When Cindy Dahl began her career as a nutritionist, it probably never occurred to her that she would one day be a judge in a culinary competition—a la “Top Chef”—tasting five-star-worthy dishes like Chilean sea bass with nested linguine and salmon in red chili sauce with garlic-piped potatoes at a nursing facility.

But for the past two years, Dahl, who heads up quality nutritional services for Plum Healthcare in San Diego, has done just that as part of the company’s Top Plum Chef competition, inspired by the popular television show.

After searching for a way to revamp resident dining programs in the company’s 18 nursing facilities, Dahl came up with the “Top Chef” idea herself, hoping it would spark the chefs’ imaginations and encourage them to take new recipes back to their residents. “I wanted to transform our kitchen services into dynamic, inspiring teams that produce creative results,” she says.

Tables Are Turned

Dahl is one of many long term care professionals who are redefining resident dining and helping to reverse the poor reputation that nursing facilities have earned over the years for serving bland, tasteless fare that even staff members won’t eat.
While it’s true that fine dining and nursing facilities are rarely, if ever, uttered in the same sentence, stringent regulations and a regimen of highly efficient systems of tray-served meals, as well as the rationale of “because that’s the way it’s always been done,” have contributed to this perception.
With the momentum of culture change at an all-time high, however, and strong support from the Centers for Medicare & Medicaid Services (CMS) for resident-centered care initiatives, providers are rethinking many aspects of facility operations.
The results are new dining programs that deliver delicious meals, attractive dining areas, and a broader range of choices for residents. For many facilities, one of the first steps to making this shift is the elimination of trays, which have been ubiquitous in nursing facilities for decades. Although the system has been relatively efficient, tray-served meals delivered to residents in their rooms hinder socialization and interactions that are so vital to quality of life.
What’s more, trays represent an institutional vestige that harkens back 50 years or more.
CMS’ support for more homelike options has been touted by culture change advocates as a signal that the agency means business when it comes to resident-centered care.
Among other things, the guidance instructs surveyors to identify compliance and noncompliance in areas of resident choices about “daily schedule, visitation issues, homelike environments, food procurement, and lighting.”
With regard to dining, CMS’ new guidance suggests that providers consider doing away with the following: trays during meal services, plastic cutlery and paper or plastic dishware, staff standing over residents while assisting them to eat, and staff interacting and conversing only with each other rather than with residents while assisting them.
The guidance also promotes certain practices, such as the use of dishware that contrasts with the table and a tablecloth color to aid residents with impaired vision to see their food.

Evidence Backs It Up

In addition to support from stakeholders and the federal government, some limited research on the topic indicates that providers are headed in the right direction.
As it happens, culture change adopters are more likely to deinstitutionalize their dining programs, according to a 2007 survey conducted by the Commonwealth Fund.
Nearly half (46 percent) of facilities that have adopted culture change have changed how meals are served, while only 22 percent of traditional homes reported they were making such alterations.
Compared with earlier research, these data indicate providers are moving forward with new dining programs. Figures from a 2004 survey of nursing facilities conducted by the Centers for Disease Control and Prevention show that 89 percent of facilities in the United States used a pre-plated, tray-style food delivery service—that is, food prepared in kitchens, placed on trays, and delivered to residents.
Six years later, the Commonwealth survey revealed that 29 percent, or three out of 10 nursing facilities, had implemented less institutional approaches to dining, such as restaurant, family, and buffet styles, and provided more dining times.
Research on the impact of different dining styles also gives credence to the need for change. A study of family-style dining that also focused on staff giving encouragement and praise to people with dementia, resulted in higher participation in eating and improvement in appropriate communication.
Another family-style dining study of persons without cognitive impairment reported improvements in quality-of-life measures, fine-motor functioning, and body weight.
A Canadian study that examined the combination of steam table/buffet-style food service and a homelike dining environment found that it optimized energy intake in individuals at high risk for malnutrition, particularly those with low body mass index and cognitive impairment.

