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 Jo Gamba, Rhiannon Edwards, Rhiannon Parker and Rhian Wilyeo

Abertawe Bro Morgannwg University Health Board

This Bevan Exemplar project developed Dietetic Assistant Practitioners to help to improve malnutrition outcomes in nursing homes.


It was identified that there were unnecessary steps in the referral process for malnutrition risk in nursing homes. Vague referrals were being received by the Health Board due to inaccurate or no screening for malnutrition.

Oral nutritional supplements were prescribed when a ‘food first’ approach (nourishing homemade fortified foods and drinks) had not yet been tried. Individuals who had been prescribed oral nutritional supplements by another professional were often not followed up and were not known to the Dietetics service, therefore supplements may no longer have been required in some cases, but were still prescribed.


The main aim of the project was to improve nutrition outcomes in nursing homes. This was delivered through the development of a Dietetic Assistant Practitioner role to engage, deliver training and support implementation of the new referral pathway.

The project aligns with the principles of prudent healthcare in the following ways:

  • Managers identified their priorities and helped the team to understand processes. Feedback was sought from attendees and further training was developed based on their requests.
  • Upskilling nursing home staff to accurately recognise malnutrition and refer directly to the dietetic department reduces reliance on GP time and resources.
  • The ‘food first’ approach reduces the need for prescribed oral nutritional supplements. Identification of inappropriate prescribed oral nutritional supplements, by reviewing relevant charts, allowed them to be discontinued.
  • Consistent use of the tool for malnutrition screening will lead to standardisation.


Challenges included that training was cancelled by the home or minimal staff attended. Therefore the project team produced learning contracts, which encouraged managers to keep in touch. They organised regular meetings for mutual feedback and to improve relationships. They also produced posters to inform staff about training rather than just booking dates in the manager’s diary.

The team is developing nutrition-related criteria for homes to achieve an award as an incentive. The team also plans to recruit Nursing Home staff as nutrition champions to embed good practice. Some homes were slower to adopt changes – the team undertook further shadowing to understand their processes and support them.


The simplified referral pathway removes the need for GP involvement, which an opportunity costing exercise estimated would save £7.40 per referral. This equates to £1191.40 (161 referrals) so far. When all homes can directly refer, there is a potential saving of approx. £3566.80 a year (based on 482 referrals in 12 months).

There is an additional cost saving of approx. £250,000 achieved by optimising oral nutritional supplement prescriptions – cancelling those not required and swapping others to first line options.

In terms of the impact on nursing home staff, following specialist training the team saw:

  • An increase in staff knowledge of malnutrition screening leading to improved accuracy.
  • Improved confidence about provision of appropriate nutrition for those at medium or high risk of malnutrition.
  • Improved knowledge of appropriate nutrition for those at medium or high risk of malnutrition.

Next steps:

The team has engaged 30 of the 48 Nursing Homes across ABMU, aiming to roll out training and referral pathway to all homes. The team is mindful of the anticipated health board area boundary change and the impact on the service. The team plans to introduce a nutrition champion role for Nursing Home staff in 2019. Evaluation is being undertaken to measure the implementation of the ‘food first’ approach.

A pilot project recording patient-related nutrition outcomes is beginning in Winter 2018/2019. The team will also be supporting nursing homes with nutrition events and developing new training related to jointly identified needs.

“A reassuring and inspiring experience, providing a fresh perspective and a wealth of experience to tap into and share.”

Jo Gamba, Lead Community Dietitian (Nursing Homes)

“The support we have received from the dietetic team within our home has been fantastic. The training sessions provided are very well attended and very interesting and interactive which makes them more enjoyable.”

Fiona Murray, Clinical Nurse Manager, Brocastle Nursing Home, Bridgend