Visiting malnourished patients at home to speed recovery, reduce readmissions

MARIA CASTELLUCCI  March 16, 2019 01:00 AM

As is the case at most hospitals, a sizable portion of patients treated at New Hanover Regional Medical Center in Wilmington, N.C., are malnourished.

The 800-bed hospital estimates that about 20% of its patients are malnourished based on results from the approximately 200 patients they’ve screened each month over the past three years.

“We can’t expect our patients to bounce back from a trauma, stroke, fall, surgery or any other medical condition if their nutrition is inadequate. Nutrition is connected to everything,” said Angela Lago, manager of clinical nutrition at New Hanover.

So in January, the hospital launched a program to better treat and manage that population post-discharge. The program involves a dietitian visiting the homes of patients who were diagnosed with malnutrition during their recent inpatient hospital stay. The goal is to identify barriers to healthier eating and ways to address them. 

STRATEGIES

Hire dietitians to screen patients for malnourishment and food insecurity.

Visit patients at home within a week of discharge to offer nutrition education and other resources.

Create food boxes for patients who test positive for food insecurity.

The program addresses a gap New Hanover identified when reviewing its nutrition efforts late last year, Lago said. Although dietitians have been diagnosing patients for malnourishment since 2016 and offering them education during their hospital stay, no follow-up was being done post-discharge.

“We didn’t know what happened to the patient when they returned home,” Lago said. “We wanted someone to go into the home and really solidify the nutritional care plan for the patient.”

Malnourishment is prevalent across the country. A January 2018 study in the Journal of the Academy of Nutrition and Dietetics estimated the condition is present in 30% to 50% of hospitalized patients age 60 or older. And for people with chronic diseases, it leads to $15.5 billion in additional healthcare spending per year through longer lengths of stay and readmissions, one analysis found.

Through a grant, New Hanover hired Skip Allen to conduct the at-home visits. A clinical outreach dietitian, Allen is referred to patients who the in-hospital dietitians diagnosed as malnourished. His goal is to meet the patients at their homes within a week of discharge.

The first visit usually lasts about an hour. Allen takes the patient’s weight and discusses eating habits and dietary challenges. Sometimes the patients have heart disease or diabetes, so Allen spends time educating them about the best foods for their condition.

For patients who also screened positive for food insecurity at the hospital, Allen asks about social or financial barriers the patient faces to healthy eating. Some patients struggle with access to food because they don’t have the money or live in a food desert. Allen said he helps patients get set up with food delivery services, government assistance programs or food pantries when appropriate. 

Patients who are food insecure are also sent home with a food box at discharge. The box, which New Hanover funds and packages in the hospital, includes enough food for a 2,000-calorie diet per day for two weeks.

 The box includes bread, peanut butter and jelly, macaroni and cheese, milk, tuna and yogurt.

“We wanted (ingredients for) simple meals they could put together, and we wanted nutritious food high in protein and calcium,” said Wayne Strauss, director of food and nutrition services at New Hanover who chose the foods for the box.

Allen asks patients how they like the food box during the at-home visits. The feedback will help determine any future changes to the contents, Strauss said.

Allen visits with the patients two more times during the 90-day post-discharge window to follow up with patients about their weight progress, health goals and any continued challenges they face to improve their eating.

The visits are free to the patients. New Hanover is paying for the services through a grant and its own funds. The cost of providing the boxes is estimated at about $7,000 the first year, which includes food and labor costs.

To assess the program’s success, New Hanover will be tracking if readmission rates decrease among malnourished patients and weight loss occurs during the 90-day at-home visit window. 

If the program shows improved outcomes for the patients, Lago said she hopes to expand the number of clinical outreach dietitians. New Hanover is also in the process of hiring two inpatient registered dietitians, increasing the total number to 10.

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