Article Archive
May/June 2024

May/June 2024 Issue

Nutrition: Malnutrition and Transitions of Care
By Lindsey Getz
Today’s Geriatric Medicine
Vol. 17 No. 3 P. 28

Research shows that older adults are at risk for malnutrition due to many factors, including those related to chronic conditions, medications, economics, environmental, psychosocial, and more. That risk can be intensified during transitions of care such as moving from home to hospital care and back again. The American Society for Parenteral and Enteral Nutrition conducted a webinar that looked at the research on this topic, Malnutrition and Transitions of Care Between Health Care Settings. Three presenters described methods to identify and address gaps in care for hospitalized malnourished patients. They also identified strategies and interventions health care professionals can implement across health care settings to support these individuals.

According to Rose Ann DiMaria-Ghalili, PhD, RN, FASPEN, FAAN, FGSA, a professor of nursing and senior associate dean for research in the College of Nursing and Health Professions at Drexel University in Philadelphia, the care continuum in older adults can include many different touchpoints with different levels of providers. But a lot of the interaction does occur in the acute care setting (the hospital) and the postacute care setting (rehab). She points out that patients coded for malnutrition tend to be 65 years old and older, and have higher infection rates, longer lengths of stay, higher costs, higher rates of death, and higher usage of home care.

Providers need to consider what patients need as they get ready for discharge from the hospital, DiMaria-Ghalili says. There are often many potential needs addressed while nutrition is overlooked. She refers to a 2015 news story about an elderly cancer patient in North Carolina who called 911 because he was hungry. The story reports that after spending several months in the hospital for cancer treatment, the man was discharged to a home with an empty refrigerator, and he was unable to get to the grocery store.

This story, DiMaria-Ghalili says, highlights the importance of focusing more attention on nutrition during a transition of care—a conclusion her own research also supports. She performed an online survey of nurses’ nutritional care practices across care settings and found that 86.6% reported conducting a nutrition screen on admission. But only 38.4% reported reevaluating nutrition at discharge.

Improving care means integrating nutritional risk assessment into predictive models to determine levels of intensity of nutritional care postdischarge, DiMaria-Ghalili says.

If a patient is high risk, intervention should be delivered by a dietitian. If a patient is medium risk, it could be delivered by nurses. And if a patient is low risk, intervention could be delivered by a social worker or a lay-health worker. DiMaria-Ghalili adds that it’s important to identify and review programs addressing nutrition at postdischarge.

Opportunities for Nutrition Intervention
Considering these problems associated with malnutrition across the care continuum, implementation of transitions of care nutrition interventions for patients with malnutrition is important to implement in both the inpatient and outpatient settings.

According to Nina Rocca, DCN, RDN, LDN, FAND, CPT, private practice owner of Prestige RD, LLC and a clinical dietitian at BayCare Hospitals in Clearwater, Florida, it’s important for providers to understand the burden of malnutrition, as it’s tied to poor health outcomes, longer hospital stays, and frequent readmission. She adds that research suggests billions of dollars will be spent on annual disease-related treatment costs associated with malnutrition.

A key finding from Rocca’s literature review for her project was that including dietitians in the transition of care process leads to significant improvements in nutrition status. If a health care facility does not have a malnutrition policy or transitions of care plans in place, Rocca says this is an opportunity for dietitians to get involved. There’s a lack of communication about patients’ nutrition status from one health care setting to another across the care continuum, and dietitians can help bring this information to the transitions of care and discharge planning process.

Rocca’s study was centered around the implementation of a five-week nutrition intervention offered to each patient identified to meet malnutrition criteria. The intervention included four interactions: an in-person interview and individualized nutrition plan, a phone call during week one from hospital discharge, a phone call during week three postdischarge, and a phone call during week five postdischarge. Nutrition recommendations and education were included in these calls.

The validated Patient-Generated Subjective Global Assessment (PG-SGA) score was used to evaluate patients’ nutrition status. Rocca found that food intake and total scores significantly improved among patients who were provided with the transition of care nutrition intervention. Additional findings from her study include that 38% reported having trouble with at least one task including shopping, cooking, or preparing meals. These patients also required additional services including elder services, food banks, meal delivery programs, and oral nutrition supplements. These needs provide an opportunity for providers to collaborate with community programs at discharge planning.

Although Rocca didn’t find that readmission rate improved with intervention, she encountered a lot of barriers in her study, including that the sample size was not met. Standardized measures to reduce readmission rates are needed. The transitions of care nutrition intervention improved nutrition status, and, she believes, with the right data and appropriate programs, readmission rates will also improve.

Thinking ahead, Rocca says that dietitians need to be included in transitions of care interventions. Hospitals should also look to identify gaps in communication among staff when it comes to malnutrition and address them. To move toward these suggestions, more research is needed.

Screening Tool to Streamline Assessment
According to Joy Heimgartner, MS, RDN, CSO, CNSC, LDN, a registered dietitian nutritionist (APII), certified specialist in oncology, blood and bone marrow transplant, and assistant professor of nutrition at Mayo Clinic College of Medicine and Science, in Rochester, Minnesota, the PG-SGA is a preadmission patient-reported screening tool that can help streamline assessment. PG-SGA includes four patient-generated historical components—weight history, food intake, symptoms, and activities and function. Heimgartner says it takes some very complex data and leverages it into a scored tool high content validity and answers/scores that can be monitored over time, regardless of setting.

The PG-SGA has been used internationally for 25 years, and is used at the Mayo Clinic for nutrition screening and assessment. It’s been validated in a wide variety of settings and clinical conditions, and is especially helpful for patients with complex medical conditions like cancer. In a pilot program, the PG-SGA was leveraged as an Epic EHR questionnaire that patients could on their own (in their patient portal) or on a tablet upon arrival at the appointment.

Electronic screening, Heimgartner says, should meet the needs of both patients and providers. Patient-reported information is valuable to discern what problems are most impactful to the patient. This particular tool was always meant to be patient-reported and was built to leverage that knowledge.

If your institution uses Epic, you can request the PG-SGA module free of charge.

— Lindsey Getz is an award-winning freelance writer in Royersford, Pennsylvania.