Mealtime Partners, Inc.

Specializing in Assistive Dining and Drinking Equipment

June 2010 Independent Eating and Drinking Newsletter

	June Topics: Eating Versus Being Fed When Medicaid Says No

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Eating Versus Being Fed

Recently the question was raised, how do you stop feeding someone who has been fed for years, and allow them to actively eat at mealtimes? First, the difference between what is meant by feeding and eating must be clarified. Many people are dependent upon another person to receive all of their nutrition, however, some of these individuals are fed and others eat. The difference is how food gets into their mouth. When fed, the person providing mealtime support puts each bite of food into the person’s mouth. If the individual eats, they are offered a bite of food, but the person eating takes the food off of the utensil, into their own mouth, at their own pace. The advantage of eating versus being fed is that it is a safer way to receive food. If a person chooses when each bite of food enters their mouth, they are less likely to choke on the food or to aspirate. (There are approximately 40,000 deaths in the U.S. each year due to aspiration pneumonia. One of the best predictors for the development of aspiration pneumonia is being fed by others.) (Calhoun, Wax & Eibling¹, DeLegge²)

For those who are fed, old habits are usually well established and body movement patterns have become second nature. For example, many people who are fed lean slightly backwards throughout the meal. When in a slight backward recline, their mouth is at an easy angle to receive a spoonful of food and the food is unlikely to fall out of the person’s mouth after it has been put in their mouth. When in a reclined position the chin naturally is raised. Often this position has remained from early childhood. It is common for infants to be “tilted” backwards when they are fed. Other people lean forward. They move as far towards the spoon as they possibly can. This is commonly a result of a desire to eat (hunger) or to be helpful to the person feeding you. Both of these positions hamper the person’s ability to eat rather than being fed.

To eat, you must be able to freely take a bite of food off of a spoon when the food is offered. To do this, you must be able to move your mouth forward, onto the bowl of the spoon, and then reverse the movement to get your mouth off of the spoon. In other words, the individual must be able to move their head forward and backward, at will. If you are reclining, even slightly, moving your head forward to the spoon demands tensing the muscles in the shoulders and back of the neck to move the head against the pull of gravity. The normal muscle pattern used to move the head back and forward, when it is upright, is a combination of all of the neck muscles. Additionally, gravity helps to tilt the chin downward when the head is upright. If your head is fully extended forward there is no way to move farther forward onto the bowl of the spoon to take a bite. Therefore, with either scenario, the individual who wants to eat versus being fed, must change their mealtime seating and positioning to incorporate the essential body movements necessary for them to eat. Obviously, for those who recline, the goal should be to adjust their seating to accommodate a more upright position; for those who are in a forward position, the goal should be to have them move back to a more upright position. (Refer to Mealtime Partners July 2009 Newsletter for a detailed discussion about seating and positioning for eating).

When addressing positioning changes, special attention should be paid to the individual’s stability. It is extremely difficult to move in a controlled fashion if your body is not well supported. Modifying someone’s body position and movement patterns requires that their muscles are taught the new information and gain new muscle tone that is adequate to support the changes. Simply changing positioning does not assure that the person will be able to move their head in a controlled manner. They must be given adequate time for the muscle control to develop.

For the greatest probability of success, all changes should be undertaken in small increments. First, modify the individuals seating position, but continue to provide all food in the customary way. Once the new positioning is familiar to both the person being fed and the person feeding them, the first several bites of each meal should be presented so that the person can eat rather than being fed. To do this, the person providing food should place the spoon close to the individual’s lower lip and hold the spoon in that location. If the person learning to eat does not automatically move forward and take the spoon into their mouth, the feeding partner should provide verbal prompting to encourage them to do so. If they still do not move onto the spoon, the tip of the spoon can be placed on the person’s lower lip (not inside their mouth). If the individual still does not take the spoon into their mouth, the spoon can be gently wiped on the lower lip, with a forward and backward movement. (A slight downward pressure on the lower lip is sometimes helpful). If the individual still does not take the spoon into their mouth, the feeding partner can gently encourage forward movement onto the spoon by placing their hand on the base of the individual’s neck and moving the head and shoulders forward very slightly. Whichever method(s) is used to teach them to eat rather than being fed, previous methods of feeding should be gradually eliminated as the user becomes more familiar with the pattern of eating. When a comfortable new eating pattern has developed for the beginning of the meal, the number of bites eaten rather than being fed should be expanded until the entire meal is being eaten.

Great patience should be exhibited on the part of the feeding partner as the ability to eat is learned. Impatience in the feeding partner is easily sensed and the person trying to learn often hurries and the pleasure and pride of acquiring a new skill is diminished and sometimes simply abandoned because they sense the frustration of the mealtime partner.

Regardless of whether someone is eating with a person providing the food, or using dining equipment like the Mealtime Partner Dining System to eat, it is always safer to eat rather than being fed, because eating diminishes the risk of choking or aspiration because the person eating controls when each bite of food is placed in their mouth.

