Nutrition During Care Transitions

Transcription

1 Nutrition During Care Transitions Rose Ann DiMaria-Ghalili, PhD, RN, CNSC, FASPEN Associate Professor Doctoral Nursing and Nutrition Science October 28, 2015

2 Objectives Discuss the gains in the push for limited readmissions Identify exemplars from CMS Innovation Grants Identify other federal and non-federal exemplars Examine knowledge gaps and research priorities

3 Begin with the end in mind. Stephen Covey, 1989

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5 Addressing Disease-Related Malnutrition in Hospital Patients: A Call for a National Goal It is the position of A.S.P.E.N. that addressing disease-related malnutrition in hospitalized patients should be a national goal in the United States and thereby help to improve patient outcomes by reducing morbidity, mortality, and costs. A malnutrition-focused national goal would better overtly address the issue of disease-related malnutrition to alert health care organizations on the need to provide optimum nutrition care. Guenter et al, 2015, TJC J Qual Pat Safety

6 Hospital Malnutrition Facts Patients coded for malnutrition tend to be 65 years and older, have higher infection rates, longer lengths of stay, higher costs, and higher rates of death (Corkins, et al, 2014, JPEN) Older adults with a malnutrition diagnosis were more likely to be admitted to hospital from SNF, and more likely to be discharged to SNF (DiMaria, et al, 2014, Gerontologist) Weight loss increased risk of 30-day readmission in medical patients (Allaudeen, et al, 2011, J Hosp Med) Failure to thrive/malnutrition frequent reason for readmission in surgical patients (Kassin, 2012, J Am Coll Surg) Malnutrition and Posthospital Syndrome an acquired, transient period of vulnerability (Krumholz, 2013, NEJM)

7 Ukleja et al, 2010; Mueller et al, 2011

8 Transition Logic Older adults at risk for malnutrition Malnutrition impacts readmission Transitional care can impact hospital readmission rates What evidence at national level to support nutrition during care transitions?

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10 Identification of Novel Case Studies Reducing Hospital Readmission Rates o N~ 21 target population adults o Hand-search of all abstracts and verified by search in PDF, nutrition, food, dietitian o N=1 focused on nutritional risk in older adults (AIM model) o Searched One-Year Evaluation Reports o Complex High Risk o Disease Specific

11 Bridging the Divide (Bridges) Program Disease/Condition Population Setting HCIA Disease-Specific Cardiovascular Disease Adults with ischemic heart disease admitted for revascularization or AMI Christiana Care Health System, Delaware Intervention 1. Transitional care coordination begins at inpatient admission through post-acute care 2. Longitudinal care management (61 st day) in outpatient setting with proactive monitoring and notification of health events and IT-enabled participant self-monitoring Team Nutrition Strengths Inter-professional care management team: MD, Hub Manager, nurse care managers, social workers, inpatient care manager, health ambassador, pharmacist Care management staff trained on health topics relevant to their work (e.g., cardiac nutrition, health literacy) Enrollment based on predictive analytics. Program assigns patients to one of three risk groups. Sustainable-CCHS to adopt post program

12 Program Disease Population Setting MyHealth Team HCIA Disease-Specific Cardiovascular Disease Patients with AMI, pneumonia, CHF, CKD, diabetes, HTN, COPD Vanderbilt University Medical Center with populations in TN and KY Intervention 1. Inpatient clinical care coordination using health IT-enabled monitoring and patient education 2. Outpatient chronic care coordination using health IT-enabled selfmonitoring and management; care coordination and personalized care plans 3. Risk level determines intensity of services Team Nutrition Comments RNs, social worker, outpatient care coordinator, MDs, medical assistants, pharmacists Outpatient care coordination activities include chronic disease education for patients (e.g., nutrition and exercise). Transition care coordinators monitor dietary compliance. Transition care coordination and outpatient care coordination have different inclusion criteria.

13 Program Disease Population Setting SEDI (Southeastern Diabetes Initiative) HCIA Disease-Specific Diabetes Adult residents of four counties in Southeastern US with type 2 diabetes ( diabetes belt ) Duke is awardee organization. Durham County, NC, Cabarrus County, NC, Quitman County, MS, Mingo County, WV Intervention 1. Spatially enabled informatics system that uses EHR, demographic and environmental data to segment based on risk of hospitalization 2. Patient-centered care management with multi-disciplinary team with treating clinician to assess and address clinical, behavioral health; social support and nutritional needs 3. Risk algorithm groups patients into 3 intervention groups; each with different intensity of services Team Nutrition Comments Varies by site. MD at each site. Other team members NP, Pharmacist, RN, RD, Social worker, Patient Navigator, community health worker Dietitians/ nutritionists provide nutrition education and expertise; coordinates nutrition-related components of intervention; healthy eating component Complexity and challenges in delivering model at 4 diverse settings

