report June 2009


Malnutrition now updated in DRGs

• Malnutrition is the silent epidemic- 35%+ in health facilities, (www.daa.asn.au), 15% in HACC clients in community (Leggo et al 2008), 50% in RAC

• The kind of malnutrition we see most is now recognised in the classification system – – disease induced malnutrition, – malnutrition in a land of plenty– Malnourished overweight persons

• As a co-morbidity it affects the casemix weighting and therefore reimbursement systems.

• The diagnosis must be by an APDSeptember 2009 HNEH Quality Exposition

http://www.daa.asn.au/

Position

• Positioning nutrition as a core health concern• Having the policy is not enough – it must be

actioned


Primary Health Care Reform in Australia Report to support Australia’s first national primary health care strategy

• DoHA, 2009

These are poor

Very little comfort here



Source: Splett P. 1996

Have we the workforce to deliver?

• We can do a good job and reduce errors mostly if there are enough qualified nutrition staff available

• Nutrition is everyone’s business and is multidisciplinary

• The professional nutrition staff should hold nationally recognised credentials. For nutrition this is the APD credential for any work that requires competence in medical nutrition therapy and foodservices in any form and in any setting.


Source; Brown Capra and Williams ; Profile of the Australian dietetic workforce 1991-2005 Nutrition and Dietetics; 2006;63:166-178


Standardised Terminology

• Errors relate to miscommunication in diagnoses and treatments

• Electronic medical records are here/coming by 2012

• They will– Facilitate information sharing– Provide nformation to measure desired outcomes – Document outcomes and therefore drive the evidence

base and standards of practice.

• We need to adopt the International Dietetics and Nutrition Terminology (IDNT)


• The lack of a standardized approach in nutrition language and terminology can lead to an inaccurate diagnosis which may then lead to inappropriate or ineffective nutrition interventions and lower quality.

• When nutrition and dietetics interventions are solely based or described by a medical diagnosis, there can be ambiguity in both the cause of any nutrition issues and nutrition management


Medical diagnosis :Diabetes Type IINutrition intervention : 7500 kJ diet, carbohydrate controlled Compared withMedical diagnosis : Diabetes Type IINutrition diagnosis : inappropriate food choiceNutrition intervention : counselling and referral to diabetes education centre

Medical diagnosis : cancer Nutrition intervention : high protein, high energy diet Compared with Medical diagnosis : cancer Nutrition diagnosis : Limited access to food Nutrition intervention : meals on wheels, home supplies of supplements

September 2009

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• This contrasts with the “IFI” approach of the National Allied Health Classification Committee, which does not include sufficient terms or details to clearly identify what practitioners actually do. It adopts a functional approach, which groups many separate issues under single codes, leading to an inability to compare outcomes.


• b 530 Weight maintenance functions – Functions of maintenance of acceptable body mass index (BMI); impairments such as underweight, cachexia, wasting, overweight, emaciation and such as primary and secondary obesity

Source: IFI coding Manual for Pilot Project 2007


Food as the tool to deliver nutrition


Food in health care is a treatment

• Calling foodservice a “hotel” service means that it can be forgotten– Treated as less important– Subjected to cost cutting at times


Would you eat these?


My challenge

• http://www.youtube.com/watch?v=dqdYxy7kHns

Make the services as good as this!!


http://www.youtube.com/watch?v=dqdYxy7kHns

Nutrition –the 4Ps

• Recognise the performance of nutrition in healthcare

• Recognise the power of nutrition to make a difference to quality services

• Adopt policies to make a difference

• Position nutrition services so they can deliver quality and excellence

• Be a leaderSeptember 2009 HNEH Quality Exposition

the 4ps of nutrition: performance, power, policy and position sandra capra am,phd,fdaa professor of...

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