Oral nutritional supplement prescribing in care homes: The benefit of dietetic review
Kate Taylor (Nutrition and Dietetics, Royal Devon University Healthcare NHS Foundation Trust).
Supervised by Dr Suzy Hope (Royal Devon University Healthcare NHS Foundation Trust) and Professor Vicki Goodwin (Faculty of Health and Life Sciences, University of Exeter).
This project was a collaboration between Community Dietitians, Royal Devon University Healthcare Trust (Eastern) and Honiton, Ottery St. Mary and Sidmouth (HOSMS) Primary Care Network.
Background and Aims:
Prevalence of malnutrition in care homes is high, in 2015 it was estimated that 35% of those entering care homes were at risk of malnourishment (Elia, 2015). As a result, oral nutritional supplements (ONS) are often prescribed. Prescription and monitoring of ONS use within residential settings varies considerably. The cost of standard adult ONS prescriptions within Devon was up to £4.45 million in the 12 months from June 2023 to May 2024, showing the considerable financial implications (https://openprescribing.net/bnf/091301/).
Locally dietetics are not funded to visit care homes, and input is limited to telephone clinics. This project explored in-person dietetic review and ONS prescribing within care homes in one primary care network within Devon, recording the potential impact on costs. One day per fortnight was committed to this project between November 2022 and March 2023.
Method:
All patients prescribed ONS (n=50) across 16 care homes were reviewed, alongside new care home referrals to community dietetics (n=39) from November 2022-March 2023. Supplements were switched to first-line formulary supplements where possible, stopped where unnecessary according to dietetic assessment, and a “food first” approach encouraged. A food first approach involves using alternative or additional foods to optimise nutrition.
Cost implications of the intervention involved comparison of cost of supplements prescribed pre-dietetic assessment, cost of new prescriptions, dietetic staff time and mileage costs. Supplement cost was calculated from the formulary and staff cost from NHS oncosts.
Measurable Impact and Results:
Patients seen represented 20% of all residents (89/436) within the 16 care homes, suggesting high potential clinical need. Mean age was 90 (SD6) years, ranging from 73-103 years. Female patients accounted for the majority (n=68). Addressing inappropriate prescribing saved £57.62 per day in prescriptions through stopping or changing ONS. Cost of dietetic staff time and mileage totalled £3105.80 over the five-month period, meaning that after 54 days the dietetic review service was saving money.
Patients often preferred first line powder-based supplements, and these were either similar or more appropriate in nutrient content than initially prescribed ONS, which are more expensive. ONS was often prescribed during hospital admission but not reviewed or prescribed by other health professionals in community.
One case study particularly highlights the benefit of dietetic review for patient care. A patient had been prescribed ONS due to pressure ulcers, a condition requiring additional calories, protein, adequate micronutrients and good hydration. Prior to dietetic review the supplement prescribed was a fat-based emulsion supplement which provided no protein and little micronutrient content. The cost was £3.15. On dietetic assessment two first-line community supplements were prescribed as they were more suitable in macro and micro-nutrient content. The cost was £1.06, saving £2.11 per day.
Lessons Learnt:
Dedicated dietetic input for care home residents appears to save costs on ONS prescribing whilst providing specialist nutritional expertise. The cost-saving shown here equates to £21,031 annually, which is enough to employ a half-time band six dietitian.
Being able to see patients face-to-face enabled a patient-centred nutritional plan, taking into account the patient's preferences and needs, decreasing the need for over reliance on ONS. Visiting care homes also enabled discussions with care home staff regarding nutritional strategies using food first. Starting the project again documentation of feedback from both patients and staff would be added to build further evidence.
Providing dietetic expertise to ensure good nutrition and hydration within care homes could also save on additional costs by reducing falls, urinary tract infections and hospital admissions (Lean et al., 2019; Nevens et al., 2013). Given opportunity to extend this project these outcomes would also be key to document.
Dietitians can provide specialist nutritional advice for older adults in residential settings, a population documented to be at risk of malnutrition. This has the potential to be cost saving, but further funding is needed to explore the wider impact of dietetic intervention.
Kate Taylor, Pre-doctoral Clinical and Practitioner Academic Fellowship, NIHR 302696 was funded by Health Education England (HEE) / NIHR for this project. The views expressed are those of the authors and not necessarily those of the NIHR, NHS or the UK Department of Health and Social Care.
References
Elia, M. The Cost of Malnutrition in England and Potential Cost Savings from Nutritional Interventions (Short Version), A Report on the Cost of Disease-Related Malnutrition in England and a Budget Impact Analysis of Implementing the NICE Clinical Guidelines/Quality. 2015. Available online: www.bapen.org.uk
Lean K, Nawaz RF, Jawad S, Vincent C. Reducing urinary tract infections in care homes by improving hydration. BMJ Open Qual. 2019;8(3):e000563. Published 2019 Jul 10. doi:10.1136/bmjoq-2018-000563
Neyens J, Halfens R, Spreeuwenberg M, et al. Malnutrition is associated with an increased risk of falls and impaired activity in elderly patients in Dutch residential long-term care (LTC): a cross-sectional study. Arch Gerontol Geriatr. 2013;56(1):265-269. doi:10.1016/j.archger.2012.08.005
OpenPrescribing.net, Bennett Institute for Applied Data Science, University of Oxford, 2024 Available at: https://openprescribing.net/bnf/091301/ Accessed 14th August 2024.
Links and contact details for further information:
Previously presented at the British Geriatric Society Autumn Conference 2023 and abstract published:
K Taylor, S Hope, V Goodwin, 2023 Oral nutritional supplement prescribing in care homes: The benefit of dietetic review, Age and Ageing, Volume 53, Issue Supplement_1, January 2024, afad246.022, https://doi.org/10.1093/ageing/afad246.022