14 Advanced Illness Management (AIM) Program Disease Population Setting Intervention Team Nutrition HCIA Complex/ High-Risk Patient Targeting n/a Patients with high burden of disease, hospice appropriate (not enrolled), likely to die in next 12 months, have rapid or significant functional or nutritional decline, recurrent and unplanned hospitalizations Sutter Health Corporation (Northern and Central California) Home-based care management and care coordination across settings and providers to address gaps in care: 1. Discontinuity between home care and hospice. Once home care services completed frail patients at risk of re-hospitalization. 2. Intermittent patterns of MD office visit and disease management programs. Patients entered hospice prematurely in lieu of access to home health. Interventions include tele-support, hospital and home health. Nurses, social workers. Target Population Nutritional Decline

15 Collaboration between Acute and Post-Acute Care Program HCIA Complex/High-Risk Patient Targeting Population Patients discharged from Vanderbilt University Medical Center to one of 23 partner skilled nursing facilities Setting Vanderbilt University Medical Center: TN and KY Intervention 1. IMPACT: Improved Post-Acute Care Transitions program for in-hospital services (Transitions Advocate-works with patient from hospital through discharge to SNF and prepares a Nursing Transition Summary. Follow up phone call to SNF to answer any remaining questions) 2. INTERACT: Interventions to Reduce Acute Cate Transfers for post-acute care services (Stop and Watch document changes in patient condition that are early warning signs of readmission and structured communication tool between clinical staff. Team Nutrition Comments RN, NP, nurse aides IMPACT Screenings are done for geriatric syndromes (e.g. malnutrition) VUMC established a Transitions Management Office to synthesize findings of all transitions-based projects throughout the medical system. Inconsistencies in Medical Record inconsistent; require follow up with patient or provider. Cut down 50% on labor intensity if relied on medical record; but would cut down 100% accuracy for geriatric syndromes.

16 Themes Strengths Nurses play primary role in transitional care Interdisciplinary team Predictive analysis to identify eligibility for services and level of intensity of intervention Hospital-based models have potential to be sustainable upon completion program Transitions to SNF also examined Weaknesses Role delineation on transitional care teams Nutrition not fully integrated into programs Dietitian missing from interdisciplinary team; one program with dietitian did not have a dietitian at all sites (SEDI) Nutritional decline not defined (AIM project) Integration of various EHRs, data use agreements

17 Gaps Nutrition during care transitions not primary focus of CMS Round One Health Care Innovation Awards

18 Nutrition during Care Transitions? Any other federal programs focused on nutrition during care transitions? Any local programs focused on nutrition during care transitions?

19 NIH-NIA Funded RCT Title: DASH-SRD Post Acute Decompensated Heart Failure Hospitalization (GOURMET-HF) 5R21AG PI: Mathew S. Maurer, MD Design: Randomized, single-blind, attentioncontrolled trial to determine the safety and efficacy of DASH/SRD for 4 weeks post discharge in 50 older adults with HTN discharged for acute decompensated heart failure. Wessler, et al. (2015). American Heart Journal, 169,

20 Other Hospital-based Post-discharge Nutrition Programs Home Plate Meal Program Johnson County, KS, AoA Steward Health Care, MA Boston Medical Center Newton-Wellesley Hospital Vernon Cancer Center Kaiser Permanente Eskenazi Health, IN University Hospitals of Morecambe Bay NHS Foundation Trust Sources: Becker s Hospital Review; Google 7-day frozen meal pack within 72 hrs. discharge; nutrition assessment within 72 hrs., identify need for outreach nurse home visit, supportive home or ongoing nutrition service. City Fresh Foods deliver daily meals to HF patients; recipes; extra nutrition counseling. Estimated cost in 2013 $66,000/month for 55 HF patients. First home-based food pantry, doctors write prescription. Healthy Habits Kitchen delivers 5 meals a month. Pilot affordable meal delivery service for high-risk discharged patients. Head Start Nutrition Program for Seniors. Partnered with Meals-on-Wheels to provide patients 60 and older with two weeks of free food. Goal reduce readmission rate from 22% to 8%. Food-to-Go bags when discharged: milk, bread, orange juice, cereal and food with long shelf life.

21 Research Priorities Integrate nutritional risk assessment into predictive models to determine levels of intensity of nutritional care post-discharge High-risk: intervention delivered by dietitian Medium-risk: intervention delivered by nurses Low-risk: intervention delivered by social worker or lay-health worker

22 Research Priorities Secondary analysis of nutrition risk data from HCIA recipients to develop nutrition risk predictive models based on readmissions, transitional care needs, chronic care needs

23 Research Priorities: Best Practices Identify and review programs instituted by hospitals to address nutrition needs postdischarge Common elements Program costs Cost savings Sustainability Patient outcomes

24 Health Policy Priorities Expand reimbursement for registered dietitians beyond diabetes and chronic kidney disease to heart failure At risk for malnutrition Dietary modifications play important role in symptom management

25 Health Policy Priorities Nutrition risk screen/ assessment incorporated into transitional care programs Nutrition risk screen/assessment upon hospital discharge

26 Nutrition during Care Transitions IMPOSSIBLE