Maggie Beer’s Big Mission – Episode 1

Malnourishment Risk 

One of the key drivers for the project that Maggie Beer mentions is the Royal Commission into Aged Care Quality and Safety which highlighted that 68% of residents in aged care facilities were at risk of malnutrition or are malnourished. 

This figure was based on data from 2014 in a study that examined 215 ambulant residents across several aged care facilities in Melbourne. It should be noted that outside Australia, a Swedish study published in 2015 followed 318 aged care residents over 24 months and found that 89% of aged care residents were malnourished or at risk of malnutrition at some stage during that period.

A specific assessment was used to determine whether an older person is malnourished or at risk of malnutrition in both the above studies – the Mini Nutrition Assessment (“MNA”).  This tool was also used as part of the research in this project. The initial baseline findings using the MNA on our much smaller sample size of 28 residents was that 7 (25%) were classified as malnourished and 15 (53%) were determined to be at risk of malnutrition. 

The MNA is a simple tool used for identifying risk rather than clinical diagnosis. The version we used can be found by clicking here. The result of the assessment is a score between 0 and 14, where a score below 12 shows a risk of malnutrition; while a score below 8 shows that the person is malnourished.

For older people, being at risk of malnourishment is more likely where there are factors such as mobility or cognitive concerns. These factors are recognised by the MNA in their scoring, but this does mean that removing risk status will not always be possible even through the best dietary interventions. 

Our result of 78% residents being at risk of malnutrition or are malnourished was significantly higher than the 68% that was highlighted in the Royal Commission. There were possible differences between our small sample study and the 2014 data from Melbourne, such as:

• not all our residents were ambulatory; 
• 92% of the residents in our project had some cognitive deficit;
• the acuity of residents has generally increased following the greater availability of in-home care since 2014; and 
• the widespread presence of COVID in mid-2023 making recent acute disease more prevalent. 

However, while the risk level was a confronting result, it was an essential baseline for the project.

Depression 

In the first episode, Maggie Beer is shocked to learn the level of residents who are assessed with signs of depression as part of the baseline research results for the project was 46%. From recent studies overseas, aged care residents assessed as having signs of depression ranged between 37% and 58%; while data from 2013 in Australia showed that 52% of residents had signs of depression. The most recent Australian study showed that the level is 49%.

While our result appears typical and reflective for aged care facilities, it is a shock to see this level of prevalence. It should be noted that while there are no similar study results showing prevalence of depression in the community of similar cohorts, it is estimated that this would also be at a higher-than-expected level.

The assessment tool used was the short-form Geriatric Depression Scale (“GDS”) which is a series of 15 statements that the person answers yes or no to. This assessment can be found by clicking here. If a person has 5 or more indicative responses, this is suggestive of depression 

It is within the responses to these questions that we might find the solutions. For example, the questions “Have you dropped many of your activities and interests?”; “Do you often get bored?”; and even “Do you feel that your life is empty?” indicate a lack of purpose and activity. But these are frequently observed responses from aged care residents. If these were addressed within the project, then a likely reduction in prevalence of depressive symptoms could be achieved.

What else did the baseline research show?

The baseline results showed some areas for improvement, while also showing some positive starting points.

In addition to the malnutrition risk and signs of depression, other results we wanted to improve on were:

• Improving nutrition – 85% of residents assessed using the Comprehensive Nutrition Assessment Questionnaire (“CNAQ”) were seen to be at risk of weight loss in the next 6 months.
• Purposeful engagement – 67% of residents expressed that they wanted to help where possible.
• Person-centred interactions – only 25% of staff-resident interactions related to choice at mealtimes were person-focused, rather than task-focused.
• Staff burnout – 46% of staff (7 out of 13) were found to be at risk using the Maslach Burnout Inventory (“MBI”).

The following baseline results were positive, but it would be interesting to see whether these could improve further as part of the project:

• Quality of life – 77% of residents reported that this was excellent or very good.
• Quality of care experience – 67% of residents reported that this was excellent or very good.
• Mealtime satisfaction – the average resident response was 46/56.
• Job satisfaction – the average staff response was 90.8/110.

Pre-packed and Processed Food

In Episode 1, Maggie Beer discusses replacing pre-packed or processed food on the menu with home-cooked versions. An early example of this shown is preparing a stock (or brodo) to use instead of soup booster.