True Choices

Not surprisingly, proponents of culture change view dining as an essential ingredient to resident-centered care in nursing facilities. The Pioneer Network, a national culture change advocacy organization, deemed the topic important enough to host a day-long symposium focused solely on dining and culture change last February.
In addition, the organization’s state coalitions offer workshops that walk facilities through the process of enhancing the dining experience for all residents “using multiple approaches to focus on their needs and preferences.” Titled “Food For Thought,” the workshops are presented by Action Pact, a consulting company that specializes in culture change.
Linda Bump, a licensed nursing home administrator, registered dietitian, and Action Pact consultant, advocates “true choice” when it comes to resident-centered dining.
She discussed her philosophy and her recent paper, “The Deep-Seated Issue of Choice,” at the Pioneer Network’s dining symposium: “Simply speaking, it is all about choice. It is as simple as asking, ‘What does the resident want?’ ‘How did they do it at home?’ ‘How can we do it here?’” Bump says.
Giving residents a choice of what to eat, when to eat it, where to eat, whom to eat with, and how leisurely to eat is a true choice, she says, “not the win-lose choice between a hot breakfast and sleeping to the rhythm of your day. Not simply the choice of hot or cold cereal, but also the raisins and brown sugar that make oatmeal a daily pleasure.”

Bump contends that true choice in dining is exemplified in “point-of-service choice,” because, “how often do
we know what foods will appeal most to us tomorrow, next week, in three weeks?”

From Dull To Delectable

Bump’s position is reflected in MediLodge of Sterling Heights’ approach to resident-centered dining. The facility, located just outside Detroit, offers buffet meals and hotel-like room service that dishes up a range of meals and beverages throughout the day and night.
Nabil Hawatmeh, the facility’s executive director of food service, began revamping the dining program about four years ago. Having worked in the restaurant and catering industries, he took a less conventional approach to creating better tasting and better looking cuisine for his residents.
“When I saw the food here I knew I had to change it,” he says. “Every day, it was either chicken or beef, and it was slapped on a plate and put in front of you.”
Hawatmeh says he went to the administrator to ask if he could test a buffet-style meal during the weekend. “So I moved the old steam table out of the kitchen and into the dining room and covered it with a nice skirt,” he says.
He knew that buffet-style meals would bring enticing aromas into the dining room and whet residents’ appetites. A dining room makeover provided additional temptation with new flooring and wall hangings and a plasma television.
Hawatmeh first tested his buffet plan during lunch and breakfast mealtimes. “For breakfast, residents had a choice of eggs cooked several different ways—scrambled, sunny side up, or poached,” he says. “We also had doughnuts, Danishes, bagels, muffins, pancakes, sausage, bacon, fresh fruit, and three hot cereals.”
Before the buffet began, however, Hawatmeh had to convince staff and residents that the idea was a good one. “I went to the resident council meetings, the directors of nursing, nurse assistants, and nurses to explain it to them. I went to the day and night shifts to convince them that it was the right thing to do,” he says.
In an effort to make the plan run as smoothly as possible, Hawatmeh also created a book that listed each of the 335 residents’ names and any information about their dietary restrictions, allergies, and assistance needs, if any, so staff could monitor them as they entered the dining room.
In addition to creating a buffet for every meal and keeping the kitchen open 24 hours per day, Hawatmeh launched an always-available room service program, which, he says, “adds to resident satisfaction by allowing night owls to satisfy a sweet tooth or request a midnight snack.”
Meals are served on china dishes and delivered to residents on a cloth-covered tray. Recognizing that presentation is almost as important as taste, Hawatmeh taught the cooks how to garnish plates with parsley, fruit, and other items to make the meals more appetizing.
After ironing out a few glitches, the new system now runs smoothly and efficiently, Hawatmeh reports.
More importantly, residents are happy with the new options and delicious food. A minimum of three to four entrees are served each day, in addition to standard items such as pizza, grilled panini sandwiches, homemade soups, and chili. “All of our soups are homemade,” says Hawatmeh, “as are most of the desserts.”
He also serves some upscale dishes on special occasions. For example, he served lobster bisque, shrimp cocktail,  and filet mignon for Valentine’s Day.

