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3
Transitional Care and Beyond
During the second session of the workshop, speakers discussed topics
related to providing care for people before, during, and after hospital dis-
charge. They explored the current and potential roles of registered dietitians
in hospitals, a multidisciplinary approach to discharge, and home- and
community-based services. Hospitalization is common among older adults
and they are being discharged sicker than in the past said Nadine Sahyoun,
associate professor of nutrition epidemiology at the University of Maryland
in College Park, who moderated the session. Transitional care models “fol-
low patients across settings, improve coordination among health care pro-
viders, and also help individuals better understand their posthospital care,”
she said. Nutrition services are an important element of transitional care
and recovery to ensure that older adults in their homes are well nourished.
ROLE OF NUTRITION IN HOSPITAL DISCHARGE PLANNING:
CURRENT AND POTENTIAL CONTRIBUTION
OF THE DIETITIAN
Presenter: Charlene Compher
Charlene Compher, associate professor of nutrition science at the Uni-
versity of Pennsylvania School of Nursing, drew on her experiences in a
hospital setting at the Hospital of the University of Pennsylvania (HUP) as
context for her presentation. HUP is rated among the top 10 hospitals in the
United States, providing trauma, cancer, transplant, cardiac, and geriatric
49
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50 NUTRITION AND HEALTHY AGING
care, yet only had 20 registered dietitians (RDs) to provide nutritional care
to the almost 800 patients per day and 42,500 admissions in fiscal year
2011. HUP has a 2014 goal of eliminating preventable deaths and 30-day
readmissions, and achieving both requires all hospital employees, including
RDs, to focus on the same goals.
The Role of RDs in Hospital Readmissions
In order to achieve its 2014 goal of eliminating 30-day readmissions,
HUP will address the factors that predict hospital readmissions, such as
those identified in Box 3-1.
There is a growing body of research demonstrating that dietitians can
help prevent hospital readmission by providing nutrition counseling that
changes patients’ behaviors and improves clinical outcomes. Studies have
shown that RD counseling can result in weight loss (Raatz et al., 2008),
improved weight management and lipid profiles (Gaetke et al., 2006; Welty
et al., 2007), sustained heart-healthy diet modifications (Cook et al., 2006),
and adherence to a low-sodium diet in patients with heart failure (Arcand
et al., 2005). Implementation of recommendations for enteral tube feeding
in long-term acute care facility patients resulted in shorter lengths of stay,
improved albumin levels, and desired weight gain (Braga et al., 2006).
Compher highlighted an “intriguing study” conducted by Feldblum and col-
leagues in Israel among adults age 65 years and older. Feldblum et al. (2011)
BOX 3-1
Factors that Predict Hospital Readmissions
Utilization Factors
• Longer length of stay
• Prior admission(s) in the past year
• Previous emergency department visits
Patient Characteristics
• omorbidity (diabetes mellitus, hypertension, congestive heart failure, chronic
C
kidney disease, depression)
• Living alone
• Discharged to home
• Medicare/Medicaid
SOURCE: Leas and Umscheid, 2011.
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TRANSITIONAL CARE AND BEYOND
compared outcomes in a control group receiving the standard in-hospital
screen or one visit by an RD to those in the intervention group receiving
three home visits by an RD after discharge combined with individualized
nutrition assessment, enhanced food intake, and nutrition supplements, as
needed. The intervention group scored better on nutritional assessments,
experienced less frequent hypoalbuminemia, and had lower mortality rates
when compared to the control group. However, Compher noted, results do
not indicate if the improvements were due to the nutrition care received in
the hospital or the RD visits after discharge, so the results are attributed to
both.
The Role of RDs in Current Hospital Nutrition Practice
As required by the Joint Commission, nutrition screening at HUP is
completed within 24 hours of hospital admission. A nurse usually com-
pletes the screening, which includes individual institutional criteria such as
unexpected weight gain or loss, gastrointestinal symptoms, obvious ema-
ciation, pressure ulcers, and home feeding by intravenous or tube route.
Patients identified as high risk are referred to an RD for a full nutrition
assessment. This assessment, which is more complex and may take more
than an hour to complete, includes
• diet history,
• weight history,
• medical history,
• medication profile,
• laboratory values,
• current conditions, and
• physical examination for nutrient deficiency or excess.
