A Multi-Disciplinary Approach to Mealtimes

1. A Multi-Disciplinary Approach to Mealtimes Presented by Emily Wechter- Speech Pathologist, for Disability SPOT September 4th 2019

2. This webinarwillcover…… • The importance of mealtimes • The roles of different professionals in mealtime management • Introduction to resources to assist you to support people in the areas of mealtimes e.g. the mealtime management modules

3. Acknowledgements • Family and Community Services (2012) The Mealtime Management Modules. Developed by Kelly Anschau and Felicity Burke. • Family and Community Services (2016) Mealtime Management: A team approach. Training package developed by the Clinical Practice Support team (Emily Wechter, LorrenKrilich, Kate McDonell, Tess Southcombe, Rebecca Allen, Jamil Masangkay, Agnes Ross, Margaret Balin)

4. Mealtimes- a holistic activity Goals for mealtimes for people with disabilities: • A safe and enjoyable mealtime experience • Increase or maintain community and social participation • Increase or maintain independence and participation • Optimize or improve health and nourishment

5. Why are mealtimes important in our roles? • Nutrition is a basic human right • Eating well promotes good health • Mealtimes are important social events • People with disabilities often need support with the activities of mealtimes • People with disabilities are often dependent on others to meet their nutritional needs and eat safely WE CAN HELP MAKE MEALTIMES SAFE, ENJOYABLE & ACCESSIBLE

6. Mealtimes and the ICF e.g. Prader Willi Syndrome Down Syndrome Autism Chronic lung disease Psychiatric Illness Stroke Cerebral Palsy Diabetes Obesity e.g. Low muscle tone Poor motor coordination Cognitive deficits Difficulties inhibition Dry mouth Respiratory issues Motor planning impairments Structural abnormalities Poor dentition Metabolic issues Dental issues Smell or taste limitations Digestion issues/ reflux Fussy eating/sensory issues e.g. Going out to eat or going to events Eating when you want to Food choice/variety Meal planning Socialising at mealtimes Comfortable eating Restrictive practices e.g. ability to sit or transfer Using cutlery Using a cup Drinking Feeding yourself Swallowing Chewing Breathing easily Digesting Weight regulation Eating at a normal rate Communicating preferences Ordering a meal Cooking Shopping Cleaning up Behaving appropriately e.g. Reliant on other people to eat Carers may have their own ideas about mealtimes and how it should be done Limited options for eating out – modified diets, accessibility equipment People staring Policies and procedures of paid carers Emotions of carers or family members e.g. Cultural considerations Ageing Religion

7. Who is in a mealtime team and who does what?

8. Speech Pathologist “I want the person to swallow safely and be able to communicate what they like and don’t like”

9. Speech Pathologist • Often the “key worker” for development of a mealtime plan • Brings the plan together based on recommendations from all parties • Assessment of choking or aspiration risks & swallowing ability, VFS (moving x-ray of swallow) etc • Monitors the impact of the strategies on swallowing function and safety • Compensatory strategies= Food texture & fluid modification, behavioural strategies and environmental changes e.g. pacing & carer education • Skill building= Teaching feeding skills e.g. chewing, transitioning between solids, cup drinking • Basic recommendations around positioning and equipment – if not complex and specialised otherwise bring in others • Does not make recommendations outside of scope of practice- will just advocate that they are explored e.g. oral care

10. Occupational Therapist “I want the person to sit well when eating and have the right equipment to promote independence”

11. Occupational Therapist • Promoting independence and participation • Positioning at mealtimes in consultation with SP and team • Assess and prescribe equipment for mealtimes to maximize independence and safety • Consider ecological/environmental assessment- how many environments? What could be inhibiting or facilitating participation? • Assess how sensory issues may impact on a person’s independence during mealtimes e.g. vision/hearing impairment, aversion to certain foods/textures/temperatures and reflexes. • Provide carer training e.g. using prompt hierarchy to promote independence.

12. Physiotherapist “I want the person to be positioned for a safe and effective swallow and move to the table easily”

13. Physiotherapist • Assess posture, including head and neck position and seating position for a safe and effective swallow • Assess muscle tone, strength and mobility as this may affect ability to participate at mealtimes and capacity to move independently • Observe the person and note if “chesty”, noisy breathing, drooling, gurgling and check if there is a history of reflux and/or respiratory infections- Consult SP • Assess the person’s mealtime responses • Provide training & instructions for carers

14. Psychologist and behaviour support specialist “I want to reduce any problem behaviours and the impact of mental illness so mealtimes are as positive and enjoyable as possible for everyone”

15. Psychologist and behaviour support specialist Dual roles • Assess behaviours being displayed and risks before, during or after the mealtimes • Assess the effect that mental health issues and treatment may be having on the individuals at mealtimes • Support the family and assess the impact of the mealtime disturbances and provide support • Support a multi-disciplinary approach for fussy eaters – desensitization • Restricted practice strategies that may be inadvertently used or necessary • Behaviour at mealtimes due to traumatic experiences • Write a behaviour/multi-dis plan or provide strategies and training to all supporting the individual

16. Dietitian “I want the person to eat for optimal health and nourishment”

17. Dietitian • Assesses a person’s measurements. This can include weight, height/length, growth, waist circumference, and estimated fat store (skin fold). • Looks at the blood test results, and sometimes requests for certain items to be checked through the Doctor. • Checks food and medication/supplement interactions, and be aware of the common side effects • Ensures the person’s diet meets their nutritional and fluid requirements (including tube feeding), that also meets the guidelines for their medical condition(s). • Recommends a diet that is person and family centred, which takes into consideration their culture/religion, likes and dislikes, different environments, knowledge and skills in food preparation, budget, and other recommendations from other therapists and doctors. • If swallowing is an issue, the person will need to be seen by a SP first.