Mixing It Up

Like MediLodge, nursing centers run by Genesis HealthCare, Kennett Square, Pa., have taken on similar changes, such as new flooring, curtains, and homelike décor, in addition to decentralizing their dining programs.
As part of a companywide adoption of culture change that began several years ago, nursing centers were given the green light to embrace trayless dining programs as well as other initiatives that have reportedly had a dramatic impact on residents’ quality of life.
As a result, most centers have tossed the trays in favor of utilizing steam tables in the dining room; preparing and cooking meals outside the kitchen, where residents can see cooks work; and hiring chefs to create palette-
pleasing selections.
“In a traditional model, you prepare the food, put it on a tray, put it on food carts, and send them down the halls,” says David Almquist, Genesis’ regional executive vice president. “Our goal is to take the food out to the patient, and whether it’s a café or whether it’s a place that does strictly trayless dining and serves all the food right there in the dining rooms, we wanted to create environments that are different.”
Genesis did not dictate a model for its centers to follow; rather, they were free to make the changes at their own discretion. The result is a variety of programs that reflect the individual needs of the centers. Some have built cafes and remodeled their dining rooms, while others have created a tableside service that enables residents to sit at tables and socialize while staff wait on them.
Another key component of Genesis’ dining transformation has been the hiring of culinary-trained chefs. “We felt like being culinary trained, knowing how to prepare and use fresh ingredients, would improve the quality of the food,” says Almquist. Ninety-nine culinary-trained chefs have been hired to serve 74 Genesis centers in 13 states. The company now boasts a total of 144 chef managers.

Everything But The Kitchen

Hammonds Lane nursing center in Brooklyn Park, Md., opened its newly renovated dining room about eight months ago. The modifications began with the idea that kitchen staff and food preparation should not be hidden away inside the kitchen walls. 
“We all agreed that everyone would be better served to get the kitchen staff out from behind the doors,” says Bill Tian, Genesis’ southern area director for food and nutrition.  
One of many positive outcomes of Hammonds’ efforts is that residents and dining staff members have developed relationships that could not have been possible before. “It has changed the role of staff from being in the kitchen and now are outside interacting with residents and asking them what they want,” says Tian.
Meals are served in a restaurant-style manner, with staff taking orders from residents, who choose from a generous menu of dishes that could rival a five-star restaurant.
Hammonds’ menus change daily, but standard options such as sandwiches and soup are always available. Breakfast, which runs from 7:00 a.m. to 11:00 a.m., is made to order. “Residents can have whatever they want for breakfast: waffles, pancakes, omelets, or eggs sunny side up or poached,” says Tian.
The move to the dining room from the kitchen was made smoother with the purchase of matching culinary uniforms for the dining staff. “It made a tremendous difference,” says Chuck Diffenderffer, Genesis’ southern area executive chef for food and nutrition. “It really brought them out as a team.”
Tian says there is an additional benefit of the new system—meals in the dining rooms take no longer to turn around than the previously noisy and chaotic tray system did. Residents are happy with the change as well. “We have thousands of people coming to breakfast now across our southern region,” says Tian.
The residents’ satisfaction is also reflected in the facility’s positive clinical outcomes: Weight at Hammonds has stabilized, “and it’s getting people moving around, which helps reduce pressure sores,” Tian says.
Staff are also buying lunch and dinner at the facility, another bonus that has brought in additional revenue. Before the change, says Tian, staff were not interested in staying in for lunch.
What’s more, the surveyors are happier and less focused on food service F-tags, while survey outcomes are consistently good.

Fine Dining On A Dime

Beaumont Rehabilitation and Skilled Nursing Center in Northbridge, Mass., took a simpler, less expensive approach to altering its dining program, says Darrold Endres, the center’s food service director. “We got rid of all trays, and it’s now as near to restaurant style as a nursing home can get,” he says.
Some areas around the central dining room were also remodeled to improve the work flow. Endres rolled the steam carts from the kitchen to the edge of the dining spaces, where staff now plate the meals as residents select them.
The menu was expanded, and the dining room tables are now decorated with tablecloths, silverware, and china, while residents enjoy calming music as they dine.
Endres notes that he and another staff member designed “from scratch” new clothing protectors, formerly referred to as bibs, and hired a tailor to make them. “The protectors were made with a high-quality cloth,” he says, adding that they resemble “something you would tuck into your shirt at a high-class restaurant.”
“There’s a certain elegance to things,” he says.
Another plus is the fact that the facility’s budget has remained virtually unchanged. “We did not have to change or advance our budget by much at all,” he says.

