Nutrition Services in Post-Acute, Long-Term Care and in Community-Based Programs
Previous chapters have described the strength of evidence supporting the relationship between nutritional status and morbidity, the provision of nutrition therapy for certain chronic diseases, and the nutrition services provided in ambulatory and acute care. This chapter addresses the nutrition services and food assistance programs needed in post-acute care, long-term care, and in community-based programs. The following programs are discussed:
Skilled nursing facilities (SNF) or hospital-based sub-acute units
Home health agencies (HHA)
Programs of All Inclusive Care for the Elderly (PACE)
Food assistance for elders in the community
Congregate feeding and home delivered meals.
During the last decade, the most rapid growth in Medicare costs has occurred in the area of post-acute care (Clark, 1998; Freedman, 1999; Jackson and Doty, 1998; Liu et al., 1999; NCHS, 1999). Many forces have fueled this growth, including the change to a capitated, prospective payment system (PPS) in acute care, legal actions by patients who were denied care in SNF and HHA programs, the shift to more aggressive reimbursement strategies by Medicare providers, and (to a smaller extent)
changing demographic, economic, and sociological characteristics of the elderly population in the United States.
Both federally funded programs and private payers are evaluating innovative ways to provide services across the continuum of care while attempting to use the least expensive and least intensive care that is appropriate (Cohen, 1998). Examples of such innovation include privately funded social health maintenance organizations (SHMOs) and programs of all inclusive care for the elderly (PACE). SHMOs are demonstration projects that combine community care services and short-term nursing home care with Medicare’s basic services. PACE is a new Medicare benefit; these programs accept the risk of providing all forms of care needed by nursing home-eligible clients for a capitated Medicare fee. When possible, these services are provided while recipients remain in their homes (HCFA, 1998).
Another trend is that traditional nursing homes are expanding “up” to include more complex services, such as subacute care, and “down” to provide less complex services, such as home care and assisted living (Evashwick et al., 1998; Lehrman and Shore, 1998). However, the largest number of elders are still being cared for by informal caregivers such as family and friends (AoA, 1998; Cutler and Sheiner, 1993).
Both federally and privately funded health insurance plans are moving from a fee-for-service system to a partially or fully capitated (PPS) in all areas of care, including skilled nursing, home care, and outpatient services.
Future trends will be affected by longer lifespans and the desire of older people to remain independent as long as possible (Economics and Statistics Administration, 1995; Hawes et al., 1999; Manard and Cameron, 1997). Increased longevity has significant cost implications. The precise impact on Medicare expenditures is unknown and depends on evolving Medicare policies and social practices, changing medical technology, and the prevalent morbidities within the older population.
As health care shifts from acute care to community and home-based programs, provided by a mix of health professionals, paraprofessionals, and informal caregivers, effective nutrition services and food assistance programs are likely to become especially important. However, the present system of including nutrition services in overall administrative costs, rather than direct reimbursement, creates a financial disincentive to address the nutrition problems of older people. If nutritional status and food security diminish as a result of this inattention, the older person may develop subsequent illnesses that require more acute and expensive care
(Cornoni-Huntley et al., 1991; Frisoni et al., 1995; Gray-Donald, 1995; Mowé et al., 1994).
SKILLED NURSING FACILITIES AND NURSING HOMES
Skilled nursing facilities (SNF) are defined as health facilities that provide the following basic services: 24-hour inpatient care that includes medical, nursing, dietary, and pharmaceutical services, and an activity program. Other services such as rehabilitation and social work, not regularly needed by all residents, may be contracted (CFR, 1998). Many SNFs provide subacute care or have special units for dementia, rehabilitation, and human immunodeficiency virus/acquired immune deficiency syndrome. Residents in these special care units often have more complex nutrition needs. SNFs are usually part of a free-standing nursing home that provides long-term care for chronically ill, frail elders. There may also be SNF units in acute care facilities.
