Raw Food Cost Funding in Ontario Long Term Care Homes Survey Report

Transcription

1 Raw Food Cost Funding in Ontario Long Term Care Homes Survey Report November l Dietitians of Canada All rights reserved.

2 Executive Summary Survey Highlights LTC Homes are serving cheaper protein foods and fewer fresh fruits and vegetables due to budget constraints Many LTC Homes are not able to provide culturally-acceptable foods or therapeutic modifications such as gluten-free diets within the current raw food cost per diem Enteral feeding costs are not covered in many LTC Homes by the additional $0.12 per diem in lieu of High Intensity Needs Funding Many LTC Homes struggle with balancing labour costs and food costs LTC Homes are primarily preparing menu items in-house, using a small proportion of outsourced products Priority Recommendations 1. Remove therapeutic and specialty menu items such as enteral feeding formulae, commercial oral nutrition supplements, gluten free specialty foods, and cultural-specific specialty foods, from Raw Food Cost per diem, so that RFC funding can be used to provide high quality foods and beverages to the entire resident population. 2. Continue annual increase for RFC per diem, determined by increase in consumer price index DIETITIANS OF CANADA I PAGE i

3 Acknowledgements Thanks to members of Dietitians of Canada s Ontario Long Term Care Action Group (DC ON LTCAG), particularly chairs Dale Mayerson and Jady Nugent, and Leslie Whittington-Carter, Ontario Government Relations Coordinator for development and analysis of the survey and drafting this report. Thanks to the Ontario Society of Nutrition Management and the Dietitians of Canada Gerontology Network for distributing the survey to their members. DIETITIANS OF CANADA I PAGE ii

4 Introduction Food is a fundamental need of residents living in long term care homes. The decisions that are made in the purchase of raw food determine the quality and quantity of meals and snacks for residents. Number 4 of the Ontario Long Term Care (LTC) Resident Bill of Rights states that: Every resident has the right to be properly sheltered, fed, clothed, groomed and cared for in a manner consistent with his or her needs. Needs should include a person s medical, cultural, religious and personal needs. Raw food costs should be adequate to meet all these needs of all individuals living in long term care. Food purchases also set the activities of the food services department. The menu is the tool used to determine the quantities of food that are needed. The types and quality of purchased food products directly impact how much time, preparation and skill is required to provide a final product to meet residents needs and expectations, and maintain or improve their nutritional status. As well, decisions regarding types and sizes of equipment for storage, preparation, and service are guided by these decisions. Methods The survey was developed by Dietitians of Canada s Ontario LTC Action Group, and pre-tested with several Registered Dietitians and Nutrition Managers working in LTC, using the FluidSurveys platform. The survey was promoted through to Dietitians of Canada Gerontology Network members, and Ontario Society of Nutrition Management members. Two reminder s were sent to encourage further responses. Response There were 382 responses with a 59% completion rate. Not everyone completed every question. 294 respondents identified as Nutrition Managers and 27 identified as Registered Dietitians. All 14 LHINs were represented, with the greatest from South West (45) and Central East (41), and the lowest from Central West (6) and North West (9). Homes were almost evenly split between for-profit (161) and not-for-profit (146). Total number of responses to this question was 307. Survey responses represent all areas of the province and evenly split between for- profit and not- for- profit homes DIETITIANS OF CANADA I PAGE 3

5 Results Meals Produced in LTC Homes The results clearly show that Dietary departments in long term care homes are providing meals for many additional programs. Both staff and managers must share their attention and resources among different kinds of meal services and expectations of various programs. Type of Program # of Meals IN # of Facilities Long term care 66, Convalescent/respite Retirement 3, Acute Catering Activation Staff meals Meals on wheels 1, Other Reported Raw Food Cost Spending Frequency of Reported Raw Food Cost Spending $ $5.00 $ $6.99 $ $7.49 $ $7.99 $ $8.49 $ $8.99 $ $9.49 $ $9.99 The majority of homes reported their actual Raw Food Cost as equal to the funded RFC per diem. This may be due to Homes unwillingness to spend more than the per diem, even though it may not be enough to provide optimal menu choices. This may also reflect pressure on Nutrition Managers and RDs to adhere to budgeted RFC per diem by making menu changes to decrease costs. DIETITIANS OF CANADA I PAGE 4