Once the assessment is completed, a nutrition care plan is developed and
the patient’s nutrition risk level is set to establish a follow-up schedule.
RDs also conduct nutrition assessments on people referred by physi-
cians, admitted with a high-risk diagnosis or condition (e.g., receiving care
in the intensive care unit), and receiving monitored nutrition support ther-
apy. RDs provide instructions for people being discharged with home tube
feeding and parenteral nutrition support, take part in discharge planning
rounds, and communicate with RDs in outpatient care centers. Compher
remarked that, while it would be ideal to provide nutrition assessment
to all patients, the process is time consuming, hospitals have inadequate
RD staff, hospital stays are too short, and hospitals’ limited resources are
used on patients for whom nutrition interventions will provide the best
outcomes.
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52 NUTRITION AND HEALTHY AGING
Potential Future RD Roles
Compher suggested that, despite limited time and resources, there are at
least three opportunities to improve the ways RDs are involved in prevent-
ing hospital readmissions:
1. Ensure that nutrition assessment goals are included in discharge
plans. Through the use of electronic medical records, patients’
nutrition assessment goals and information could be transmitted
directly to their discharge plans. This may assist discharge plan-
ners in making the appropriate referrals. Ideally, RDs would be
included on the discharge planning team to review hospital records
for nutrition care plans that require home support, identify people
whose nutrition status has changed and who require increased
care, and communicate with staff at outside facilities that provide
postdischarge care.
2. Increase cases receiving nutrition assessments. Compher acknowl-
edged that hospitals may not have the staff, funding, or time to
increase the number of people screened and assessed. She suggested
using dietetic technicians to conduct the screenings and referrals
and to focus on those people most likely to be readmitted, includ-
ing everyone 65 years and older and patients admitted through the
emergency room. She also suggested that dietitians screen patients
in the emergency department in order to begin nutrition care early
or to identify patients in need of nutrition services although not
being admitted and make the necessary referrals.
3. Improve integration of hospital and post hospital nutrition care.
Although achieving this goal requires more trained nutrition pro-
fessionals in the community, it would be beneficial to have hospital
RDs more involved in post hospital care. Compher proposed hav-
ing RD positions in heart failure programs, all outpatient clini-
cal programs, and community geriatric care programs. She also
suggested paying RDs for home visits to conduct nutrition as-
sessments and providing hospitals with financial incentives for
avoiding readmissions.
Closing Comments
Compher concluded by noting the importance of moving from the
current level of RD availability into a future with enhanced nutrition care
for older adults. It may be daunting but it is imperative that the nutrition
community “take the challenge” to prevent hospitals from discharging
nutritionally compromised people who are more likely to be readmitted.
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53
TRANSITIONAL CARE AND BEYOND
TRANSITIONAL CARE: A MULTIDISCIPLINARY APPROACH
Presenter: Eric A. Coleman
Eric Coleman, professor of medicine and head of the Division of Health
Care Policy and Research at the University of Colorado at Denver, reiterated
the importance of a team approach to providing transitional care, stressing
that the most important teammate is the one receiving the care. The ultimate
goal for transitional care is “to create a match between the individual’s care
needs and his or her care setting.” Achieving that goal can reduce frequent
and costly readmission rates; the Medicare 30-day hospital readmission rate
is nearly 20 percent (AHRQ, 2007) and hospitals with high readmission
rates are financially penalized under the Affordable Care Act.
The Role of Nutrition in Hospital Readmissions and Transitional Care
While nutrition plays a role in improving general health, the role of
nutrition in hospital readmission remains unclear, Coleman said. There
are studies linking the two but they mostly explore undernutrition, are
observational, sometimes rely on clinical assessment or laboratory results,
and rarely explore the role of supplementation (Friedmann et al., 1997).
He noted that “the role of nutrition is likely entangled with chronic ill-
ness, frailty, [and] socioeconomic status.” Nutrition should not be used as
a bartering tool in a hospital’s efforts to provide intervention in a patient’s
home, cautioned Coleman. For example, in order to avoid financial penal-
ties, hospitals are eager to intervene on high-risk older adults and may use
nutrition services as an incentive to persuade them to agree to home visits.