Medicare covers 100 days of SNF care per benefit period, but it must follow a 3-day hospital stay; days 21 through 100 are subject to a copayment by supplemental insurance or by the patient.1 Until 1998, SNFs received retrospective, cost-based reimbursement. Medicare began the transition to a PPS in 1998, and phase-in is expected to be completed by 2001. This system is based on encounter with the patient rather than on an episode, such as an admission for a specific diagnosis as in acute care facilities. In the PPS system, SNFs are paid an all-inclusive, predetermined, federal per diem rate regardless of actual costs of patient care. The rate is adjusted for the SNF’s case mix, based on resource use; the case mix components that affect costs are nursing and rehabilitation use. Billing for Part A along with the services that were covered under Medicare Part B in the past, such as contracted services with rehabilitation personnel, are consolidated. Other Part B services, such as physicians’ care, are still billed separately (Congressional Research Service, 1998; House Ways and Means Committee, 1996).
When a person no longer needs skilled nursing care, she or he may continue to reside in a nursing home for chronic care. In this case, Medicare payments for Part B-covered services (except physicians’ services) are made directly to the nursing facility, whether the services are pro-
vided by an employee of the nursing home or by an outside person who contracts with the nursing home. The rest of the costs of nursing care are borne by the patient, supplemental insurance, or Medicaid.
In both the old retrospective payment system and the new PPS system, nutrition services are considered part of the per diem rate and not reimbursed directly, as are rehabilitation services. Use of a dietitian is mandated by both licensing and accreditation standards (CFR, 1998; JCAHO, 1998a). However, as SNFs face more financial risk with the new PPS, there is increased potential for cost containment of basic services (Grimaldi, 1999).
Need for Nutrition Services and the Role of the Nutrition Professional
Even though SNFs and nursing homes are required to have a dietitian, the amount of time dietitians actually spend in these facilities varies. The time budgeted for a dietitian in a facility often depends on state requirements, the severity of patients’ conditions, nutrition interventions needed, results of previous licensing and accrediting surveys, and economic factors within the SNF and the community. State requirements for licensing of SNFs include the minimum level of dietitian coverage; although it varies, 8 hours per month is not uncommon. Little can be accomplished when nutrition problems are identified at this level of service. When a dietitian works part-time, there must be a full-time person in the facility to provide daily oversight of the food and nutrition services. This is usually a certified dietary manager.
Identifying Nutrition Problems
In 1986, the Institute of Medicine (IOM) Study on Nursing Home Regulation (IOM, 1986) recommended the use of a uniform, comprehensive and outcome-oriented assessment procedure for nursing home residents. The Omnibus Budget Reconciliation Act (OBRA) of 1987 enacted many of the IOM recommendations, including the requirement that all Medicare and Medicaid-certified nursing facilities implement the recommended assessment instrument. This is now part of the statutory and regulatory requirements for long-term care facilities (CFR, 1998; USC, 1998).
The Resident Assessment Instrument (RAI) was developed and validated at the Hebrew Rehabilitation Center for the Aged in Boston under a contract with the Health Care Financing Administration (HCFA) (Hawes et al., 1995; Morris et al., 1990) and updated to its present form, version 2.0, in 1995 (Allen, 1997). The RAI includes standardized procedures and forms for collecting data (Minimum Data Set [MDS]). Certain conditions
trigger further assessment, based on standard Resident Assessment Protocols (RAP). The final step is to develop a comprehensive resident care plan based on the MDS and RAP information.
The following aspects of nutritional care are evaluated in the MDS: oral problems, height and weight, weight change, nutrition problems (altered taste, hunger, uneaten meals), approaches to nutritional care (nutrition support, mechanically altered food, therapeutic diets), and food intake. In addition, other aspects of care that affect or are affected by nutrition are also evaluated: dental care, skin condition, and hydration. There are specific RAPs for nutritional status, feeding tubes, dehydration/fluid maintenance, dental care, and pressure ulcers that provide guidelines for the clinician’s assessment, treatment, and evaluation.
