Development of a Dietetic Support Worker Lee Bell Context Latrobe Regional Hospital 256 Bed regional referral centre Wide range of acute, sub-acute & mental health Aged care setting 16 GEM, 10 Nursing Home, 2 Respite One dedicated dietitian 4-8 hours per week Menu monitors to assist clients requiring special diets to choose from hospital menu framework. Focus on malnutrition Background • Malnutrition risk screen of aged care ward – n 24 – 8 at risk of malnutrition – 4 clients at risk had no dietetic referral 50% – All of these 4 clients were in the highest risk category for malnutrition • Forecast workforce & population pressures meant thinking critically about skill mix The Vision • Improve the client journey • Address issues of access to dietetic services • Allow all staff to work at their maximum skill level Role Development • Steering group established • Facilitated workshops • Stakeholder liaison – Internal – External Abbreviated Process Map Admission Nursing Assessment Review progress, Full dietary Dietitian Diet Education Discharge tolerance, Assessment agreed preparation Admission to aged care ward education Advanced Screen Supps/Diet Enc +/- Monitor Discharge DSW ward ordered assist preferences arrangements meals Speech Discharge Full Therapy Pathology preparation swallowing planned assessment Menu monitors Diversional therapy PSA AHA etc Dietetic Support Worker – Defined Clinical • Screen all clients for risk of malnutrition • Diet and supplement ordering as prescribed by dietitian • Assist and encourage client to take prescribed supplements • Monitoring patient preferences • Provide assistance and encouragement at meal times • Ensure weekly weights and food charts completed Administrative • Maintaining dietetic stores • Participation in quality activities • Manage the delivery of enteral formula and equipment • Other administration including minute taking, photocopying, maintaining databases, confirming appointments, preparing for groups Malnutrition Universal Risk Screening Tool • Validated tool for use in hospitalised elderly • Designed for use by the non professional • Maintains validity when height and weight cannot be measured • Quick to use Stratton RJ, et al. British J Nutrition. Feb 2006 95(2):325-30 Education and Training • CS&HTIB translated the knowledge and skills required for the role into RTO competencies • Original recommendation not well suited – Certificate III Health Service Assistance (Nutrition and Dietetic Support) – Supplementary training • Model chosen was due to inadequacies in current training and logistical barriers Analysis of existing competencies • Certificate III Health Service Assistance provided some basic desirable competencies. • Desirable competencies were shared across Cert. III (Nutrition and Dietetics) and Cert. III (AHA) but were inadequate for new role. • Cert III AHA efficacious as foundation training – Availability of qualification in rural/regional area – Versatility – Provides career structure for AHA Additional training required • Additional training commissioned (Hygiene and food handling, MS) • In House training developed – Working knowledge of therapeutic diets and products – Awareness of nutritional risk factors in aged care – Legal/ethical framework – Communication styles/providing encouragement – Malnutrition screening (anthropometry, mathematics, no lift training) – Documenting in medical history – Safe feeding practices, swallowing and dysphagia – Patient administration software systems – Administrative skills (touch typing, documenting meetings – Warehousing principles and managing stock – Time management and prioritisation of workload CS&HTIB advised additional training requirements of pilot would be suited to Cert.IV program Implementation • Jan 2006 to May 2006 • Addressing barriers to change – Key stakeholder representation in design stage – Unit manager support – Inservices to nursing, food service and dietetic staff – Regular feedback sought – Ethics – DHS & state level union negotiations – DAA Learnings • Morning handover meeting with dietitian and regular reporting time to discuss dietary changes • Scope of practice required narrowing due to patient confusion between role of dietitian and support worker. • Developed system of ward enteral feed requirements to allow delivery to wards by DSW • Hours of work required structuring around meal times • Important that all tasks were performed under direct supervision of Accredited Practicing Dietitian • Exclusion criteria for malnutrition screening • Assumed prior knowledge and time required for training was underestimated. Time management and prioritisation skills. Evaluation • State wide evaluation measures – No increase in length of stay – No complaints pre or post pilot implementation • Pilot specific measures – Improved access to dietetic services for patients at risk of malnutrition – Improved efficiency of dietetic time Improved access to services • Patients at high risk of malnutrition receiving dietetic intervention improved from 20-40% to 100% Percentage of patients screened at high risk of malnutrition 30.00 25.00 20.00 High risk % 15.00 Seen by dietitian 10.00 5.00 0.00 Screen 1 Screen 2 Improved efficiency of dietetic time Average dietetic time per client per month 1.8 1.6 1.4 1.2 1 0.8 0.6 Ma y J une J uly Aug Sep Oc t Nov De c J an Fe b Fe b- DT Efficiencies to be gained • Proficiency of DSW in new role • Referral criteria for malnutrition screening • Tighter guidelines for patient reviews by DSW • Improved structure for handover meetings Cost Effectiveness • Costs (per month) – Dietitian Grade 1 Year 3 $1300 – Qualified Allied Health Assistant $1400* • Principal Diagnosis of malnutrition – DRG K61Z Severe nutritional disturbance $8700 – DRG E46(A-C) Protein Energy Malnutrition $8700 • Additional Diagnosis – May have impact on length of stay (1-40 days) Where are we now?
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