Oral nutritional supplements in care homes

Demands on access to primary care are increasing with the rising prevalence of long-term conditions, multi-morbidity and the impacts of Covid-19 (Greenhalgh et al, 2020; Julia et al, 2020; Pettigrew et al, 2020). Medicines use is increasing, and with one in four adults in primary care in the UK taking five or more medicines daily, there is a need to workforce plan in order to meet prescribing needs (Avery et al, 2012). Mobilising the primary care workforce, including non-medical advanced practice health professionals, is important in order to address UK primary care prescribing and medicines optimisation needs (National Prescribing Centre, 2010).

The number of healthcare practitioners in Northern Ireland (NI) who are eligible to prescribe continues to increase each year. In addition to the more traditional medical prescribers, appropriately qualified nurses and pharmacists have been able to prescribe independently since 1997. Additional professional groups such as podiatrists, optometrists and physiotherapists have more recently joined this list of authorised non-medical prescribers. Traditionally, prescribers have worked in either primary or secondary care, and mechanisms to facilitate prescribing are largely reflective of these two environments (National Prescribing Centre, 2010).

NI lacks a mechanism to allow many prescribers working at interfaces to prescribe medication directly to the patient. Specifically, care home residents, who are assessed as having additional nutritional requirements, should have a management care plan that aims to meet their complete nutritional requirements.

To supplement the first step of fortified food measures, oral nutritional supplements (ONS) are often prescribed by GPs, usually on the recommendation of a dietitian, causing duplication of effort and delays in treatment. While ONS products are not prescription-only medicines, prescription can be common practice in order to facilitate supply of products. GPs can initiate ONS themselves, at patient request and at the request from other health professionals. In one area in NI, an audit from 2015 found that in 800 patients who were prescribed ONS, 309 were under the care of the Trust dietetic team. The remaining 491 patients had ONS initiated by a primary care health professional or were discharged for management by the GP practice. At the time of the project, dietitians did not have prescribing rights, but changes to legislation have now been introduced to support supplementary prescribing of medicines in secondary care by advanced practice dietitians. Regardless of prescribing rights, dietitians already have the skills and expertise to assess and monitor residents for nutritional needs, recommending and stopping nutritional products as clinically indicated, and it is reasonable to propose that the clinical responsibility for ordering these items can sit with them.

‘Understanding and overcoming the barriers to implementation is crucial to fully enable dietetic-led ordering of ONS for residents in care homes in Northern Ireland’

A nutrition pilot in 2019 involving eight care homes in one Health and Social Care (HSC) Trust locality identified that waste of ONS products over a 3-month period in care homes accounted for 24% of the prescribing costs. A key recommendation for improvement suggested by the care homes, GP practices and community pharmacists, was the direct input of dietitians into the ordering process. Elsewhere, NHS Tayside has successfully implemented a dietetic led stock order service for care homes in the Dundee area (Walker, 2019).

The service has demonstrated improved management of residents and prescribing savings mainly achieved from reduced wastage due to inappropriate prescribing. Additional savings have recently been identified as a result of an NHS managed supply process. Despite these reported benefits of alternative ways of ordering products, there can be difficulties with implementation and barriers to adoption with such a change to practice. Understanding and overcoming the barriers to implementation is crucial to fully enable dietetic-led ordering of ONS for residents in care homes in NI, which has the potential to reduce need for generation of a GP prescription, use of enhanced skills and empowerment of the profession and, ultimately, improvement in patient care (Edwards et al, 2022). Understanding ways to improve the adoption and implementation of evidence-based nutritional support interventions into routine practice is a particular gap in the existing evidence (Thomson et al, 2022a).

This pilot study tested dietetic-led ordering of ONS for residents in care homes in Northern Ireland, without the need for generation of a GP prescription. Monthly stock orders for the care home residents were raised by the dietitian rather than individual resident orders.

Aim

To test a dietetic-led ordering of ONS for residents in care homes in NI without the need for generation of a GP prescription. The specific objectives of the project were to:

• Deliver the ‘Good Nutritional Care in Care Homes’ educational package to participating care homes and assess knowledge gained
• Evaluate the potential volume of prescribing activity, patient compliance with ONS products supplied and the range of ONS products offered as part of the new model
• Explore the time taken for dietetic recommended ONS supply
• Evaluate the new model activity for compliance to dietetic formulary
• Evaluate changes in the ONS ordering process with the new model
• Evaluate cost savings with the new model
• Explore dietitian, GP and ONS suppliers (community pharmacists or Business Services Organisation Procurement and Logistic Service [BSO PaLS]) perspectives on the benefits, challenges and suggestions for full implementation of the new model.

