Optimizing Food and Nutrition Services in Assisted Living Facilities for Older Adults: The FANCI (Food And Nutrition Care Indicators) Study

Author: Shirley Y. Chao

Dissertation School: Tufts University

Pages: 309

Publication Date: May 2008

Availability:
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Access Number: 10843

Abstract:

The objectives of this research were several. They are: 1) to identify important food and nutrition care indicators (FANCI) in assisted living facilities (ALFs); 2) to develop a checklist to assess food and nutrition service qualities in ALFs; 3) to develop a consensus service style in food and nutrition services in ALFs based on views of national experts and the practicing dietitians who worked in ALFs; 4) to assess the degree of consensus within the national experts panel on six key food and nutrition service areas; and 5) to examine the association among both the national experts’ and the practicing dietitians’ backgrounds and personal views, and their ratings of the relative importance of services styles.

The research was also designed to: 6) ascertain which food and nutrition quality indicator national experts and practicing dietitians favored being embodied into regulations; and 7) to determine whether the regulations that the majority of the survey respondent believed should be regulated were in fact included in the regulations of the 50 states in the year 2007.

The FANCI survey consisted three parts. Part One was an 88-item questionnaire derived from ALF regulations in 50 states during the year 2003 and from literature reviews of food and nutrition standards applying to comparable food service establishments. It covered four domains: dining room (21 items), food services (34), general nutrition (20), and therapeutic nutrition (13). Respondents were asked to rate each item on a scale from one (not important) to five (extremely important) as a key quality indicators, and to answer "yes," "no," or "not sure" on whether they favored a regulation for each of those indicators.

Part Two of the questionnaire included four scenarios of service emphases in six food and nutrition services areas (dining room environment, meal services, meal quality, general nutrition services, food service employee qualifications and training, and therapeutic nutrition services.) It asked respondents to choose one of the four services style emphases (home style, restaurant/hotel style, medical, or a combination of these three) that best matched their opinions of how ALFs should be operated.

Part Three of the FANCI questionnaire was on personal views and consisted of three questions to which respondents provided their views of level of agreement (on a seven-point scale): the desirable degree of autonomy ALF residents should have in making food choices, ALF residents’ capability to make wise dietary choices, and the role of ALFs.

The survey was administered via the Zoomerang online survey service (Zoomerang 2006, MarketTools, Inc. San Francisco, CA) over the Internet.

The respondents included 153 national experts in nutrition, health, and aging services pertaining to ALFs: gerontological nutrition (39 percent), aging and disability (22 percent), assisted living (16 percent), food services (14 percent), and geriatric medicine (9 percent). In addition, 882 practicing dietitians who were members of two American Dietetic Association Dietetic Practice Groups (DPG) focusing on aging and long-term care facilities: the Gerontological Nutritionists Dietetic Practice Group (GN-DPG) and the Consulting Dietitians in Health Care Facilities Dietetic Practice Group (CDHCF-DPG), who were also employed in ALFs.

SPSS 15.0 for Windows (SPSS 14.0, SPSS Inc., Chicago, IL) and Stata 9.2 for Windows (StataCorp LP, College Station, TX) were used for statistical analysis and descriptive statistics.

Descriptive analysis was used to identify the key quality indicators and a consensus service style in food and nutrition services in ALFs. It was also used to assess the degree of consensus within the national experts’ panel on six key food and nutrition service areas. Finally, it was used to ascertain which food and nutrition quality indicators national experts and practicing dietitians favored being embodied into states’ ALF’s regulations.

Spearman rank order correlations were calculated to examine the associations among respondents’ responses to the opinion questions about ALFs’ residents and facility.

Logistic regression was used to determine which characteristics of experts, when considered individually (crude) or together (adjusted for other characteristics and attitudes), may have influenced experts to include wellness considerations in their judgments of the optimal service emphases for food nutrition services area in ALFs.

Ordinary Least Squares (OLS) linear regression analysis was used to determine the effects of the respondents’ characteristics and attitudes on the service styles.

Pearson chi-squared analysis was carried out on the quality indicators to determine how the ratings of the practicing dietitians and the quality indicators compared to the national experts.

Pearson chi-squared tests were performed to determine the differences between the national experts and the practicing dietitians in degree of agreement regarding regulation. A Bonferroni correction was used to adjust the observed level of statistical significance for the number of comparisons tested. Comparisons that were not statistically significant after Bonferroni correction were presumed to indicate a "substantial consensus."

The response rate for national experts was 63 percent and it was 23 percent for practicing dietitians. The results showed that majority (more than 80 percent) of both the national experts and the practicing dietitians rated the 57 FANCI indicators as highly important. Most respondents (89 percent of national experts, 84 percent of practicing dietitians) wanted a combination of indicators that included both health and amenity service styles as being highly important. The 57 items rated most important were consolidated into a checklist. A service model that incorporated all of these elements appeared to be most appropriate.

Sixty-three percent of the experts favored the services emphases including "wellness" considerations were that the expert was a education as dietitian and the experts’ had the belief that ALFs should be health promotion and maintenance facilities, the experts’ personal views exerted a powerful influence.

There were 28 FANCI checklist indicators that a large percentage (more than 80 percent) of the national experts and/or the dietitians practicing in ALFs favored be regulated. These indicators were focused particularly on staffing. Seven out of the 18 indicators achieved "substantial consensus." When compared to states’ regulations, only three indicators were covered by regulations in more than half of the states in 2007.

Respondents provided useful insights for developing a consensus model for food and nutrition services in ALFs. There was a clear agreement on the most important indicators for food and nutrition quality. There was uniformity/variability among disciplines on appropriate philosophy and models governing nutrition and other services in ALFs.

Both the national experts and the practicing dietitians from the two ADA DPG groups preferred a service style that included both health and amenities.

In terms of which food and nutrition services should be regulated in ALFs, both groups believed that the need for regulation varied by area of concern. Regulations are one effective way to promote quality. It is possible that some degree of regulation may prove to be prudent and necessary. Voluntary standards and best practice models might also be effective; however, they would need to be more widely adopted and coupled with more training and education to assist ALFs to further improve the quality of food and nutrition services they provide.

Some of the long term objectives of this study were only partially met. More work needs to be done before FANCI checklist can be widely adopted by the regulators and operators as a quality benchmarker. Those include education and training sessions for health professionals, policy makers, operators, and ALF consumers on the importance and impact of good nutrition to older adult’s mobility, health and quality of life. In addition there is a need to develop evidence that shows older people still can benefit from good food and nutrition care ad the importance of preventive and therapeutic nutrition to prevention and management of chronic diseases. The most important task is for the food and nutrition experts, such as registered dietitians to develop evidence to convince the ALF operators that the benefits outweigh the costs if ALFs promote quality food and nutrition services. In addition, dietitians should work with other professionals to further validate the checklist, promote its use, and establish optimal service models for food and nutrition services in ALFs for older adults.

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