Nutrition Services in the Acute Care Setting
In 1967, inpatient hospital costs comprised close to 63 percent of all Medicare payments, while the combined payments to skilled nursing facilities (SNFs), home health agencies (HHAs), and outpatient services were less than 9 percent. During the past two decades, Medicare payment reforms and cost containment initiatives have changed the proportion of payments to inpatient hospitals. By 1996, inpatient hospital costs had dropped to 48 percent of Medicare payments and SNF, HHA, and outpatient services had increased to almost 26 percent of total Medicare payments. However, Medicare spending was concentrated on a relatively small percentage of enrollees. In 1996, approximately 12 percent of Medicare enrollees accounted for more than 75 percent of Medicare payments. The three groups of high-cost users were those with end-stage renal disease, beneficiaries who died (services became more intense as they approached death), and beneficiaries who required an inpatient hospital stay. The leading diagnoses for hospitalized beneficiaries, in terms of Medicare dollars spent, were malignant neoplasms, heart disease, fractures, pneumonia, and cerebrovascular disease (Health Care Financing Administration, 1998). Nutrition is involved in the primary, secondary, and/or tertiary prevention of each of these diseases or conditions.
MEDICARE REIMBURSEMENT IN ACUTE CARE, SHORT-STAY HOSPITALS
A prospective payment system is used by Medicare to reimburse for inpatient hospital costs. This system is based on diagnosis-related groups.
Coverage includes room, meals, nursing services, operating and recovery rooms, intensive care, inpatient prescription drugs, laboratory tests, and x-rays. Professional nutrition services, formulas, and parenteral solutions are also included in this payment.
ROLE OF THE NUTRITION PROFESSIONAL
Licensing standards require that hospitals employ a registered dietitian full-time, part-time, or on a consulting basis. Nutritional needs of patients must be met in accordance with recognized dietary practices and in agreement with orders of the practitioner responsible for the care of the patient (Code of Federal Regulations, 1998).
The Joint Commission on Accreditation of Health Care Organizations (JCAHO) requires that all patients are screened for nutrition problems and, when a problem exists, there is appropriate nutrition intervention. This is an interdisciplinary process. Examples of the roles that various health care providers play can be found in Box 9.1. JCAHO standards also require that a patient’s readiness to learn be evaluated and that discharge planning and good transitional care begins when the patient is admitted to the hospital. The JCAHO designates the geriatric population as a high-risk group and has emphasized nutrition in its inspections during the last few years (JCAHO, 1996).
Identification of Nutrition Problems at Admission
Because of the JCAHO standards, most acute care hospitals have procedures to identify or screen patients for nutrition problems within 24 hours of admission. This may be done by the nurse, dietetic technician, or dietitian. The most common criteria used in this evaluation are diagnosis, weight, weight change, need for diet modification or education, problems with chewing or swallowing, diarrhea, constipation, and food dislikes or intolerance. The screening tool may also include specific laboratory values, such as serum albumin and cholesterol concentrations, and hematologic values such as hemoglobin and total lymphocyte count.
If a problem is identified in the screening, the patient is to be evaluated further by the dietitian. In-depth nutrition assessments may include such things as evaluation of anthropometric, biochemical, and clinical data; evaluation of energy and nutrient intake at home or in the hospital; evaluation of access to food at home; calculation or measurement of energy and nutrient needs; and assessment of learning needs. All of this is
done within the context of the patient’s disease or condition and any other treatment received. Interventions may include diets that are modified in macro- or micronutrients, diets that are modified in consistency, nutrient or energy supplementation using liquid dietary supplements, vitamin and mineral supplements, enteral or parenteral nutrition support, or nutrition counseling.
Continuum of Care
The nature of nutrition counseling has changed with decreased lengths of stay in acute care facilities. For the most part, patient education in hospitals involves teaching “survival skills” and linking the patient with a dietitian in the ambulatory setting where conditions are more conducive to helping people make long-term behavior changes. However, the lack of reimbursement for nutrition services in the ambulatory setting often limits the resources available to people once they have been discharged from the hospital. Patient education and the ability of people to manage their own care has been reported to be negatively impacted by short stays and inadequate ambulatory nutrition services (Weinberger et al., 1988).
