Imagine this—you sit down to dinner and the server brings you a lovely plate of fan tailed shrimp with roasted red potatoes and freshly steamed vegetables. The plate is as pretty as a picture with artfully sculpted lemon wedge garnishes and delicately chopped fresh parsley decorating the rim of the plate. We have all heard the old adage, “you eat with your eyes first,” but does this hold true in nursing homes? Is the meal described a fantasy only suited to five star eateries or can it be a reality in long-term care? To gain some insight into this, we asked nutrition leaders in the long-term care industry to weigh in and discuss if a more generous food budget would improve customer satisfaction and the perception of not only their dining program, but of the facility as a whole. Their answers might surprise you.
       Jean Howard, MS, RD, LD, Auxvasse, Mo: I hear staff members talk about their residents and say things like, “They just aren't hungry,” or, “They can't eat that much food." I used to buy into that argument, until I saw the same residents eat while they were on a picnic outing or in a restaurant. They could and would eat the staff “under the table.” The fact is, that residents eat less because the food served in their nursing care facility is less interesting, tasty, or appealing. Spending more money on food would enable dietary departments to offer more fresh fruits and vegetables, and more nutrient-dense foods. Many of the cheaper entree items contain lots of breading. When a less expensive can, package, or pie is used there is almost always a noticeable difference in the amount of fruit or vegetables per serving.
       Kathleen C. Niedert, MBA, RD, CSG, LD, FADA, Cedar Falls, Iowa: The residents and their families really do not have any idea about the actual food budget. What they do see is the end result-the menu and what is produced and served. Their knowledge is based on quality and quantity of foods and beverages served. Many prospective families do want to see the menus and are amazed at the foods we serve when compared to other facilities, so it does affect perception. With a larger budget I would consider even more choices within the select menu and expansion of open dining hours. Resident choice is what it is all about; allowing the residents to have what they want when they want it.
       Liz Friedrich, MPH, RD, LDN, Salisbury, NC: Food is one of the most visible pieces of patient care in a facility. If the food does not look or taste appetizing, the perception of lack of money spent may carry into other areas of patient care. It makes sense to invest in the food and dining experience because meals and dining are such an important part of the resident's experience.
       Stephanie Petrosky, RD, Plantation, Fla: Some of the highlights of our current menu are comfort foods like meatloaf and a baked potato bar which are very cost effective. It may not work for all crowds, but it goes back to customizing for the population served. Presentation, care and concern, and careful preparation make even the most modest of menus more acceptable. Another direction that can help to improve perceptions is to offer variety and flexibility with food served. Designing production systems around the resident's requests as much as possible will also help to limit waste and redundancy in the budget. This might mean figuring a better way to gather menu selections or serving from a cart at the table instead of a tray line. It might take some effort to develop new systems but it is worth it when you can make your residents and administrators happy.
       Anna de Jesus, MBA, RD, Tempe, Ariz: There appears to be a correlation between higher food budgets and the perception of quality, not just by the residents, but by staff members as well. When the cooks know the food cost is low and they are dealing with a low to middle of the road product, there is not as much pride in cooking. They cut back on portion sizes because of fear of running out of food. They also talk to other staff about the low food costs who in turn, talk to the residents and families. Of course, staff attitude is also a function of the foodservice manager's attitude. With a higher food budget, more money can be spent on better cuts of meat, more variety, more fresh fruits and vegetables, better desserts (real cheesecakes) garnishes, more special event meals and theme meals, salad/soup of the day, dessert cart, omelet stations and more.
       Karen Powell, RD, Santa Barbara, Calif: With a larger budget, we could improve the appearance of our plates with better food selection and more garnishing. This would potentially improve meal intake and thereby reduce medical nutrition supplement usage. I would focus on improving the quality and selection of meats, fruits and vegetables. Increasing the amounts of fresh fruits, and vegetables would increase the fiber content of the menu, improve plate appearance, and potentially decrease constipation and use of bowel medications among residents.
       Abbe M. Breiter, MS, RD, LD/N, Coral Springs, Fla: You do not have to spend a lot of money to make food taste good or look nice. Our residents want a good meal that is palatable to their “older tongue” and meets their cultural needs. A prospective family will never see a food budget in order to make a judgment call on the food quality. What they will experience is walking into a dining room that offers a home-like environment adorned with colorful plates, napkins and tablecloths.
       Digna Cassens, MHA, RD, Los Angeles, Calif: When considering the food budget, we must not forget the labor budget, which is often more important. I would rather have a higher labor budget and a lower food budget to allow for better food preparation with a very clean, well run kitchen. The two must go together: food budget and labor budget.
Customizing menus to the population is equally important. Corporate menus are a thing of the past. Developing a menu template that can be changed by each facility in a chain based on residents’ preferences including geographic, religious, and ethnic backgrounds is paramount to achieving high dietary satisfaction levels.
       Janelle L. Asai, RD, LD, Portland, Ore: A higher food budget generally means there is more support for a superior dining program from upper management. There can be more attention to garnishing the plate and the overall appearance of the food. With an increase in food dollars, there are generally more fresh fruits and vegetables routinely on the menu. There can be more variety in the number of menu selections that are offered and more attention placed on meeting an individual resident’s food preferences. For example, with a more generous budget, the facility can focus more on pureed diets and mold pureed foods to improve the presentation, flavor profile, and nutritional composition. Ultimately, this translates to an increase in quality of life for residents.
       Linda S. Eck Mills, MBA, RD, LDN, FADA, Bernville, Pa: Residents in long-term care facilities eat to live and live to eat. Food is a major focus of their day-three meals each day, activities with food, snacks between meals and more snacks at bedtime. If the food budget was increased so food was more appealing, would this result in better meal consumption, less plate waste, less unintended weight loss, and fewer pressure ulcers? It is certainly something to consider.

       Stacy Fisher, RD, LD, Austin, Tex: Restrictive food budgets tend to limit the overall resident experience when it comes to meals, but the solution is not as simple as putting more dollars into food cost alone. While the food budget can limit the availability and quality of some foods, there is also a need for improvement in basic food preparation techniques. More dollars spent on employee training to improve plate presentation and increase tray accuracy are just as important as dollars spent on food. More highly skilled employees would enable more cooking from scratch. This even has the potential to offset some food costs since convenience items are frequently purchased at a higher price to save employees’ time. I have seen much happier residents when hospitality aides are available in the dining room to ensure everyone is satisfied with their meal. This not only expedites the delivery of food substitutions, but also provides an opportunity for residents to give immediate feedback.
       Wayne Toczek, Foodservice Consultant, Norwalk, Ohio: Perception begins with communication and often the first response to a dietary complaint is, “It is not in our budget.” When dealing with family members and customers or residents, problems need to be understood before acting in a defensive mode or claiming to be a “victim” of the budget. Perceptions and complaints depend on much more than the budget including menu variety, enticing descriptions of the menu items, food products used, preparation methods, consistency in following recipes and specifications, and meal delivery including food temperature, plate presentation, and taste.
       Susan McCorkell Worth, RD, LD, Beaverton, Ore: The bottom line is that residents and family members do not have any idea about the technique a nurse used to give an injection or if the nursing aide tucked the corners of the bed linen under the mattress properly. Food is the thing we all have in common!

Nancy Collins, PhD, RD, LD/N

       Final thought: In the words of George Bernard Shaw, “There is no love sincerer than the love of food,” and that love does not end the minute you are admitted to a long-term care facility. With some attention to detail, a renewed sense of purpose, and a focus on customer satisfaction, all meals will not only be nutritious, but enjoyable too.