ABSTRACT
Background: It is challenging to identify single measures appropriate to meet the needs of the whole dietetic caseload, to measure the impact of clinical interventions. This has lead to failure to identify the impact of specific dietetic services and nutritional interventions. Having searched the literature, there were no validated outcome measures for dietetic interventions. In the absence of recognised measures the BDA [1] has produced guidance, covering six domains, to improve practice and demonstrate clinical and cost effectiveness, the only measure that included all six was the Therapy Outcome Measure (TOM) Enderby et al. [2]. The aim of the work was to develop and implement Dietetic TOMs to: - Establish whether interventions are effective. - Improve reflection on practice. - Support service development and improvement. - Demonstrate we provide services that are: clinically cost effective, efficient, responsive and equitable. Process: (NB Only for Innovative Service Development Abstracts) After identifying TOMs as the outcome measure of choice, we undertook training in TOM methodology and consistency of scoring with Professor Enderby, who developed TOMs. This was then subsequently cascaded to all staff. From whole service caseload, commissioning requirements and patient demographics and need, we identified six clinical areas that would provide a TOM for the majority of patients accessing the service, these were: obesity, under nutrition, home enteral feeding, diabetes, irritable bowel syndrome (IBS), and Cardiovascular Disease (CVD). The clinical teams working in these areas developed and piloted the relevant TOM. We undertook a six month pilot, firstly with case notes, and then with patients to test usability, validity, reliability, as well as issues of recording and reporting the data. We undertook a peer review process to ensure consistency of approach and language and then extended the pilot outside of the development teams to the whole service. After further review, the final TOMs were then validated by Professor Enderby. Outcomes: (NB Only for Innovative Service Development Abstracts) he Leeds Community Healthcare (LCH) Dietetic Service has developed and implemented six validated TOMs for dietetics in the Community. This is a validated tool developed by Prof Enderby and measures the clinical outcome of interventions. LCH Dietetics has developed and amended the framework to meet the needs of our teams and service users. The six TOMs are new frameworks and have Prof Enderby validation. The six TOMs developed cover the range of interventions offered in the broadest sense. Every service user will have at least two outcome measures recorded, (baseline and end point) to assess the quality and effectiveness of the dietetic intervention. This will not only demonstrate to our ‘customers’ the effectiveness of what we do, but also enable us as a dietetic service to assess our clinical effectiveness in dietetic practice and make improvements based on this knowledge, to ensure we continue to improve and deliver the best possible care to Leeds residents. Conclusion: TOMs ensure that LCH dietetics can identify the difference their specific dietary interventions make to patient care. TOMs enables effectiveness to be a measured in a consistent approach. This will demonstrate to all stakeholders, including commissioners, that dietetic services are clinically cost effective, efficient, responsive and equitable.
ABSTRACT
Background: Malnutrition is a cause and consequence of disease, affecting at least 3 million UK adults (Elia, 2010 [1]) of which 93% are in the community at a cost to the NHS of £13 billion/year, BDA [2]. Food should be first line treatment for anyone identified as at risk of malnutrition, Crawley and Hocking [3]. Oral nutritional supplements (ONS) are often inappropriately prescribed to treat malnutrition Gall et al. [4]. The current annual spend on ONS in Leeds is approximately £1.7million for around 1500 patients. This innovative service aims to receive 1000 new patient referrals and as a consequence make £300,000 of savings through clinical and cost effective use of ONS usage in the community. Process: The success of a pilot project led to the citywide dietetic-led service. This process is outlined below. Ethics approval was not required. 1. A 12 month pilot project in Leeds North CCG involved a retrospective audit which was carried out with 8 GP practices in 2011/12, to assess current ONS prescribing. Concurrently all Leeds North CCG practices could refer any adult patient on ONS, directly to the dietetic team. 2. This pilot project identified 315 people on ONS with 83 patients assessed and reviewed by a dietitian. The audit showed less than 20% of patients were appropriately prescribed ONS. Dietetic intervention made an average saving of £2.62 per patient per day by getting the right patient on the right product for the right length of time. This equates to an annual saving of £79,372.90. 3. The impact of this work led to investment (until 03/2014) to implement a city wide community ‘Eating and Drinking Team’ to raise awareness of the need to identify and treat malnutrition, through nutritional screening, promoting ‘food first’ principles, appropriate prescribing practices, and pathways, to ensure the best outcomes for Leeds residents. 4. Targets for the new team were set at 1000 new patient referrals, with 3000 patient contacts to enable annual cost savings of 20% per year (approx £300,000). Outcomes: In the first two full quarters of activity (Jan-Jun 2013), the service has: Cost savings are generated by preventing inappropriate prescribing by getting the right patient on the right product for the right length of time. Increase in referrals, activity and outcomes (not discussed here) demonstrate the need for a dietetic-led service, with additional and longer term investment to recognise the referral rate and the savings. Conclusion: Dietetic-led interventions for reducing the risk of malnutrition can be successful in promoting the role of the dietitian and achieving significant cost savings.