Making It Work

Among the challenges for Endres was fitting all the pieces together. “To organize all the people, times, transportation, change rooms, and breakdown tables and making sure that it all goes smoothly was the biggest challenge.”
Residents dine in seven different places, which makes the system somewhat complicated. Adding to the intricate process are meals that are individually tailored to meet the needs of residents with Alzheimer’s.
Endres says his food service contractor, Newton, Mass.-based Unidine, was instrumental in helping him transition to the new program. “Unidine helped us prepare the food items, menus, and orchestrate the system to make it flow well,” he says.
Food service vendors are a common presence in the health care industry. Menus, meal preparation, and dining management are integral to a facility’s operation, and vendors offer a range of services that help the buildings run smoothly and free up time to focus on other tasks.
The new dining trend has sparked some innovative responses from vendors, many of whom now offer consulting services, technical assistance, and fresh foods and ingredients that have never before been in the vernacular of health care facility food service.
Cura Hospitality, a food service and consulting company based in Orefield, Pa., assisted Presbyterian Village at Hollidaysburg, a continuing care retirement community in Pennsylvania, in decentralizing its dining program about two years ago. A renovation of the campus included the construction of two additional kitchens in order to serve the different levels of care within the community, says Deb Larkin, director of food service at Hollidaysburg.
The installation of country kitchens—a kitchen that opens up to the dining area—in the assisted living and skilled nursing levels “allows residents to see and smell the cooking as it happens,” she says.
Also new are two dining rooms. Larkin says the company changed the dining style entirely and had staff trained in ServSafe, a food service safety training program.
“Residents come in and dine whenever they choose,” says Larkin. “They can either seat themselves or a staff member will seat them. They are given a menu, which includes the special features for the day and the standard items available every day.”
As she began procuring new items such as china and silverware for the dining rooms, Larkin also enlisted the residents’ help. “We had them sample the china and silverware to see how they held it, if it worked for them,” she says.
The community purchased red Fiesta Dinnerware because it stimulates appetite and blue plates so that residents with visual impairments could better see the food.

Pilot Offers Useful Advice

Culture change advocates in the state of California have been on board with resident-centered approaches to dining since 2007. Eager to test some models in a pilot project, a coalition that includes the California Association of Health Facilities (CAHF) and the California Culture Change Coalition theorized that motivating providers to alter their dining programs to more resident-centered approaches would promote the adoption of additional culture change initiatives within facilities.
Jocelyn Montgomery, director of education for CAHF, was able to convince CMS’ Region IX to back a Culture Change Dining Pilot, which launched in February 2008. The 11 participating facilities were asked to adopt at least one of the following dining practices: restaurant-style, buffet-style, or an expanded snack program.
At the conclusion of the pilot, which ran for eight months, the coalition released a guide, “The Person-Directed Dining Package,” which contains information about the pilot, a list of participants, and sample policies and forms.
Plum Healthcare’s White Blossom Care Center in San Jose participated in the pilot and took on buffet-style dining. According to a summary of the facilities’ experiences, White Blossom’s installation of buffet dining improved residents’ socialization, encouraged them to participate in other activities, and stabilized their weight.
Among the lessons learned: Teamwork is essential to setting up and cooking the meals, and support from the administrator and the director of nursing was imperative to getting the program off the ground.

Lessons Learned

As word has spread about the success of MediLodge’s buffet- and room service-style programs, Hawatmeh has been asked to speak to facilities and organizations in Michigan and surrounding states about his experience.
State surveyors are also interested in what Hawatmeh has to say. Since he launched the dining program, he has presented at several of Michigan’s joint surveyor/provider training sessions.
Some of Hawatmeh’s take-home advice about making the transformation is aimed at getting providers to understand that residents need to have greater control over their mealtime choices; they should be offered a variety of appetizing, nutritional food choices; and they should be given an enjoyable, upscale dining experience.
Hawatmeh also emphasizes that excellent customer service is vital to the success of this program, just as it is to any business. He recommends listening to residents, quickly responding to any complaints, and training staff on the program’s importance.
One testimonial about his program speaks to the importance of pleasing the residents: “The new dining program brought back the glamour of the resident’s younger days.”