Existing research provides mixed reports on the success of the RAI. Some reports indicate improvement in the identification of and intervention for nutrition problems in the nursing home (Blaum et al., 1997; Rantz et al., 1999), whereas others report continued problems. In 1998, the Senate heard testimony regarding the persistence of nutrition problems in California nursing homes, despite the federal regulations requiring assessment, intervention, and monitoring (GAO, 1998). Because of the complexity of the RAI screening and planning process, documentation and the actual care of nursing home residents may not be linked (Rantz et al., 1999). In one descriptive observational study (Kayser-Jones et al., 1997), dietary intake as recorded by the certified nursing assistant (CNA) was significantly different from actual food consumption; in some cases the CNA was observed recording food intake data before the resident actually ate a meal or consistently recording an intake of more than 75 percent, irrespective of the resident’s actual consumption (less than 75 percent food intake is the trigger on the RAP for further evaluation for poor food intake).
Nutrition Problems in Nursing Homes
The relationship between nutrient intake and pressure sores illustrates the complexity of nutrition research in the older nursing home resident. Advanced age, chronic disease, multiple and varying levels of treatment, poor nutrient intake, immobility, and cognitive impairment all contribute to unclear conclusions in studies. In all nutrition studies, three aspects have to be addressed: (1) the contribution of undernutrition to morbidity and mortality, (2) how the disease or condition alters nutrient and energy needs, and (3) the role of nutrition intervention in reversing the disease or condition.
Does Undernutrition Contribute to the Development of Pressure Sores? Undernutrition is a frequently cited risk factor for the development, presence, and inadequate healing of pressure sores (Finucane, 1995). The prevalence of pressure sores among frail, bedridden patients may be as high as 20 percent (Barbenel et al., 1977), and treatment of these wounds can prolong hospital stay and consume considerable health care resources.
Data linking recognized measures of nutritional status with pressure sores in the acute, rehabilitation, or chronic care settings are limited. Observational studies with older people have yielded mixed findings. Poor nutrient intake has been related to the development of pressure sores (Bergstrom and Braden, 1992; Berlowitz and Wilking, 1989) or to their failure to respond to treatment (Allman et al., 1986; Gorse and Messner, 1987). However, an association with nutrient intake has not been consistently observed. Sullivan and Walls (1994) studied 350 geriatric rehabilitation patients prospectively. Twenty-six percent developed complications, including 42 pressure sores of Grade II or higher. There was no association between average daily nutrient intake and these complications.
Are Nutrient Needs Altered in Those with Pressure Ulcers? Breslow and coworkers (1991) described observations of 26 nursing home residents who received tube feedings. Most of the patients were immobile, incontinent, and mentally impaired. The needs and nutrient intake of 14 people who had pressure sores were compared to those who did not. Those with pressure sores were slightly older and had lower body mass indices than those who did not have sores. The investigators concluded that those with pressure sores had higher nutrient requirements than those who did not, based on the energy and protein needed to gain weight or restore serum proteins to normal levels. They also concluded that energy and nutrient needs were being underestimated in patients who had pressure sores.
Does Nutrition Intervention Play a Part in Healing Pressure Sores? There have been few prospective, controlled trials studying the role of nutrition intervention as an independent variable in the prevention or treatment of pressure sores. Myers and colleagues (1990) randomized patients with pressure sores either to usual care or to special nutrition support consisting of nutrition assessment and prescribed intervention. Even though subjects in the intervention arm were excluded from analysis if they did not receive prescribed energy intake and supplements, the intervention was ineffective in improving pressure sore status. Breslow and coworkers
(1993) studied the effect of dietary protein on the healing of pressure sores in malnourished patients. They found that pressure sores healed in those patients receiving a high protein intake (24 percent of total kilocalories) and adequate kilocalories to prevent weight loss. However, their results were confounded by small sample size, nonrandom assignment to groups, and other forms of treatment. A more recent trial by Hartgrink and colleagues (1998) contrasted pressure sore outcomes in 129 hip fracture patients randomized to receive either nocturnal tube feedings or no supplemental feedings. They excluded patients with pressure sores of Grade II or higher on admission. In the treatment group, only 40 percent of subjects tolerated placement of a nasogastric feeding tube for more than 1 week and 26 percent of the subjects for more than 2 weeks. The subjects randomized to the tube feeding group had a greater overall energy and protein intake, but no significant differences in serum albumin levels or the development and severity of pressure sores at 1 and 2 weeks were found. There was also no impact on the development or severity of pressure sores in the subset of subjects who actually received the tube feeding.