The Role of the Patient in Transitional Care
In order to determine how to improve the quality of transitional care,
Coleman suggested talking to people receiving the services. He said they
report feeling unprepared and unsure of what to do when they return
home. They are confused because they receive conflicting advice from
professionals in various health care settings, and they do not know who to
contact to reconcile the discrepancies. Finally, they are frustrated because
their family caregivers are left to complete tasks that the professionals left
undone. Often people receiving transition services interact with their health
care providers for only a few hours a week. Therefore, they, or their family
members, end up acting as their own caregivers, making decisions without
the skills, tools, or confidence to provide effective care. As shown in Ed
Wagner’s Chronic Care Model (see Figure 3-1), an informed and active
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54 NUTRITION AND HEALTHY AGING
Community
Health System
Resources and
Health Care Organization
Policies
Clinical
Self- Information
Delivery
Management Systems
Decision
System
Support Support
Design
Informed, Prepared,
Productive
Activated Proactive
Interactions
Patient Practice Team
Functional and Clinical Outcomes
FIGURE 3-1 Wagner’s Chronic Care Model.
SOURCE: Wagner, 1998. Reprinted, with permission, from the American College
of Physicians.
R02158
patient is vital to achieving improved functional and clinical outcomes
Figure 3-1
(Wagner, 1998; Wagner et al., 2001).
editable vectors
The Care Transitions InterventionTM
The Care Transitions InterventionTM (CTI) is a low-cost, low-intensity
intervention designed to build one’s skills and confidence and provide the
necessary tools to encourage the patient to be an informed and active
decision maker during care transitions (Coleman, 2011). The interven-
tion consists of one home visit within 48–72 hours after discharge and
three phone calls within 30 days. The patient’s “transition coach” models
behavior for how to handle common problems, role-plays the next health
care visit, elicits the patient’s health-related goals to be accomplished in
the next 30 days, and creates a comprehensive medication list. Because the
patients and caregivers are members of their own interdisciplinary team,
they identify their own health care goals and the skills needed to coordinate
their care across settings. The four areas that patients identified as those
they need the most help with (referred to as the “four pillars”) are
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TRANSITIONAL CARE AND BEYOND
1. development of a patient-centered health record,
2. assistance with medication self-management,
3. follow-up with primary care physician and specialists, and
4. knowledge of “red flags” or warning signs and symptoms and how
to respond.
The patient-centered health record contains the patient’s current medi-
cal conditions, warning signs that relate to the patient’s condition, a list of
medications and allergies, advance directives, and space for the patients
to list their questions or concerns to discuss during their next health care
visit. The transition coach initially meets with the patient prior to hospital
discharge to introduce the program and patient-centered health record,
establish rapport, and schedule the home visit. During the home visit,
the patient indentifies a 30-day health-related goal; the coach reconciles
the patient’s medications; and they role-play how to respond to red flags,
obtain a timely follow-up appointment, and raise questions for health care
providers during subsequent visits. The phone calls are conducted to follow
up on active coaching issues, review the four pillars of the intervention,
estimate the amount of progress being made, and ensure the patient’s needs
are being met (Coleman, 2011).
CTI Key Findings and Next Steps
Results from the CTI showed that reductions in hospital readmission
rates were significantly lower at 30 days postdischarge (the time period
in which the transition was involved). Furthermore, significantly lower
rates at 90 and 180 days postdischarge demonstrate the sustained effect
of the coaching. The net cost savings for 350 patients over 12 months
was $300,000. CTI has been adopted by 500 health care organizations in
38 states and resulted in reduced 30-, 60-, and 80-day readmission rates
(Coleman et al., 2004; Crouse Hospital, 2008; Parry et al., 2006; Perloe
et al., 2011). Preliminary data from evidence-based care transition grants
from the Administration on Aging and the Centers for Medicare & Medic-
aid Services show that 16 states are employing models to help older adults
stay in their homes after discharge from hospitals, rehabilitation centers, or
skilled nursing facilities, 11 of which are implementing CTI. In April 2011
up to $500 million was made available by the Secretary of the Department
of Health and Human Services under the Affordable Care Act Section 3026
to fund organizations to provide evidence-based transition care services to
high-risk Medicare recipients (CMS, 2011).
