Eating is one of the greatest pleasures in life. But as some people age and their health falters, they may endure a meal more than enjoy it.
Staffers at Trinity Lutheran Manor, a 120-bed nursing home in Merriam, Kan., found that out the hard way. Just a couple of years ago, more than 10% of the residents had suffered from significant weight loss during their stays. Trinity Lutheran officials thought that the taste of the food had something to do with meals being left mostly uneaten.
Actually, taste had little to do with it. Interviews with residents revealed that preparation was the problem. Little consideration had been given to the fact that some 70% of Trinity Lutheran's residents had functional or cognitive limitations.
Cutting a piece of meat, buttering a roll, opening a milk carton, removing a baked potato from tin foil or a straw from a paper wrapper were beyond their abilities.
Even waiting for food to be served was a daunting task. Many of Trinity Lutheran's residents suffer from Alzheimer's disease or another form of dementia and would grow confused and leave the table within a minute or two if there was no food to greet them.
"It was a very unfriendly setting," says Pam Dockery, Trinity Lutheran's general manager of hospitality.
Barbara Frank, the former administrator of Trinity Lutheran who oversaw the revamping of food service, recalls a low point, when residents were to be served cellophane-wrapped crackers with cream cheese as an appetizer. "You wouldn't eat that (snack) at home," recalls Frank, now administrator of a nursing home in Kansas City.
"The average stay at a nursing home is two years. You're spending close to $120,000 during that time, but we hadn't thought of customer service and how it applies in that situation," she says.
The problems were discovered in a six-month process of interviewing residents and staff, and photographing and studying Trinity Lutheran's food preparation services. In January 1998, the first steps were taken to change things.
Small things have made a big difference. Main courses are cut into bite-sized pieces after cooking, then reassembled. Scoops for preparing food are now reduced in size to alleviate patient complaints about portions being too large. Beverages are served in glasses rather then in sealed containers. Muffins are on the table at the beginning of breakfast, and salads or appetizers are there at the start of lunch and dinner to encourage residents to remain in the dining room. Foods with contrasting colors and bright garnishes are added to help residents better navigate their meals.
For those with visual impairments, meals are served on navy-blue plates to deepen contrast. Legally blind residents who can only distinguish shades of light receive meals on bright yellow plates. And for those who might have issues with the food served, other choices are available. Restrictions on seasonings also are liberalized to improve taste.
"If residents have eaten seasoned foods for their entire lives, then it probably isn't going to hurt anyone to continue," Dockery says, noting that the elderly also need a boost to their failing taste buds. Older cookbooks also were consulted to give residents foods they may have enjoyed in the past, such as pineapple salad.
To further boost morale, eating and drinking are linked to special events. A "happy hour" is held daily, while Friday is "Margaritaville," where musical entertainment is provided. Alcoholic beverages are served at both events. Many residents don't drink, but the availability of alcohol can lighten the mood, Dockery says.
An ice cream cart also circulates at least twice a week during the day. Visitors are encouraged to participate in order to get the residents to eat as well.
The cost for all these changes was insignificant: about $1,500 to purchase an additional institutional food processor, plus two new full-time employees to help with food and beverage preparation and service.
The results have been anything but insignificant, however. Within a year, the number of residents losing weight decreased 75%, while overall fluid consumption at meals nearly doubled. Resident complaints about food service also dipped by about half. The overall decrease in wasted food has allowed Trinity Lutheran to buy better quality food for the residents.
Although the changes sound reasonable, they weren't easy to accomplish: It took two years to perfect the changes. Communication among staff was critical. Nurses needed to agree to help shepherd residents into the dining room, while the cook staff had to clearly communicate their supply needs.
"They might not have had enough backup foods, such as cinnamon (coated) slices of apple to provide the correct contrasts for a dish, or we might have had a new hire who didn't know the process," Frank recalls.
And some changes that appeared to be a piece of cake under the program guidelines were anything but.
"Cake cut up into strips just falls apart," says Dockery of the reason residents are now served cupcakes.