There are multiple causes of pressure sores, but poor nutritional status is probably a contributing factor. Energy and nutrient requirements seem to be increased in patients with pressure sores. Although it follows that nutrition intervention should have an effect on reversing pressure sores, confounding variables such as an inadequate understanding of the nutrient and energy needs in this condition, problems with study design, and inadequate research methods do not permit this conclusion. More research is needed to develop better methods for assessing nutrition status, as well as the relationship between nutrient intake and the development and reversal of pressure sores.
Inadequate fluid intake among nursing home residents has been reported in a number of studies and can lead to increased morbidity and hospitalizations (Chidester and Spangler, 1997; Gaspar, 1999; Kayser-Jones et al., 1999). Ensuring adequate water intake is particularly important because elders often have a decreased sense of thirst. They may also be dependent on caregivers for help in consuming liquids and food. A nursing protocol has recently been published that helps identify and address dehydration (Mentes and The Iowa Veterans Affairs Nursing Research Consortium, 1998). The American Dietetic Association has also developed a nutrition protocol that describes assessment and intervention strategies (Vogelzang, 1999).
A substantial number of nursing home residents have problems with dysphagia, which if not addressed may result in aspiration pneumonia and undernutrition. This condition illustrates the interdependence of the nutrition professional and speech pathologists, occupational therapists, nurses, and physicians in providing appropriate nutrition care to the nursing home resident. In one study (Kayser-Jones and Pengilly, 1999), a bedside swallowing evaluation was done: 45 out of 82 nursing home residents were found to have some degree of dysphagia, yet only 10 of these 45 residents had been referred to a speech pathologist or occupational therapist for a previous evaluation. Once dysphagia is recognized, aspects of feeding such as positioning the resident during meals, consistency of foods, size of bites, and feeding techniques can be altered. Groher and McKaig (1995) studied 740 nursing home residents. They found that 36 percent were on mechanically altered diets. Following an evaluation for dysphagia, it was determined that almost all of these residents could tolerate diets at a higher level than they were receiving. For example, the majority of residents receiving tube feedings or pureed foods could tolerate mechanically soft diets.
Chapter 4 describes commonly used markers and syndromes of undernutrition. Some of the important issues from that chapter are repeated here. In a review of studies evaluating nutritional intake in chronically institutionalized older people, 5 to 18 percent of nursing home residents had energy intakes below need (Rudman et al., 1989). Twenty-six percent met the MDS criterion for poor oral intake. A more recent study reported that 9 percent of nursing home residents met the MDS criterion for hunger (Blaum et al., 1997).
Weight loss has been shown to predict mortality in older people (French et al., 1999; Losonczy et al., 1995; Wallace et al., 1995; White et al., 1998). However, it is a relatively insensitive predictor in nursing homes because food intake may decrease several weeks before routine weight measurements (often monthly) are taken. Low serum albumin levels have been reported to predict mortality in residents of long-term care facilities (Abbasi and Rudman, 1993; Henderson et al., 1992; Rudman et al., 1987; Woo et al., 1989). Using the first National Health and Nutrition Examination Survey (NHANES) data, 14 risk factors were identified that were related to a low serum albumin (Reuben et al., 1997). People with six or more of these factors had an odds ratio of 6.44 of having a serum albumin level less than 3.8 g/dL. Among these factors were being 65 or more years old, having conditions that interfered with eating, being edentu-
lous or having poor dentition, having little or no exercise, and having a low sodium diet prescription. All of these factors are common in nursing home residents.