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56 NUTRITION AND HEALTHY AGING
Closing Remarks
Coleman concluding by summarizing the four factors that promote
successful implementation of CTI: (1) model fidelity, (2) selection of an ap-
propriate transition coach, (3) execution of the model, and (4) support to
sustain the model. Successful implementation of CTI can reduce readmis-
sion rates by helping older adults and their caregivers become informed and
active participants in their care transitions.
NUTRITION IN HOME- AND COMMUNITY-BASED SYSTEMS:
PERSPECTIVES FROM THE FIELD
Presenter: Bobbie L. Morris
Through her position at the Alabama Department of Senior Services,
Bobbie Morris visits older adults in their homes and senior centers and
learns about the nutrition services they are receiving. Services provided
under the Older Americans Act (OAA) Elderly Nutrition Program aim to
promote health, provide nutritious meals that meet current dietary guide-
lines and older adults’ needs, reduce social isolation, and link adults to
social rehabilitative services through other home- and community-based
long-term care organizations. Her experiences suggest that facilities that
promote fun and physical activity in addition to the OAA services of meals,
nutrition education, counseling, and screening and assessment may have
higher rates of participation.
Services Provided Under Title III C of the OAA Nutrition Program
Under Title III C of the OAA Nutrition Programs, meals can be served
through congregate or home-delivered services. Congregate nutrition ser-
vices provide meals five or more days a week in a group setting, including
adult daycare, whereas home-delivered meals are hot, cold, frozen, dried,
canned, and supplemental foods that are distributed to adults’ homes.
In both cases, nutrition education and counseling are provided to the re-
cipients and, in the case of home-delivered meals, their caregivers (AoA,
2011a). The numbers of congregate, home-delivered, and total meals served
through the OAA Nutrition Services program over the past 10 years are
shown in Table 3-1.
As mentioned in a previous presentation, the number of home-delivered
meals has increased over the years while the number of congregate meals
has decreased, possibly indicative of the number of frail older adults staying
in their homes, Morris said. She suggested that the decline in total meals
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TRANSITIONAL CARE AND BEYOND
TABLE 3-1 Number of Meals Served Through OAA Nutrition Services
in the United States
Number of Meals Served
Fiscal Year Home-Delivered Meals Congregate Meals Total Meals
2000 143,804,683 116,016,249 259,820,932
2001 143,719,629 112,243,758 255,963,387
2002 141,958,732 108,333,836 250,292,568
2003 142,889,385 105,905,622 248,795,007
2004 143,163,389 105,606,162 248,769,551
2005 140,132,325 100,530,354 240,662,679
2006 140,212,524 98,031,661 238,244,185
2007 140,990,040 94,877,137 235,867,177
2008 146,897,367 94,196,192 241,093,559
2009 149,188,917 92,492,669 241,681,586
NOTE: Data include number of meals served in 50 states, District of Columbia, and U.S.
territories.
SOURCE: Data from 2000–2004: AoA, 2009; data from 2005–2009: AoA, 2011b.
served is partially due to increases in fuel and food costs that exceed pro-
gram funding increases.
Flexible Meals Services
Morris described several flexible meal services funded by a variety of
sources. In some cases, meals may be offered at a range of locations and at
various times during the day. Voucher programs provide participants with
the option to go to a restaurant or grocery store and order a meal or pur-
chase items that meet the required nutrition guidelines. In some areas where
there are limited restaurants, hospital vouchers can be used to purchase a
meal from a hospital cafeteria. In some areas, meals may also be offered
at homeless shelters. Flexible meal packages include options for receiving
more than one meal per day, such as a hot meal at lunch and a frozen meal
for dinner, or shelf-stable meals for weekends, holidays, and emergencies.
Meals can be provided through local and statewide contracts, at on-site
kitchens, and by shipments to participants’ homes. For example, a local
contract could arrange for a community nursing home or restaurant to pre-
pare and deliver meals to homebound adults or congregate meal facilities.
Alabama has a statewide contract with Valley Food Service for preparation
of all hot and frozen meals for the state. The benefit of a statewide contract
is reduced meal costs; however, it also limits the variety of available foods
and results in all state participants receiving the same meal.