18. Nurse “I want the person to have all their medications, have good chest health, have good oral care and be assisted appropriately”

19. Nurse • Nursing assessments (issues identified e.g. gagging/vomiting regularly; difficulties managing saliva; noisy breathing; frequent chest infections; consider medications) • Documentation and monitoring of e.g. weight, dehydration, elimination. • Development of Care Plans e.g. Bowel Management Plan • Evaluation- treatments are modified to reach best outcomes • Referral to other professionals e.g Clinicians, GP, Specialists, Dentist. • Has a role in overseeing and monitoring healthy eating & drinking practices and overseeing the implementation of therapy plans. • Nurse can deliver education to families, carers and support staff e.g. medication administration via gastrostomy-PEG tube.

20. Dentist “I want the person’s teeth and mouth to be clean and a good oral care plan in place”

21. Dentist • Assessment and management of gum disease, tooth decay, dental erosion • Oral care strategies • Adaptations for disabilities e.g. difficulties managing thin fluids, positioning, oral aversion, nil by mouth, reliance on others for oral care • Dry mouth, excess secretions • Impact on behaviour e.g. can’t communicate pain • Oral hygienist may also develop an oral care plan and provide carer training

22. Role boundaries • As a team we work together • We should all know the strategies that the team members are recommending and come up with a coordinated mealtime plan and support the person and carers to implement it • You CAN’T make decisions and changes to recommendations outside of your scope of practice

23. Resources to guide us: The Mealtime Management Modules • http://ngolearning.com.au/mealtime-management/

24. Format of MMMs • E-learning/self directed learning tool • Takes approximately 2 ½ hours to complete • 13 sections or modules with combination of written information, links and videos as well as mini quizzes to test knowledge • Case study which puts it all together • Assessment at the end • Links to resources including an appraisal which can be used by workplaces to assess the transfer of knowledge into practice.

25. What is covered • Why mealtimes are important and what they involve • Frameworks policies and procedures we follow around mealtimes including ICF and Evidence Based practice- links to the resources within the program • Who is in a mealtime team and what do they do • Considering personal factors in mealtime management e.g. considering culture • Identifying signs and difficulties at mealtimes- e.g. signs of swallowing difficulties • What to consider in a mealtime assessment

26. What is covered • Importance of nutrition and enteral nutrition • Positioning, sensory processing and medication • Oral care • Developing mealtime management plans • Ethical decision making e.g. informed consent, duty of care issues • Best Practice Tips

27. Resource shelf

28. Particularly useful tools and resources • The Nutrition and Swallowing Risk Checklist • Mealtime management plan templates https://www.facs.nsw.gov.au/__data/assets/pdf_file/0007/590704/111-N-and-S-tools-and-templates-accessible.pdf • Nutrition and swallowing guidelines https://www.facs.nsw.gov.au/download?file=590702 • Mealtime Management for Nurses Practice Package https://www.facs.nsw.gov.au/download?file=301784

29. The Nutrition and Swallowing Risk Checklist • Developed by Family and Community Services/ Ageing Disability and Home Care • Nutrition and Swallowing issues were identified as a big concern in residential facilities in 1997 • Lead to development of policies and procedure including the checklist • Still a concern! • Free to use and available on the internet - can be given to caregivers or completed by clinicians

30. The Nutrition and Swallowing Risk Checklist • Preliminary information e.g. personal info , BMI, • 24 yes/no questions looking at common risks or activity & participation limitations • Summary page at end to document actions for areas identified as an issue (i.e. answered “yes”)

31. Mealtime management plans • Holistic way to document your strategies for a safe and comfortable mealtime which encourages independence and participation • Can be completed jointly by everyone on the team (remember to maintain your scope) • Additional template called “my eating and drinking profile” meant for support workers to complete

34. Nutrition and Swallowing guidelines • Comprehensive written resource • Aimed at disability support workers but a good overall summary of mealtime strategies, considerations etc across mealtime activities • Also could be given to carers as easy to read handouts for certain goals/strategies related to mealtimes

37. Mealtime Management for Nurses Practice Guide • Based on the practice guide for therapists but now housed under FACS website for Nurses • More “professional” version of N&S guidelines Covers: • Identifying and managing nutrition risks • Screening, assessing and managing dysphagia • Enteral nutrition- decision making and management • Readings, resources and links

39. Questions