New model of prescribing and methods

A new model of dietetic-led ordering of ONS was developed by a Task and Finish Group involving relevant stakeholders from across the HSC system in NI. The group conducted extensive stakeholder engagement to define the key principles of the model and scope out the arrangements that needed to be in place. The agreed non-medical ordering process (NMOP) facilitated dietitian-led direct ordering of ONS for care home residents with monthly stock orders for the care home raised by the dietitian rather than individual resident orders.

Two supply mechanisms were tested:

• ONS supplied by the community pharmacy contractor who normally supplies medicines to the care home
• ONS supplied by BSO PaLS (a similar approach to NHS Tayside supply model) (Walker, 2019).

The Task and Finish Group met regularly throughout the pilot to facilitate quality assurance and to identify and resolve any issues with service design and delivery.

The educational package ‘Good Nutritional Care in Care Homes’, designed and developed to support the regional prescribing support dietetic team, was delivered through four 1.5-hour online training sessions to staff at the care homes taking part. This provided training on the importance of nutritional screening, assessing the risk of malnutrition using the Malnutrition Universal Screening Tool (MUST), the steps required to introduce a nutritional action plan for treating under nutrition and the underlying conditions/factors that affect intake including fluid and their management.

Outcome measures

• Care home staff knowledge polls were carried out using the Citizen Space platform before and after the delivery of the ‘Good Nutritional Care in Care Homes’ educational package.
• The number (%) of residents supplied with ONS, the number (%) of residents under the care of dietetic services, the number (%) of ONS items supplied, whether residents had been reviewed within recommended timelines and the length of time for ONS supply, at baseline and end-point audits were compared.
• The number (%) of residents complying with the items prescribed and the range of products offered at baseline and end-point audits were compared.
• The number (%) of prescriptions compliant with the NI formulary at baseline and end-point audits were compared. Items prescribed were reviewed to determine compliance with NI Formulary choices (for those therapeutic areas for which a formulary exists). Best practice guidance indicates that clinicians should aim for at least a 70% compliance rate with medicines' formularies. Only items that have a listed product type in the formulary were assessed for compliance; i.e. there are no formulary choices for the following ONS product types: Dysphagia IDDSI Labelled Desserts; Dysphagia Pre-Thickened ONS; Modular Low Volume Products.
• A process map and the resident journey was compiled by dietitians in each Trust at baseline and end-point audits.
• The average monthly cost of ONS pre-pilot versus during the pilot were compared (average monthly prescribing costs pre-pilot were obtained from prescription payment data collected in NI).
• Qualitative data were collected via stakeholder feedback sessions and survey using the Citizen Space platform from both GPs and ONS suppliers.

Analysis

Data was audited for a 1-week period at the start (April 2021) and end (June 2021) of the pilot. Audit activity was collated using Microsoft Excel. Data was quality checked and re-categorised as necessary. Descriptive statistics were used to summarise activity at the start and end of the pilot. Process maps and resident journeys were recorded by clinicians taking part in the pilot. Steps and time taken were summarised. Qualitative responses from virtual stakeholder feedback sessions and clinician surveys were themed and reported.

Average monthly prescribing costs pre-pilot were obtained from prescription payment data collated by BSO Family Practitioner Service (FPS). The time period for costs analysis extended beyond the pilot period to ensure results were as robust as possible (the analysis period was January to November 2021).

Results

Between April and June 2021, six care homes from three HSC Trusts in NI participated. An audit of ONS prescribing was undertaken before and after the pilot was delivered at each care home. Data was collected by the dietitian responsible for delivering pilot activities at each care home.

Good Nutritional Care Training

Attendance at the four training sessions of the Good Nutritional Care Training delivering during the project ranged from two to 12 attendees across three of the care homes. The knowledge polls showed an increase in care home staff knowledge across all areas after each training session (Figure 1).

