Problems to solve for the larger Long Term Care facilities

A case study

It’s no surprise to most of us that a 362-bed skilled nursing facility faces several key challenges in food service. Hundreds of different sets of tastes, preferences, and health requirements, multiple locations all needing served simultaneously, and a mission to serve good, hot food where it needs to be and when it needs to be there. Many facilities find that it’s almost impossible to pull it all off without making real compromises in meal options offered, cost efficiency, consistency of service, and the time/locations where residents can eat

Well, several facilities across the country are finding solutions to achieve all of their goals without making big sacrifices. Let’s study a particular 362-bed skilled nursing facility in Troy, New York and see what obstacles that they considered critical and how they approached them.

The Mission… Once you get over a certain number of beds, it is no longer feasible or desirable to have one central dining area. At some point, it just becomes too far for most of the residents to physically get themselves there. Dining rooms are expected to be smaller and more intimate with that "homey" feel. Of course, this means multiple dining rooms scattered throughout a facility.

So the actual challenge for us to analyze can be broken down as:

Prepare, deliver, and serve a large variety of meals and food items for a large group of people at the same time. Prepare, deliver, and serve these meals in accordance to the special, individualized, and sometimes complex, dietary requirements of the clients. Prepare, deliver and serve these meals in accordance with all food service laws and regulations. Basically, serve the right meal, with the right consistency, to the right resident, at the right temperature, at the right time.

There are many ways to approach each angle of this challenge statement. Here are the specific ways that one particular 362-bed skilled nursing facility in New York, Van Rensselaer Manor (VRM) approached each requirement:

Complex dietary requirements, the difficulties: VRM uses software to create an individualized dietary profile of each resident. This includes the resident's diet, consistency, tastes, and daily special requests. Each resident's individualized meal ticket is generated with this. The meals needed for residents end up with so much variety that it would be incredibly costly (if not practically impossible) to have 9 different dining rooms each be capable of preparing or plating every single item needed 3 times a day.

VRM has one central kitchen where all the food is prepared. To plate every meal in the dining rooms would demand each food item offered and every variation be put together in bulk, sorted, panned up, and distributed to each dining room. Once in the dining room, all of the food items would have to be handled again as they are plated and allocated for service to the residents. Each dining room would require at least two staff members just to perform this duty, and dining rooms would still see rushes with residents forced to wait in line for their food. That's 18 staff tied up for at least two hours each meal with the set-up, plating, and clean up. Each dining room would have to be outfitted with all the hot and cold equipment needed for holding and serving these meals. There would also have to be enough space in the dining rooms to accommodate this equipment. All of these obstacles would only result in greatly reducing the variety of items available to the residents.

Van Rensselaer Manor solves all of these problems by pre-plating the food right in the kitchen rather than limit the variety available to the residents. Using electric heated / refrigerated food carts (HR carts), the resident's meals are put together in a central kitchen and then delivered to the various dining areas. The benefit to this approach is that plating the meals for 362 people is much more productive if it is done on an assembly line from one location. Less staff is needed. The meal items are only handled once. All of the food items are readily available and accessible in the kitchen, and the bulk food items only need to be delivered to one nearby area.

Plating: Each resident's meal is specified on a printed ticket. There are two copies of the tickets; one for the cold line and one for the hot line. Three staff members work the cold line. The cold items for each resident are put on cafeteria-style trays. Each HR cart has one heated side and one refrigerated side, so these trays, along with the resident's ticket, are placed into the cold side of the HR cart. Four staff members work the hot line. The hot items are plated up, covered with an inexpensive non-insulated dome, and placed into the hot side of the cart, again along with the resident's ticket. The hot line is responsible for ensuring that the hot plate matches up with the corresponding cold tray. The cold line takes about an hour to fill the nine carts and the hot line takes about an hour and a half with a combined 7 staff members for all 362 meals.

Meal Delivery: The next trick is to get the meals from the central kitchen to the 9 dining rooms, spread out on 3 separate wings on 3 different floors. The HR carts are simply rolled to their designated dining rooms, parked, and plugged back in. The hot food stays hot and the cold food stays cold. At serving time, the cold tray is pulled, the hot items are added to it, and it is given to the resident. Staff is now available to help serve and assist the dining rooms rather than being tied up in a serving line. Another benefit of the HR carts is that if a resident is a late riser or out for an appointment, their meal can be held at the correct temperatures until the resident is ready to eat.

An alternative option used by many is the pellet system, where hot food is put on a hot base under insulated lids and served. While this system may work for the delivery of a meal, the meal must be served very soon after plating or it will be served at unacceptable temperatures. As each cart is filled, it must be delivered and served before the pellet loses its heat, so it takes away any flexibility from residents to eat at their desired time and leads to meal quality inconsistency. The pellet system can be adequate for smaller facilities, but it is difficult to achieve reliable results in larger facilities.

VRM has been using the heated and refrigerated carts (HR carts) for decades. Their initial investment performed for about 20 years before needing replacement. The evaluation of this system compared to the other two primary systems should consider up-front investment, on-going costs (labor and dinnerware items), and meal quality for the resident. Here is a chart summarizing the comparison for VRM.

 Decentralized platingPellet systemHR carts
Economics• Investment: steam tables, cold holding, hot holding, kitchenette, bulk food transport for all 9 dining rooms
• 18 staff
• Replace bases every 2-4 years
• Expensive domes
• Enough staff to rush meals after plating
• Investment: HR cart for all 9 dining rooms
• 7 staff
Meal Quality • Less variety / customization
• Less staff interaction
• Must serve immediately
• Hot food cools off
• Cold food only room temp
• Full customization
• Hot and cold served when resident is ready

Summary: There are many good systems and technologies available for food service. It’s a huge industry with lots of innovation. Thankfully, there has been a good focus on developing systems and products specifically for the Long Term Care industry and its unique challenges.

As you evaluate which products can best help you meet your goals, it’s wise to think beyond ‘how we’ve always done it’. I have 150 or 200 or 300 or more beds at my facility. What is the best system to use for that? It can be good to see how everyone else is doing it and see what can be learned.

To see a video that walks through the food service process at Van Rensselaer Manor MP4

For more information in heated / refrigerated food carts
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