Advances in Malnutrition Combined Final
Transcript of Advances in Malnutrition Combined Final
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SPEAKERS:
ADVANCES IN MALNUTRITION
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Susan Saffel-Shrier, MS, RDN, CD
Certified Gerontologist
Professor
Department of Family & Preventive Medicine
University of Utah School of Medicine
Salt Lake City, Utah
THE ADVANCES IN ADDRESSING MALNUTRITION
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No Disclosures
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Bridging High Quality Malnutrition Screening, Assessment,
and Intervention for Older Adults from Hospital to Home:
Impact of Nutrition Home Visitations
Susan Saffel-Shrier, MS, RD, CD, Certified Gerontologist
Amy Covington, MS, RDN, CD
Charlotte Vincent, PhD, RDN, CD
ACL INNOVATIONS IN NUTRITION PROGRAMS
AND SERVICES GRANT
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Objectives: Why, What, Who, Where &
How
Review premise of current ACL malnutrition grant
• Why project is timely
• What project entails
• Who are players
• Where project was conducted
• How YOU can apply to your setting
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University of Utah ACL Innovation Grant 101
• Who: University of Utah and Aging and Adult Protective Services and three Utah Area Agencies on Aging (AAA)
• What: Develop a high-quality, malnutrition home visitation pilot program for home delivered meal (HDM)
• Malnutrition project outcomes:
• Implement malnutrition protocol, training, and resources for nutrition home visitation programs
• Demonstrate a transferable home visitation model program
• Provide RDN directed nutritional assessment and interventions •improve coordination of home and community-based services (HCBS) to address malnutrition risk factors
• Tailor nutrition home visitation programs for urban, rural, or frontier
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Why: Malnutrition Project
51.3 billion annual cost– disease associated malnutrition
1 out of 2 older adults at risk for malnutrition
Need Outcomes That Matter
Impact of nutrition assessment and therapy • Hospital readmissions
• Quality of life
• Functionality
• Social isolation
• Mental health
• Cognition
• Coordination of services
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What: Malnutrition Assessment
An acute, subacute or chronic state of nutrition in
which a combination of varying degrees of
overnutrition or undernutrition with or without
inflammatory activity have led to a change in body
composition and diminished function.
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What: Screening vs Assessment
The purpose of screening is to determine whether an
assessment is needed. The purpose of assessment is to
gather the detailed information needed for a treatment plan
that meets the individual needs. ... Screening is a process
for evaluating the possible presence of a particular
problem.
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What: Comprehensive Nutrition
Assessment RDN licensed to performed | Components: Best Practice
• Functional assessment
・Instrumental activities of
daily living
・Activities of daily living
• Social/environmental
assessment: social
determinants of health
• Medical history
• Dietary intake
• Nutrition-focused
physical exam
・Anthropometrics: Muscle
wasting/Fat loss
・Hand grip Strength
• Mental
・Cognition
・Depression
• Health care wishes
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What: Malnutrition & Social Determinants of Health
10%
20%
30%
40%
Physical EnvironmentImpaired physical function
- Transportation- Adequate food prep- Access to food
Working appliances
Medical CareChronic/acute illnessPainIncontinenceSensory deficitsMedicationsDepressionCognitive impairment
Socio-Economic FactorsFood insecurityLow health literacySocial isolationFamily support
Health CareSelf-efficacyResilienceLife satisfactionAddictionsFood safety
Malnutrition
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•Lower Body• Thigh
• Knee
• Calf
• Ankle
• Upper Body• Temples
• Orbital
• Clavicle
• Shoulders
• Ribs
• Arms
• Hands
What: Nutrition Focused Physical Exam
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Temporal Wasting
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Orbital Region
Normal
Moderate
Severe
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The Blind Men and the Elephant John Godfrey Saxe (1816-1887)
Who: The Elephant in the Room & Malnutrition
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Who Are the Players?
Health care providers• Hospital readmissions
• Population health
• Nutrition services
Administrators
Insurance companies
Community-based services• YOU
• Home health
• Skilled Nursing
• Etc
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Who: ACL Grant Participant
Characteristics
• 75 yrs.
• Female
• Lives in a home alone
• Divorced
• Does not have adequate
finances
• 44% use other services (food
stamps, HEAT, lifeline, food
pantry/bank, subsidized
housing, tax abatements)
• Is a U.S. citizen or resident
• Caucasian
• Not a vet or spouse of a vet
• 50% have pets
• Reports anxiety
• Reports depression
• Able to heat and serve pre-
made meals
• Able to eat independently
• Can feed, dress, and groom
themselves, but requires
assistance ambulating
• Have had UWL in the past 6
months
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Who: Home Assessments Impact on
Participants
Adherence to nutrition recommendations
• Manage nutrition Rx
• Apply nutrition concepts to daily eating
More likely to continue MOW
Understand importance of nutrition in maintaining health
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Who: Registered Dietitian Nutritionist (RDN):
Community vs Clinical
Antiquated terms:
Clinical RDN = Hospital
Community RDN = Public health
Food Service RDN?