Nutrition Interventions in Nursing Homes
Use of Modified Diets
Diets that are overly restricted in sodium and fat or do not contain familiar foods may result in a decrease in food intake and weight loss (Buckler et al., 1994). The American Dietetic Association has taken the position that there should be careful assessment of patient needs prior to using modified diets (ADA, 1998b). This assessment should include medical, psychosocial, and quality-of-life issues. Menus and dining experiences should accommodate food preferences, preserve residents’ dignity, and emphasize their joy in eating (ADA, 1998a). A liberalized diet, with only moderate changes in sodium, fat, and sugar, has been shown to meet the majority of nursing home residents’ needs (Aldrich and Massey, 1999).
Feeding Nursing Home Residents
Many nursing home residents have physical or cognitive impairments that affect their ability to feed themselves. Observational studies, which include both qualitative and quantitative methods, describe the effects of feeding-related care on the intake of nursing home residents (Porter et al., 1999; Steele et al., 1997). When family and nursing home staff demonstrated positive, caring feeding techniques, residents’ food intake often improved or did not worsen. Other residents observed, however, failed to receive the needed help with feeding. In some cases, cognitively impaired residents were fed forcibly in violation of best-practice care. Studies have also reported inadequate nutrient intake (Porter et al., 1999) and inappropriate vitamin and mineral supplementation (Porter et al., 1999; Rudman et al., 1995) in nursing home residents.
Use of Liquid Dietary Supplements
Liquid dietary supplements are frequently prescribed when food intake is poor. The role of these supplements in the nutritional care of nursing home residents is not well understood. Retrospective studies, as well as prospective controlled trials, have shown that liquid supplements resulted in improvements in nutrient intake, weight, and some serum markers (Elmståhl and Steen, 1987; Johnson et al., 1993; Turic et al., 1998). However, other descriptive studies which have included observation of
the actual feeding practices in nursing homes reported that supplements were sometimes ordered inappropriately and, when ordered, were not consumed by the resident all of the time. Frail residents did not always receive help opening containers, other patients and staff members consumed supplements, or supplements were consumed in place of meals (Kayser-Jones et al., 1998; Porter et al., 1999). It remains unclear as to what role liquid supplements play in the nutritional care of the long-term care resident.
Use of Tube Feedings
The 1987 OBRA regulations and guidelines state that a comprehensive assessment of a patient’s ability to eat must be done before tube feedings are used. The facility must also document that it is unable to maintain or improve the resident’s nutrition status through oral intake. The regulations also recognize the patient’s autonomy to refuse tube feeding (Thomas et al., 1998).
Tube feedings have been shown to benefit some nursing home residents (Morley and Silver, 1995). There was shortened rehabilitation time and/or decreased morbidity and mortality in residents who received supplementary tube feedings following femoral neck fractures and chronic pulmonary disease (Bastow et al., 1983; Delmi et al., 1990; Whittaker et al., 1990).
Although short-term use of tube feeding that addresses specific reversible feeding problems may be appropriate, it is questionable if long-term tube feeding in the old, severely demented resident is appropriate (Mitchell et al., 1997, 1998; Peck et al., 1990). It is important that residents, their families, and a multi-disciplinary team, including the nutrition professional, consider the outcome and consequences prior to initiation of tube feedings.
Reasons for Problems
Many factors affect food intake in the elderly nursing home resident. Changes in taste and smell, the effects of chronic disease and multiple medications, depression, and a decreased basal metabolic rate and activity all may cause a decreased appetite and desire to eat (Abbasi and Rudman, 1994). Some studies have shown that investigation into causes of poor food intake is disorganized. Even when nurses and dietitians alerted physicians to feeding and weight problems, the physician seldom investigated the causes, such as swallowing disorders, poor oral health, anorexia, or depression (Johnson et al., 1993; Kayser-Jones et al., 1997, 1998).
Elders may also experience problems related to chewing and swallowing, manual dexterity, and altered cognition that make them dependent on others for feeding. However, staffing levels and skills may affect the quality of feeding assistance received. There are often too few CNAs to help with feeding, especially at the evening meal. There are also not enough registered nurses and dietitians to oversee and train CNAs about appropriate feeding techniques and to ensure the maintenance of a pleasant dining environment (Kayser-Jones and Schell, 1997; Porter et al., 1999).