Hospital dietitians also work with discharge planners, attempting to provide a smooth transition between the hospital and nutrition services in skilled nursing facilities or home care. However, few dietitians work in home care and the hospital dietitian is often called upon to advise home care agencies or home infusion companies about patients long after they have been discharged from the hospital.
Hospital dietitians may also refer patients with continuing nutrition or food assistance needs to community agencies, such as food banks, congregate feeding programs, and home-delivered meals.
Older People Needing Intervention for Undernutrition
Hospitalized people have more complicated and costly illnesses today than they did 20 years ago (Duffy and Farley, 1995). Although the overall length of stay has decreased, those patients with the most complex nutrition problems often have longer stays than the average patient and use more nutrition services during their hospital stay. The 24-hour requirement by JCAHO for screening is unrealistic and labor intensive. The methods adopted by many institutions to meet this requirement lack validity in the identification of undernourished patients, often depending on information that is unreliable (see chapter 4) or unavailable.
Some patients are discharged before screening and intervention can take place. Others do not receive the care needed because human re-
sources are tied up with a mandatory screening process that is cumbersome and ineffective. The screening process may need to be simplified and focused on those patients with the most complex nutrition problems. The deadline for completion may also need to be extended so that screening of short-stay patients with the least complex nutrition problems does not overwhelm the limited resources available. Human resources could also be better used to help those patients with the most complex problems, including those needing help with food choices, feeding, or monitoring food intake.
There is also evidence in the literature that intervention for many older people in acute care hospitals is inadequate. Burns and Jensen (1995) reviewed the medical records of 268 “young” (aged 65 to 80 years) and “old” (over 80 years) elderly patients from seven admitting services in a tertiary care teaching hospital. Data in the medical record were used to evaluate the patients’ nutritional and functional status, hospital mortality, readmission, and disposition outcome. Data that were needed to
evaluate nutritional status were found in most of the medical records (i.e., serum albumin [31 percent of records]; total lymphocyte count [95 percent of records]; percent ideal body weight [90 percent of records]). Even though investigators found that severe malnutrition was common in this elderly population, there was little evidence that the patient’s physicians had identified or documented this. The presence of a positive malnutrition index was associated with older age, impaired functional status, and greater mortality. Patients with malnutrition also required more subsequent health care based on hospital readmissions or referrals to skilled nursing or home care.
Mowé and Bøhmer (1991) studied 121 hospitalized, older patients in Norway. Using anthropometric data (height, weight, triceps skinfold, and midarm circumference measurements), they determined that more than 50 percent of the patients had protein–energy undernutrition. No patients had been given a diagnosis of malnutrition, only a few were characterized
as malnourished, and only two of the most undernourished patients received nutrition support while they were in the hospital.
A sample of 250 older patients, admitted to a Department of Veterans Affairs hospital was studied prospectively beginning at hospital admission (Sullivan et al., 1989). A medical and nutritional profile was developed based on information extracted from each patient’s chart. This included admitting diagnosis, secondary diagnoses, laboratory values at admission or when first obtained in the hospital, and the physician’s and dietitian’s work-up. Patients were classified as low risk (44 percent of patients), moderate risk (24 percent), and very high risk (15 percent) of having protein–energy undernutrition, based on serum albumin, total lymphocyte count, and weight for height or body mass index. The rest of the patients (17 percent) had so little data that nutritional status could not be determined. During the entire study period only 36 percent of the study patients and 44 percent of the at-risk patients received a formal evaluation by a dietitian. Dietary intake data for the patients at risk were questionable and nurses reported having inadequate time to monitor nutrient intakes. Patients at risk for protein–energy undernutrition were significantly older and had longer hospital stays.
The most commonly cited reason that nutrition problems are not addressed in the hospital is lack of education or understanding of the importance of nutrition by physicians (Burns and Jensen, 1995; Mowé and Bøhmer, 1991; Sullivan et al., 1989).