Prescribing activity

As displayed in Table 1, at the beginning of the pilot, there were 209 residents living in the pilot care homes. Some 48% (n=101/209) of those residents were being supplied one or more ONS items for nutritional support. By the end of the pilot, 30% (n=67/222) of residents at the pilot care homes were on ONS. There was an increase in the number of ONS items that were initiated through dietitian recommendation from the start (82%) to the end of the pilot (98%). Notably, at the end of the pilot no ONS items were being requested by the care home or initiated by a GP. Results indicated improved resident compliance with ONS products prescribed and a greater number of snacks and snacks with a modified texture offered by care homes.

Table 2 provides details on the ONS items and prescription timelines for those residents in the care of dietetic services. Not all residents prescribed ONS were under the care of the Trust's dietetic teams. Forty-nine per cent (49/101) were under dietetic care services at the start of the audit and 93% (62/67) were under dietetic care services at the end of the audit. Some residents may have been discharged from the dietetic team but were continuing with ONS for review by the GP, or in other cases ONS was initiated by the GP without dietetic input; for example, on request of the care home, or residents may have been awaiting assessment by dietetic services.

Of the ONS items supplied to residents, most corresponded with a dietetic recommendation at the start and at the end of the pilot. The discrepancy between the dietetic recommendation and the actual ONS were due to an incorrect frequency of prescription, omission of the item, prescription of incorrect item or unknown. By the end of the pilot, more ONS items were supplied to the resident more quickly (within 2 days).

Compliance with NI formulary

A subgroup of ONS products could be analysed for compliance with formulary (i.e. there are no formulary choices for some ONS product types, such as dysphagia IDDSI labelled desserts). Results indicated good levels of compliance with formulary at both time points and an increase in compliance, with 64% (56/88) of products compliant with the NI nutrition formulary at the start of the pilot compared with 79% (41/52) at the end of the pilot.

Process maps and patient journeys

A process map for the ordering of ONS products in care homes was collated for two HSC Trust areas using the Community Pharmacy Supply and for one HSC Trust using the BSO PaLS Service. There was a reduction in the number of steps and a reduction in the time taken in all pathways (Table 3). Positive effects of the NMOP pilot were documented in the patient journeys (Table 4), with benefits for individual patients and more opportunities for clinicians to use their skills for patient benefit.

Costs of ONS

Over the course of the pilot, there was a reduction in average monthly spend on ONS for the majority of care homes (Figure 2). The net average reduction in cost per month across the six care homes was £3621. This could be extrapolated to over £43000 annually for the care homes participating in the pilot. Dietitians reported increased caseload due to shorter referral times or identification of unmet need for nutritional support which may explain the increased costs in some homes during the pilot.

Stakeholder session and surveys

Key themes were identified from the stakeholder feedback session (involving 15 stakeholders) and the survey (24 responses). Most of the survey responses were from the GPs and GP pharmacists. Themes in relation to benefits, challenges and requirements for regional roll-out from the new model were summarised.

Benefits of dietitian-led ordering and alternative supply mechanisms

The majority of respondents (92%) felt that dietitian-led ordering of ONS via stock order benefited the resident and reported a reduction in the time to supply ONS, improved resident choice, improved food fortification practice, reduction of burden on GP practices and community pharmacies, more efficient use of ONS, reduction of waste of ONS and more streamlined communication with appropriate health professionals.

Other positive effects of the project included implementation of the software (Inhealthcare) to assist with stock management and improved working relationships. Specifically, respondents stated that the time to arrange delivery of stock was greatly reduced with the community pharmacy supply route and provided immediate access to ONS for new residents.

Eighty-three per cent of respondents indicated that the dietetic ordering and alternative supply mechanisms were beneficial and reported cost savings, improved mechanisms for care homes, less waste and reduced GP input required. Specifically with regards to waste, respondents highlighted that non-labelling of ONS facilitated the use of products across a number of residents where appropriate and that changes to resident ONS requirements were easier to facilitate without incurring waste. Additionally, the new supplement record easily identified the unacceptability of a particular product for specific residents and facilitated a greater choice of products for residents. Furthermore, the NMOP negated the need to dispose of ONS if the resident was admitted to hospital or deceased.

Eight per cent indicated that they were unsure if the new model benefited residents and there was one negative comment from a dietitian relating to the volume of paperwork. Seventeen per cent highlighted reservations with the BSO PaLS supply mechanism and the need to ensure dietitians were informed of stock availability.