Did you know that the Mealtime Partner Dining System was designed specifically to make it accessible for those with cognitive disabilities. The clear bowls and their positioning within the immediate view of the user, allow the user to see each food choice that is being offered to make food selection easy. The device has variable timing capabilities that allow its operation to move as fast or slow as the user needs, providing adequate processing time to recall the sequence for taking a bite of food. Also, the smooth/fluidic action of the spoon that is all completely within the immediate view of the user lessens the likelihood of the device’s motion startling the user.

In addition, the flexible mounting and positioning capabilities of the Mealtime Partner meets a diverse range of user needs, including wheelchair users and those who do not sit at a table to eat. The Mealtime Partner is very patient. It will never rush the eater into taking the next bite, leaving plenty of time for socializing.

For more information about the Mealtime Partner Dining System, you can visit the Mealtime Partners' website, or view our 4 minute video.

Clear bowls and compact movement lesson cognitive requirements

When Medicaid Says No

Most people who receive healthcare through a Medicaid program have had the experience of receiving a notice that Medicaid will not authorize funding for a service or piece of equipment that their healthcare provider has prescribed for them. When Medicaid denies coverage what should you do? Most people assume that the denial is the end of the road for that claim and that they will have to manage without the service or equipment. However, when Medicaid denies a request for coverage they must provide a reason for denying the claim. Common reasons for not authorizing payment for a claim are: it is not medically necessary; it is a convenience item or service; it is not the least expensive appropriate alternative; it is not a covered item or service; it is not durable medical equipment (DME). (For more about medical necessity, please read the October 2009 Newsletter Topic: Medical Necessity for Assistive Dining Equipment.

When a denial notice is received, the reason for the denial should be carefully examined. It is not uncommon, that the Medicaid reviewer is not aware of state of the art of DME, as technology changes rapidly and what was accepted as a standard piece of equipment a year or two ago, is now obsolete and has been replaced by something new. In many such cases, Medicaid was not provided adequate information to make an informed decision and, therefore, further information should be provided. Nevertheless, if the client and their healthcare providers disagree with the reason for the denial they should submit an appeal following the instructions on the denial notice. If this does not resolve the disagreement the client has a right to a Fair Hearing where an impartial hearing officer will decide the merits of the claim based on information provided by both Medicaid and the client. A Fair Hearing should be requested, in writing, within thirty days of the denial notice, following the instructions on the denial notice, and must not be viewed as an intimidating experience. It is provided to allow client’s recourse when they believe that Medicaid has made an erroneous decision. (Always keep copies of all of the paperwork associated with a claim and notes about any conversations with Medicaid to be able to provide a complete chronology of the claim history, should it be needed.) After explaining to the Hearing officer why the reasons that Medicaid has denied the equipment are incorrect, they will usually reverse the denial and order Medicaid to provide the equipment.

When coverage for a Mealtime Partner dining system is denied, Mealtime Partners, Inc. is always willing to help provide information that may be of value in an appeal or a Fair Hearing. We have assisted and advocated for many clients and have a wealth of information regarding defending the need for a Mealtime Partner. Feel free to contact us by phone (817-237-9991) or email (info@mealtimepartners.com) if you need help. There is no charge for this service, we are pleased to help.

Due to the great importance of proper hydration, Mealtime Partners recommends that everyone be provided the means to drink at any time they wish. For most individuals, dehydration is 100% preventable. And yet many people with disabilities suffer from some level of dehydration almost constantly.

Mealtime Partners, Inc. provides a variety of drinking systems that can meet the needs of most individuals. Most of these systems can be mounted on a wheelchair, or bed. To learn about the Mealtime Partners drinking systems, click here. Information is available to help you select the right drinking system. And, if you still have questions about selecting a drinking system, please call us at 800-996-8607. We will be pleased to assist you.

A Mealtime Partners Tip: Never feed someone who is reclining or lying down, unless a medical condition allows no other option. That position presents the highest risk of aspiration for someone who is eating or drinking. If someone is ill enough to require being in a lying position for eating and drinking, seek the advice of your physician (or other healthcare professional) to determine how to provide food and liquid in the safest way possible.

We want your feedback! If you have comments or suggestions to expand and/or clarify the information in our Newsletter articles, please feel free to email us at: newsletters@mealtimepartners.com. Comments from our readers help us provide better, more complete information to the community that we serve.

June 2010 Newsletter References

1. Calhoun, K. H., Wax, M., Eibling, D. E., Expert Guide to Otolaryngology. American College of Physicians, American Society of Internal Medicine. Published ACP Press, 2001.

2. DeLegge, M. H., Aspiration pneumonia: Incidence, mortality, and at-risk populations. Journal of Parenteral and Enteral Nutrition, Nov/Dec, 2002.

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