EFFECTS OF UNDERNUTRITION ON FUNCTIONAL STATUS IN THE ELDERLY
In 1994, more than one-third of the admissions to nonfederal acute care, short-stay hospitals were for people at least 65 years old. Functional status in the elderly may be lost during acute care hospitalization (Sager et al., 1996). In a large study, the Hospital Outcomes Project for the Elderly, activities of daily living such as bathing and dressing, deteriorated significantly between baseline admission to an acute care hospital and discharge. Forty-one percent of the older individuals were reported to have a continued decline in functional status 3 months after hospitalization; they were unable to recover from hospital-acquired disabilities and had developed additional ones since discharge (Riedinger and Robbins, 1998). The functional decline was attributed to the illness, medical and surgical treatment, and adverse events associated with hospitalization, such as drug events and bed rest or reduced mobility (Sager et al., 1996). Older patients often enter the hospital in an undernourished state which is then exacerbated by changes in diet or inadequate intake as the patient
undergoes various diagnostic and therapeutic procedures (Palmer et al., 1998; Riedinger and Robbins, 1998).
FUTURE AREAS FOR RESEARCH
Although the optimal method for identification of undernutrition in hospitalized older people has not been determined, the methods currently employed lack validity and are cumbersome and resource intensive. Additional research needs to be conducted in this area.
Acute care hospitalizations are associated with a decline in functionality of older people. Poor nutritional status at admission and inadequate nutrient intake during hospitalization may contribute to this decline. Evidence in the literature indicates that identification and intervention for nutrition problems in older patients may be inadequate. Education in the hospital setting is often limited to teaching patients “survival skills” and referring them to the ambulatory setting for additional counseling. However, lack of reimbursement in ambulatory settings limits the resources available to people once they have been discharged from the hospital. Hospital dietitians often provide guidance to home health agencies and home infusion companies who may not have adequate staffing of qualified nutrition professionals.
Current standards for screening and assessing nutritional status in hospitalized Medicare beneficiaries need to be reassessed and revised. JCAHO requirements for hospital-based nutrition screening, assessment, intervention, and surveillance warrant comprehensive review. In particular, the methods adopted by many institutions to meet 24-hour screening requirements lack validity in the identification of undernourished patients, often depend upon information that is unreliable or unavailable, and are cumbersome and resource intensive.
Changes in reimbursement have to be made in the ambulatory and home-health settings to provide additional nutrition resources for individuals once they have been discharged from the hospital (see chapters 11 and 12).
Burns JT, Jensen GL. 1995. Malnutrition among geriatric patients admitted to medical and surgical services in a tertiary care hospital: Frequency, recognition, and associated disposition and reimbursement outcomes. Nutrition 11:245–249.
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Mowé M, Bøhmer T. 1991. The prevalence of undiagnosed protein-calorie undernutrition in a population of hospitalized elderly patients. J Am Geriatr Soc 39:1089–1092.
Palmer RM, Counsell S, Landefeld CS. 1998. Clinical intervention trials: The ACE unit. Clin Geriatr Med 14:831–849.
Riedinger JL, Robbins LJ. 1998. Prevention of iatrogenic illness: Adverse drug reactions and nosocomial infections in hospitalized older adults. Clin Geriatr Med 14:681–698.
Sager MA, Franke T, Inouye SK, Landefeld CS, Morgan TM, Rudberg MA, Siebens H, Winograd CH. 1996. Functional outcomes of acute medical illness and hospitalization in older persons. Arch Intern Med 156:645–652.
Sullivan DH, Moriarty MS, Chernoff R, Lipschitz DA. 1989. Patterns of care: An analysis of the quality of nutritional care routinely provided to elderly hospitalized veterans. J Parenter Enteral Nutr 13:249–254.
University of California at San Francisco Medical Center. 1998. Policies and Procedures for Nutrition Services. San Francisco, Calif.: University of California at San Francisco Medical Center.
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