Challenges

Seventy-five per cent of stakeholders reported some challenges, including difficulties with introducing change, the time required for set-up of the processes, underestimation of dietetic resource required at start-up and challenges around engaging care home staff in stock management processes. There were some reported barriers to IT literacy among care home staff, and IT software and hardware resource in care homes.

Some respondents reported some issues arising from the BSO PaLS model including that the BSO PaLS supply model had a more limited range of ONS, supply difficulties and that additional steps were required in the authorisation process for e-procurement.

Improvements for full implementation

Over half of respondents (58%) advised on improvements for full implementation, which included improvements in raising awareness, training, funding, shared learning and communication to residents and families. Most of the respondents (96%) indicated that they were happy for dietitian-led ordering of ONS for care home residents to continue and welcomed the efficiencies achieved during the pilot. Respondents reported that they valued the governance arrangements which had been put in place and emphasised the need for recurrent funding to secure continued appropriate dietetic input.

Discussion

This project demonstrated that dietitian-led interventions for ONS supply resulted in a displacement of activity from GPs and the empowerment of dietitians' skills to support appropriate nutrition interventions and discontinue inappropriate ONS, while maintaining compliance and alignment with best practice medicines optimisation policies. Improvements in the clinical pathway process, including a reduced number of steps and reduced process time, aligned with medicine optimisation policies to get the right product to the right patient, at the right time (Department of Health, 2015).

The outcomes from this NMOP pilot project align with factors reported in the literature that facilitate ongoing NMP, including patient care, clinicians' prescribing role and practical aspects (Graham-Clarke et al, 2022). The efficiency and quality findings from the new model practices in this project add to the wider body of evidence supporting NMP, including improvements in a range of safety and patient-reported outcome measures (Noblet et al, 2018).

The experience of this NMOP project can serve as an example of the capacity and commitment required to deliver a NMOP in other patient service pathways. Several studies have underlined that a coordinated, collaborative and inclusive approach across systems levels is essential for non-medical prescribing to be fully implemented (Noblet et al, 2017; Stewart et al, 2017). In agreement with the literature, collaborative working and collective leadership involving a multidisciplinary task and finish group was key to the successful implementation of the project.

Specifically linked to benefits for care home residents, issues around compliance and acceptability of ONS can play a role in inadequate nutritional support (Murphy 2022; Thomson et al, 2022b). Uptake of and compliance with ONS can be poor (Payette et al, 2002).

This new model intervention, including training and a dietetic-led streamlined process for ordering, addressed a number of reported barriers to ONS compliance, including lack of knowledge and difficulties with implementation (Gibbs et al, 2019). The results suggest that this approach can save clinicians time and improve resident compliance, maximising the effectiveness of ONS products. In addition, the new model provided an increased product range and a reduction in product waste. These findings improve understanding around ways to improve the adoption and implementation of nutritional support interventions into routine practice (Thomson et al, 2022a).

Economic evaluation of ONS has found that it is cost effective in the care home setting (Thomson et al, 2022b). Economic evaluation of ONS in the care home setting has found that cost effectiveness is unclear (National Institute for Health and Care Research, 2023). In this project, there were considerable differences in expenditure on ONS from home to home, as care homes have different bed capacity and each resident has individual nutritional needs. However, overall, this pilot of an innovative dietetic-led approach demonstrated how further savings on ONS products can be made. In this practice area in NI, ONS continues to be prescribed alongside dietitian initiatives to increase awareness of food first and food fortification as an alternative to ONS.

Conclusion

The pilot highlighted a number of challenges and areas for improvement in order to take the model forward as standard practice. Due to the multi-disciplinary and multi-agency nature of the new model, managing the change was challenging. Clear and timely communication with the wide range of stakeholders was key in ensuring ownership of the pilot and successful implementation of the multiple new processes. It is important to note that this pilot project was implemented during the Covid-19 pandemic, which was a challenging time with a constantly changing healthcare landscape.

Overall, areas for consideration in moving forward to full implementation include the need for central leadership and buy-in from all stakeholders with the inclusion of all five HSC Trusts, and further logistical requirements to enable successful implementation of a regional supply model.

Key Points

• This pilot of a new model for oral nutritional supplements supply demonstrated benefits for care home residents, clinicians and the Health and Social Care system in Northern Ireland
• The results from this project improve understanding around ways to improve the adoption and implementation of evidence-based nutritional support interventions into routine practice