6 Changes to Menu Survey respondents were asked about the changes they would like to make to their menu and the foods and beverages offered to residents, if there were additional funds available. They were also asked what changes had already been required to adhere to RFC budgets. Most respondents would improve the quality of meats and other protein, and serve more fresh fruit and vegetables if they had additional funds; reducing these items were the most common menu changes made to reduce expenditures. If you had additional funds for the raw food budget, what changes would you make to your menu or food purchases? Top 10 Changes # of Responses Improved proteins 83 More fresh fruit 64 More fresh vegetables 60 Better quality 34 Better desserts 19 Thickened fluids & supplements (more, purchased) 13 More variety 13 More fresh food 12 Less premade/processed foods 11 Better snacks 10 Total 319 Most respondents would improve the quality of meats and other protein, and serve more fresh fruit and vegetables if they had additional funds; reducing these items were the most common menu changes made to stay within RFC funding. What changes have you made to menu to allow you to stay within the Ministry of Health and LTC raw food cost funding? Top 10 Responses # of Responses Cheaper protein 61 Less fresh fruit/fresh vegetables 30 Cheaper desserts 26 Remove expensive items 24 More homemade foods/fewer pre-made items 18 More canned/frozen foods 16 Buying lower quality 15 More casserole dishes 12 Juice crystals 11 Cheaper snacks 10 Total 223 DIETITIANS OF CANADA I PAGE 5

7 Therapeutic Diets and Texture Modifications Respondents were asked about therapeutic and texture modifications they are NOT able to provide within the raw food cost funding. The responses given most frequently included therapeutic items such as gluten-free foods and thickened products, and cultural foods such as kosher, halal, or vegetarian meals. With the increasing complexity of resident care and cultural diversity of the LTC population, these cost pressures will likely continue to increase. Type of Modification # of Responses Gluten free foods 39 Cultural foods (kosher, halal, vegetarian) 20 Thickened products 15 Strict diet needs (renal, low Na, etc.) 11 Pre-made pureed foods 9 Tube feedings 9 Supplements 6 Specialty milks 2 TPN 1 Meal Production and Service The majority of homes use conventional production methods, where foods are prepared and served within a short time frame. Homes also purchase pre-prepared food products for some of their menu items, and a smaller number use cook-chill/freeze systems. % of Conventional Cook-Chill/Freeze Outsourced Production 0-30% 9 homes 26 homes 96 homes 31 50% 23 homes 3 homes 23 homes 51 70% 22 homes 0 homes 4 homes % 147 homes 2 homes 2 homes DIETITIANS OF CANADA I PAGE 6

8 Show Plates Eighty-five percent of homes report using show plates to inform residents of their meal options. Show plates are used to help residents choose among menu options by showing the actual food items when making their selections. This is intended to overcome communication issues and provide a more resident-centred dining experience. However, the cost of show plates can have a substantial effect on the Raw Food Cost budget as the food is generally discarded as it cannot be kept at appropriate temperatures during the entire meal service. Most homes have multiple dining areas, each requiring use of 2 or more show plates. For example, a home with 6 dining rooms using 2 show plates per dining room at lunch and supper would be serving 24 additional plates of food each day, roughly equivalent to 7 8 additional meal days. Various methods to decrease this expense have been tried with some success, including using mini showplates with very small portions of each food item, or using pictures instead of actual foods. Research is needed to identify the best method of offering choice to all residents. Use of Showplates at Meals No 15% Yes 85% Commercially-prepared Modified Texture Foods LTC Homes meet the needs of residents with chewing and swallowing difficulties through modified texture diets, and beverages of modified consistency. The choice of preparing these items in-house or purchasing them is based on a quality, cost, menu variety, and labour availability. Homes that choose to purchase commercially prepared items will incur higher food costs, however the products are consistent quality, texture, and consistency, and require less staff time to prepare. In-house preparation generally can be done at lower food costs and provides more variety but requires more staff time for production and comprehensive quality assurance processes to ensure foods and beverages are the correct texture and consistency. Responses to this survey question showed that most homes are doing a combination of in-house and purchased items for minced and pureed foods and thickened beverages. Thickened products and purchased pureed foods were among the top items reported as unattainable with current raw food cost funding as noted on page 6. DIETITIANS OF CANADA I PAGE 7

