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Recipes for Dining Transformation

What the culture change movement has learned is that although thought to be more efficient, the institutional schedule and shift-driven way of working is actually inefficient. To wake someone who does not want to be awakened, to take them to a meal they do not want to eat, to serve food they do not eat, only to take them back to their room to sleep in most cases, is not efficient. Instead time and money are wasted, thus making self-directed, individualized care a win-win for residents, for staff, even for the bottom line.
Carmen Bowman, Founder of Edu-Catering


Getting Started: Before you choose your ingredients and start cooking, it's important to address the culture change concepts and the reasons why you are engaging in change in the first place. Core practices of choice, relationships and creating home are the "ingredients" that are necessary for your
implementation recipe and at the heart of any culture change implementation. Without adding these ingredients into the mix, you might find that the most enhanced dining program doesn't achieve your goals when residents can't choose when and what to eat. We found some great resources to get you started on examining these core ingredients in your organization. Choose one or more, but don't miss out on this most important preparation step. It's the KEY to your success!

Get Cooking on your Dining Program: Once you've explored the ingredients in your organization, it's time to get cooking. This is the opportunity to explore the supportive practices for your Dining Program that will help maintain choice, relationships and creating home for residents. For the Dining
Program Toolkit, we have a few ideas to get you started. Some are easier and some are harder. Or, maybe, you'll want to go a completely different direction. Just like browsing through a cookbook, these
thoughts just may provide the inspiration that moves you forward in your planning process.

Tools (links to resources in green)
New Dining Practice Standards (Pioneer Network and the Rothschild Foundation )   Δ  Δ
Low Cost Practical Strategies (Lois Cutler and Rosalie Kane)  Δ  Δ  Δ
Promising Practices in Dining (Pioneer Network)  Δ  Δ  Δ
Artifacts of Culture Change (Centers for Medicare & Medicaid Services)  Δ   Δ
Life Happens in the Kitchen Workbook by Linda Bump (Action Pact)   Δ 
Food for Thought All Day Workshop (Action Pact)   Δ 
Nourish the Body and Soul Training DVD (Action Pact)   Δ 
Dining with Friends 20 minute Video (Alzheimer's Resource Center of Connecticut, Inc.)   Δ  Δ
Transforming your Dining Services DVD (M.O.V.E. Oregon's Culture Change Coalition)   Δ 
Person Directed Dining Package (California Culture Change Coalition)   Δ  Δ
Creating Home II CMS/Pioneer Network National Symposium on Culture Change and the Food and Dining Requirements, Background and Speaker Papers (Pioneer Network)   Δ  Δ
Culture Change and Dining Education Modules (Kansas PEAK Nursing Home Initiatives)  Δ  Δ  Δ
Dining Room Design (Dementia Design Info)   Δ  Δ
Design on a Dollar (Pioneer Network)  Δ  Δ  Δ
Getting Started (Pioneer Network)  Δ  
HATCh Model – Individualized Care (Healthcentric Advisors, formerly Quality Partners of Rhode Island)  Δ  Δ
Household Matters Toolkit Dining Services (Action Pact)  Δ  Δ 
Meal Time Matters (IDEAS Institute)   Δ 
Planetree and Picker Long-Term Care Improvement Guide Part Three: Practical Approaches for Building a Resident-Centered Culture includes Culinary Engagement (Planetree)  Δ  Δ  Δ
Path to Mastery (Eden Alternative)  Δ  
Providers Revamp Dining to Please the Palette (Provider Magazine)   Δ  Δ


Would you believe that regulations support many of the changes highlighted in Toolkit resources? We thought that you would want to know, so we highlighted a few important regulations below. As you discuss your changes with regulators, bring them to the table by stating your intent to honor regulatory guidelines.

NutritionF325: "Appetite is often enhanced by the appealing aroma, flavor, form and
appearance of food. Resident-specific facility practices that may help improve intake include providing a pleasant dining experience (e.g., flexible dining
environments, styles and schedules), providing meals that are palatable,
attractive and nutritious (e.g., prepare food with seasonings, serve food at
proper temperatures, etc.), and making sure that the environment where
residents eat (e.g., dining room and/or resident's room) is conducive to dining."
Restaurant Style
No regulations prohibit restaurant style dining. In fact, restaurant style is very individualized, offering choice as required by Tag F242 Self-determination and Participation.
Choosing meal
times through self-determination and participation
F242: "Residents have the right to have choice over their schedules, consistent with their interests, assessments and plans of care. Choice over schedules includes (but is not limited to) choices over the schedules that are important to the resident, such as daily waking, eating, bathing, and the time for going to bed at night. Residents have the right to choose health care schedules consistent with their interests and preferences, and the facility should gather this information in order to be proactive in assisting residents to fulfill their choices."
Steam Tables
F371: CMS specifically mentions the time frame food can be on a steam table follows a 4 hour rule: "The maximum length of time that foods can be held on a steam table is a total of 4 hours."
Open Dining (Frequency of Meals): CMS Response to the Questions on the "14 hour rule"
CMS guidance in the 2007 Survey & Certification letter S&C-07-07 answering culture change questions including "the 14 hour rule" and the resident right to choice: "The regulation language is in place to prevent facilities from offering less than 3 meals per day and to prevent facilities from serving supper so early in the afternoon that a significant period of time elapses until residents receive their next meal.  The language was not intended to diminish the right of any resident to refuse any particular meal or snack, nor to diminish the right of a resident over their sleeping and waking time.  These rights are described at Tag F242, Self-determination and participation.  You are correct in assuming that the regulation language at F368 means that the facility must be offering meals and snacks as specified, but that each resident maintains the right to refuse the food offered."
24-hour dining
No regulations prohibit and 24-hour dining maintains better compliance with F242 Self-determination and participation.


If a recipe is a hit, it could become a regular staple. At the same time, you wouldn't want to keep using a recipe that doesn't work. That's why it's important to measure results proactively and share what you find with the organization. This is your chance to keep tweaking until you get it right. Why not
give it a go?

We recommend you access these resources for summarized research and accounts of outcomes associated with Individualized Dining:

New Dining Practice Standards

The Food and Dining Side of the Culture Change Movement: Identifying Barriers and Potential Solutions to furthering Innovation in Nursing Homes Creating Home in the Nursing Home II: A National Symposium on Culture Change and the Food and Dining Requirements

Quality of Care Impact: Reduced Weight loss; Increased protein and energy intake; Reduced supplement use (more "real food" intake); Decreased nutrition and hydration related clinical conditions (e.g., pressure ulcers, urinary tract infections)

Organizational Outcomes: Lower food costs; Reduced food waste; Less money spent on cost of nutritional supplements; more consistent food temperatures

Quality of Life Outcomes: Increased participation and communication (especially in persons with dementia); Increased satisfaction with dining

Download Just In Time Toolkit - Recipe for Dining Transformation