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58 NUTRITION AND HEALTHY AGING
Prioritizing Services
Despite the availability of Title III nutrition services and programs like
Meals On Wheels, there are still people on waiting lists for meals. The OAA
states that “services are targeted to those in greatest social and economic need
with particular attention to low-income individuals, minority individuals,
those in rural communities, those with limited English proficiency, and those
at-risk of institutional care” (AoA, 2011a). In order to determine who is most
in need of service, nutrition risk is assessed using tools such as the Nutrition
Screening Initiative checklist (Posner et al., 1993) and the Mini Nutritional
Assessment® (Nestlé Nutrition Institute, 2011; Vellas et al., 1999). Morris
stressed the importance of properly training staff on how to administer the
assessment tools to ensure that the questions are asked correctly and the ap-
propriate information obtained. Other ways to determine who on the waiting
list receives meals or to provide alternate services include
• decisions made by a Senior Center Advisory Board based on need;
• a first-come, first-served approach;
• sponsored meals provided by organizations such as churches, rotary
clubs, and women’s clubs; and
• managing delivery routes to redirect meals intended for those who
cancelled their meal service to be delivered to other people in the
same area.
Closing Remarks
Morris closed by sharing her view that a “no wrong door” philosophy
would provide seamless access to services regardless of how or where some-
one encounters the service system. She suggested that service programs and
funding streams be brought together to ensure that older adults receive the
information, referrals, and care they need. The long-term goal is for older
adults to make informed choices for their long-term care, while reducing
and controlling Medicaid spending, decreasing nursing home and institu-
tional care, increasing availability of home- and community-based services,
and reducing the number of people on waiting lists for nutrition services.
DISCUSSION
Moderator: Nadine R. Sahyoun
During the discussion, points raised by participants included the role of
nutrition in transition services, the role of physicians in the referral process,
and patients’ perception of needs during and after discharge.
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TRANSITIONAL CARE AND BEYOND
Role of Nutrition in Transition Services
Nancy Wellman questioned why nutrition is not a larger component of
transition services. Coleman noted that while nutrition was mentioned dur-
ing his qualitative research, the focus of the CTI model is patient-identified
goals, not those chosen by the health care provider, so nutrition will not be
addressed if it is not one of the patient’s goals. Rose Ann DiMaria-Ghalili
followed up by pointing out that none of the transitional care models
published by the Remington Report included a nutrition component. She
said this is “quite alarming” and believes nutrition screening should be
conducted throughout the transitions. She also suggested that health care
professions using various screening tools collaborate to ensure consistency,
and nurses would be amenable to using whatever tool is recommended.
Role of Physicians in Referral Process
Jennifer Troyer referred to Compher’s statement that two-thirds of refer-
rals to RDs for nutrition assessment were from physicians and wondered if
it was the same physicians repeatedly making the referrals. Compher stated
that it was a variety of physicians, possibly due to HUP’s role as a teach-
ing hospital; residents make referrals following the lead of physicians they
respect and continue to refer patients to RDs as they move up the tiered
levels of training. Heather Keller asked why more people were not being
referred to RDs as a result of the nutrition screening, and why physicians
were making the majority of referrals. One-third of HUP’s beds are intensive
care unit beds; therefore, referrals for those patients are more likely to come
from a physician. Coleman noted that hospital stays are shorter and people
may be discharged before laboratory results from the nutrition evaluation
indicating nutrition problems are received. He said, “if we’re going to pursue
these evaluations, it’s also worth thinking about the workflow, about what
happens when the lab comes back abnormal and the person left 24–48
hours ago.”
The Patient’s Perception of Need During and Postdischarge
James Hester asked about the panelists’ experiences understanding
patients’ perceptions of their needs during discharge and postdischarge,
including their receptivity to their nutritional needs. Compher noted that
based on her personal experience individuals who are being discharged
from the hospital want more than anything to be home and in a situation
they understand and can control. Coleman agreed that individuals tend to
feel inundated while in the hospital, and suggested letting them get settled
in their homes and then addressing some of the issues several weeks later,
when they may be more prepared to think about them. Sahyoun added
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60 NUTRITION AND HEALTHY AGING
that individuals may have support from their family and friends the first
few days after discharge but then there is an adjustment period while they
figure out how to handle situations on their own. She suggested “that in
the transition of care there is a role to play in making people aware and
empowering them [with knowledge] about what [nutrition] resources are
available in the community” in addition to other health services.
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