Expansion of breadth and depth of nutrition services
Clinical RDNs needed in the community
Clinical RDNs needed to assess community-based
malnutrition
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Where: Malnutrition Cycle
Home
HospitalHome Health
Rehab
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Where: Bridging Transitions of Care
• Transitions of care: “A set of actions designed to ensure the
coordination and continuity of care received by patients as they
transfer between different locations or levels of care.” (E Coleman)
• Or, more simply, “every transition of care involves a throw and a
catch.
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Where: Transitions & Malnutrition
Patient outcomes• 2 out of 3 Medicare beneficiaries are readmitted or die within 1 year of
their index hospitalization.*
• About 50% of hospital discharges are associated with at least one
medication error.†
• About 50% higher readmission rate associated with malnutrition**
Costs• Hospital readmissions among Medicare recipients cost $26 billion
annually, of which $17 billion is potentially avoidable. ‡
• Malnutrition increases hospital cost between 19%-29%***
*Jencks SF, Williams MV, Coleman EA. NEJM 2011
**Isabel M et al Clinical Nutr 2003;22(3):235.
***Guerra RS J. Hum. Nutr. Diet., 29, 165.
†Moore C et al. J Gen Intern Med 2003.
‡Robert Wood Johnson Foundation, 2013.
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Where: The “Silo” Problem
Medical care & health care “silos” often do not communicate well with one another:
• Financial silos・e.g. government/private insurance
• Professional silos ・e.g. hospital/clinics/community
services/providers
• Technological silos ・e.g. non-interoperable electronic health records
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How: Take the Malnutrition Challenge
Awareness
Recognition/identification
• Screening
• Assessment & treatment
Coordination of services
Across continuum of care
Transitions of care
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Seanna Marceaux, MS RDN LD
Do Our Meals ‘Work’?
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Objectives
• About Meals on Wheels Central Texas
• Why outcomes matter?
• Our experience with translating research into practice
using an evidence-based screening tool
• How we piloted and implemented this process
• How this is used for program evaluation, prioritization and resource
allocation
• Our current outcomes
• What now?
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Meals on Wheels Central Texas
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NHI Department
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Why Outcomes Matter
for Meals on Wheels
programs?
Justification for funding has moved from
the concept of:
‘Doing good in the community’ ‘A Portfolio of investment’
Experience-based
food consumption,
satisfaction, self-reported
health improvement
Measurable Outcomes
health, functional,
healthcare related
outcomes
Reduce uncertainty, reduce risk = creates value for our Stakeholders
Kali S. Thomas (2015) Outcomes Matter: The Need for Improved Data
Collection and Measurement in Our Nation's Home-Delivered Meals
Programs, Journal of Nutrition in Gerontology and Geriatrics, 34:2, 85-89,
DOI: 10.1080/21551197.2015.1031591
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Why Outcomes Matter
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Meals
Our Marquee Program
MTM (Medically-Tailored Meals)
Chronic Disease Self-
Management
•General Health
•Diabetes-Friendly
•Heart Healthy
•Renal-Friendly
•Digestive-Friendly
*Soft and Pureed versions for each are
available
CHOICE MEAL PROGRAM
Increasing Satisfaction
Beef or chicken?
Turkey or Vegetarian?
Clients decide – promoting dignity
and independence!
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Our Current Demographics
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Meals on Wheels Central Texas
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Impaired Nutrient
Absorption & Utilization
Taste & Smell
Diminish
Poor Oral Health
Body Composition
Changes
Poor Appetite
Transportation
Physical Disability
Xerostomia
Dysphagia
Poly-pharmacy
Chronic Disease
BMIDehydration
Low Income / Food
Insecurity
Minority Status
Living Alone Depression
Bereave-ment
Cognitive Decline
Factors Strongly Influencing Nutritional
Well-Being
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Malnutrition
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What We Know
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An evidence-based approach to measure success
Using the Mini Nutritional
Assessment
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Mini Nutritional Assessment (MNA)
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Feasibility Pilot, 2011
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Focus Group with Case Managers
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3 Month Pilot
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Results of Pilot
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FY 2018
2 out of 3 new Meals on Wheels clients who
were malnourished or ‘at risk’ improved in
just 3 months
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Meals on Wheels program shown to
significantly improve nutrition status
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An evidence-based approach to prioritize resources
and measure success
Using the USDA Food Security
Questionnaire
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Food Insecurity (FI)•
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USDA Food Security Questionnaire
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Scoring Guide
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% of Food Insecure Clients
Before and After One Year on Meals
53%
29%
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What Now?
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Progress NOT Perfection
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Mini Nutritional Assessment
http://www.mna-elderly.com/
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USDA Food Security Questionnaire
https://www.ers.usda.gov/topics/food-nutrition-
assistance/food-security-in-the-us/survey-tools.aspx
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Thank you!