Soup booster has been widely used in aged care kitchens to either create a soup or to provide a stock base for a soup. This is like using a powdered soup or stock cube at home – quick and cheap, but not as nutritional or tasty. However, brodo is a staple ingredient where a home-cooked version is beneficial and can be used in a lot of cooking, not just soups.

The aim was to reduce the use of pre-packed or processed food as it would be impossible to eliminate these from an aged care menu, not least because some are very popular with residents. For example, ham and cheese croissants are a resident favourite and to attempt to cook these from scratch would be time-consuming and difficult.

What Did the Menu Look Like Before the Project?

Breakfast was generally a choice of cereals or porridge 6 days a week, supplemented with toast, tea, coffee, and juice, with a hot breakfast available one day each week.

Lunch was a choice of 2 main courses for people able to eat a regular texture; while for people on a texture modified diet there was only 1 option available which did not necessarily correspond to the other main courses offered. There was a dessert available, as well as fruit. 

Evening meals consisted of soup; a choice of a meal, a salad, or a selection of sandwiches; and a dessert or fruit. 

Meals were served in a single dining room for 44 residents, although several residents opted to dine in their room. Identical meal choices were available for residents wherever they chose to dine.

In between meals, there was morning tea, afternoon tea, and supper available. These were often cakes, biscuits, or small pastries / pies. Options for people with texture-modified diets were more limited and were often mousses or pureed fruit.

Cost of Food in Aged Care Facilities

In episode 1, the then cost of food per resident per day was suggested at $11 per resident per day, which was the rate in December 2022. 

Although by the start of the project this had increased to $12.95, in part due to inflationary costs, this level was still around average for the residential aged care sector. While this may not sound much on an individual basis, if this amount was applied to a household of 4 people, it is the equivalent of a weekly food budget of over $360. 

However, above the cost of the food is the much higher cost of employing people to cook or convert the food into meals or snacks – something that a domestic household does not generally incur. When you take the employment costs of chefs, cooks, and kitchen assistants into account, the costs are much higher (approximately around another $20 per resident per day).

As identified in the report shown in Episode 1, there was an amount of pre-packed or processed food purchased for our menu. While these are undoubtedly nutritionally inferior, the cost of using these can be offset through reducing the staffing hours required to convert or cook into a meal. Consequently, food costs are not quite as straightforward as purely being the price of ingredients and can differ according to different locations and varying labour markets.

How are Food Services Funded in Aged Care?

As outlined in Episode 1, aged care providers receive a basic daily fee from all residents which is equivalent to 85% of the aged pension. At the time of filming this was $58.98 per day and it is now $61.96. 

There may be other aged care costs depending on each individual resident’s circumstances as assessed by Centrelink, such as an accommodation payment (lump-sum or daily payment) or a care fee contribution. We currently have 52% of our residents who are required to pay a full accommodation payment, with 32% not required to pay anything towards their accommodation. Additionally, 56% of residents are not required to contribute towards the cost of care. 

However, the basic daily fee is paid by every resident and this needs to cover the following costs:

• Food;
• Employment costs for chefs, cooks, kitchen assistants, laundry, and cleaning staff;
• Chemicals;
• Equipment used in kitchens, laundry, cleaning and dining areas (excluding capital items such as ovens, dishwashers, washing machines, dryers); and
• Utilities – gas, water, electricity.

For many years it has been noted that these costs incurred exceeded the basic daily fee. While this is still the case, the losses have reduced. This is in part due to a $10 supplement that was initially brought in following the Royal Commission in 2021. This appeared to be removed in July 2022 but was in fact absorbed into the care subsidy (although not directly care related). 

Following the Stage 2 determination of the Work Value Case becoming operative on 1 July 2023, a separate hotelling supplement was introduced at $10.80 per resident per day, which uncoupled the supplement from being part of care revenue and provided a 15% wage increase for chefs.

As such, in 2024 the revenue for non-care and non-capital items can now be regarded as the basic daily fee plus the hotelling supplement – a total of $73.20 per resident per day. This has reduced losses in this area, but it is still some way below the average expenses incurred, which were estimated in March 2024 by StewartBrown (chartered accountants with an aged care specialist practice area) at being around $82 per resident per day.

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