9 Prepare all in-house Prepare some in-house and some purchased Use only purchased product Total responses Pureed food products Minced food products Thickened beverages 123 (55.4%) 95 (42.8%) 4 (1.8%) (86.1%) 29 (13.4%) 1 (0.5%) (37.4%) 119 (52.4%) 23 (10.1%) 227 Oral Nutritional Supplements (Purchased and Made-In-House) What is the approximate per resident per day cost of nutritional supplements (Purchased supplements include, for example, Boost, Ensure, Resource, Great Shake; examples of made-in-house supplements include milkshakes, high protein pudding). Of the 206 responses to this question, 37% (77 respondents) were not sure of their cost per day. The most prevalent reported costs for purchased supplements was in the range of $ $0.50 per resident per day, and the cost of made-inhouse supplements was most prevalent in the < $0.10 category and $0.20-$0.50 category. These costs represent a significant portion of the RFC funding, reducing the amount available to be spent on menu items. A food first approach to decreasing supplement use is often recommended, however many homes report difficulty implementing this with current staffing levels. Daily Cost Per Resident for Nutritional Supplement Purchased Made in- house Information systems are needed to provide NMs and RDs with accurate and up- to- date costs 1/3 of respondents were not sure of cost per day of nutritional supplements or enteral formulae DIETITIANS OF CANADA I PAGE 8

10 Enteral Feeding (Tubefeeding) Enteral feeding delivers nutritionally-complete formula directly to the stomach or intestine, and is used when consumption of foods and beverages orally is not possible. A LTC resident may be prescribed enteral feeding due to severe dysphagia (resulting from stroke or other neurological disorders), or other conditions such as cancer that affects the mouth or throat. Although evidence does not support the use of enteral feeding as a means to prolong life in severe dementia, it is used in some instances. Most homes reported a low number of residents requiring enteral feeding (0 2), however there were also many homes that had 3 or 4, and several that reported up to 11. Number of Residents on Enteral Feeding # of Homes # of residents requiring enteral feeding The costs of enteral formula that exceeded the RFC funding was reimbursed through the High Intensity Needs Fund (HINF) until 2013, when the Ministry of Health and Long Term Care changed policy and provided an additional $0.12 per resident per day funding for all residents, in part to streamline requirements for HINF processing. Due to the variable number of residents requiring enteral feeds, and the variation in costs associated with different formulae, the additional funding is not sufficient in many homes, as shown below. There have been anecdotal reports of LTC homes refusing admission to residents requiring enteral feeding due to the additional costs, which is also reflected in the additional comments section below. Adequacy of Funding to Cover Enteral Feeding Costs No 59% Yes 41% DIETITIANS OF CANADA I PAGE 9

11 Additional comments Many survey respondents provided additional comments, which are quoted directly and grouped into categories: Complexity of Resident Care No way to stay within RFC budget with inflation of food and acuity of residents Raw food budget should align with situation of the home and number of special needs High intensity needs money has been used up to transport 2 residents to and from dialysis Resident needs are greater now and more costly Incorporate diet interventions into CMI funding formula Staffing Staffing hours need to be addressed Better cooking and more cooking time available would reduce need for supplements More complex production and over budget in labour trying to keep food cost down Current funding for manager ours is low, difficult to get everything done properly Need dietary staff finding to increase due to more complex interventions We need more funding for labour, no time to make homemade food Can t hire FSWs or Cooks, need more FSW hours in production. We had a special breakfast, had to ask managers to help out Families expect our resources are limitless. They call MOH to state we don t offer choice if we don t provide short orders (scrambled eggs for supper). Hospital work is less pressure, I wish I would never have chosen FSM in LTC. Need increase in labour 2 responses Need more staffing hours, especially for cleaning in outbreak We can t buy more fresh produce without staff to prepare it. Staffing levels not enough to provide in-house texture modifications and high protein Need more staff to make everything homemade Need more hours for staff and manager Rising Food Costs This is the first year in 20 years I cannot keep up with cost of food Cost of food should keep up with cost of living Member of HealthPro GPO, Rebates applied to any Raw food coverages, special dinners funded with money donated by Auxiliary Last year case of beef was $180, this year $298 for same thing. I am continuing to make menu changes I hope the bureaucrats from MOH will enjoy the pleasurable dining with $7.87 when they get into LTC Food costs of basic items go up because they know we have an increase in raw food budget 2 responses We provide wine with lunch, it comes from our food cost. DIETITIANS OF CANADA I PAGE 10

12 It is a never-ending battle to maintain food cost with current prices Snack menu is very expensive Raw food cost does not reflect raw food price increases Specialty Products and Enteral Feeding Using closed system for tube feeds due to less nurses than in hospital Anything related to tube feeds should be subsidized by MOH Need more money for high intensity costs, resident expectations, supplements 5 responses Gluten free products for 3 residents are very expensive Supplements should be covered under nursing We cannot afford and we do not accept tube feedings More costs for vegetarian, gluten free, renal and tube feeds. We can t refuse residents based on dietary needs 12 cents does not cover cost of tube feeding We have more texture-modified diets. We need more money and more help. We are getting a tube feed residents and a gluten free resident. We are in big trouble. Resident Satisfaction and Nutrition We could not provide extras at Christmas and New Year Poor food satisfaction scores due to raw food budget Resident weights are dropping and resident satisfaction is down We can t provide variety or choices I had to revise menu and take out even more good desserts, replace meat with cold cuts, reduce variety in snacks, etc., because first food order at the beginning of the year went up 3.4% Need increase in raw food budget to meet required nutrition intake NMs are always playing catch-up for optimal nutrition for residents Can t provide a varied menu and stick to RFC funding Very difficult to balance $ and resident needs Our residents deserve better $9-10 food cost causing panic, stress and job insecurity, can t offer nutrition with rising food cost Using cheaper meats, need to cook longer to be tender Other Prisoners get $4 more per day than LTC 3 responses Some months are over budget, other months to recover budget C homes should have higher funding based on inefficiencies of layout $7.87 isn t enough to get coffee and breakfast let alone 3 meals and 3 snacks. There is a lot of waste simply because we have to give residents milk even when they don t want it. Younger residents are complaining, equipment is antiquated, no appropriate now to increased beds DIETITIANS OF CANADA I PAGE 11

13 Future Considerations In addition to the priority recommendations for the Raw Food Cost funding envelope, further considerations to improve quality food and nutrition care in LTC homes are proposed. Priority Recommendations 1. Remove therapeutic and specialty menu items such as enteral feeding formulae, commercial oral nutrition supplements, gluten free specialty foods, and cultural-specific specialty foods, from Raw Food Cost per diem, so that RFC funding can be used to provide high quality foods and beverages to the entire resident population. 2. Continue annual increase for RFC per diem, determined by increase in consumer price index Other Recommendations Invest in research to determine appropriate staffing standards for Registered Dietitians, Nutrition Managers, Cooks, and Food Service Workers to support optimal outcomes Support research into menu standards and provision of fortified foods to decrease the amount of food waste Research support could include access to data collected by the MOHLTC, as well as funded time to perform practice-based research Evaluate the effect of documentation and reporting requirements on resident-centred care DIETITIANS OF CANADA I PAGE 12

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