Licensing agencies need to develop more effective oversight with respect to feeding, supervision of staff, and other nutrition-related issues. In response to Senate hearings on California nursing homes (GAO, 1998), HCFA has drafted investigative protocols to better evaluate the outcome of care related to pressure sores, weight loss, hydration, and dining and food service, including the way CNAs and others are trained and supervised in feeding nursing home residents. The American Dietetic Association has also responded by developing risk assessment tools (ADA, 1998a; Vogelzang, 1999).
HOME HEALTH AGENCIES
HHAs are defined as private or public organizations that provide or arrange for the provision of skilled nursing services to people who are unable to leave their temporary or permanent place of residence. According to the National Association of Home Care, there are more than 20,000 providers of home care services to some 8 million people who require services for acute illness, long-term health conditions, permanent disability, or terminal illness. Medicare certifies approximately half of the home care programs (NAHC, 1999).
Unlike skilled nursing facilities, Medicare does not require a 3-day acute care stay prior to coverage of home health care services. HHAs are required to provide preventive treatment and rehabilitative services for the specific problems related to the physician’s referral. The treatment provided through HHAs must be consistent with standards of practice for the discipline involved and the person providing the care must be registered, licensed, or certified to provide the service (CFR, 1998).
Medicare beneficiaries pay nothing out-of-pocket for covered home health visits. Medicare currently reimburses HHAs on an interim payment system (IPS), although a PPS is currently under development. A 4-year transition to the PPS system of reimbursement began in late 1999. The appropriate unit of service and the number, type, and duration of
visits will be determined. Per-beneficiary limits will be calculated from cost-reporting periods ending in fiscal year 1994 and updated by home health market-based surveys (Berke, 1998; Caring, 1998; St. Pierre, 1999).
The current IPS system is a retrospective cost-based system. Per-visit cost limits are determined separately for each type of covered home health service, such as skilled nursing, rehabilitation services, social services, and home health aide services. The services of a nutrition professional are not covered.
Medicare currently pays for some aspects of home parenteral and enteral nutrition. In order to obtain Medicare reimbursement, the patient must be unable to meet nutritional requirements using an oral diet for more than 90 days. For parenteral nutrition support, the patient must have a nonfunctioning gastrointestinal (GI) tract due to interruption in continuity or impairment in absorptive capacity. For enteral nutrition support, there must be a disruption in the ability to ingest oral foods or impairment of the upper GI tract, which interrupts the transport of food to the small intestine (Giglione, 1988; Goff, 1998).
Coverage regulations for enteral and parenteral nutrition are under the Prosthetic Devices section of Medicare. This section, which covers such things as pacemakers, braces, and artificial limbs, also defines reimbursement for home nutrition support. The assumption in placing nutrition support in this section is that it is a prosthetic device for a dysfunctional GI tract. For this reason, Medicare does not cover nutrition support if it is provided to a patient who has a functioning GI tract (e.g., intradialytic nutrition support in end-stage renal disease). Nutrition support is also not covered for the patients with significant nutritional needs, but who will be able to eat within the 90-day time period. Medicare covers solutions and equipment, but not the consultation by a nutrition professional needed for the assessment of energy and nutrient needs, implementation, and monitoring of the effects treatment on nutritional status (Goff, 1998).
Need for Nutrition Services in Home Health Agencies
Health statistics show that more than 2.4 million Medicare beneficiaries received home care services in 1996. Half had chronic diseases that are normally treated with diet (NCHS, 1999). Others report that patients who receive home care services have a high prevalence of malnutrition and need some type of nutrition services (Rebovich et al., 1990).
Malnutrition can be a risk for early nonelective hospital readmission. In one study of 92 nutritionally compromised Medicare beneficiaries, those with weight loss and failure of serum albumin levels to improve during the first month after hospitalization were at higher risk of hospital
readmission than those who maintained or increased their postdischarge weight or improved their serum albumin levels (Friedmann et al., 1997).
Some evidence indicates that nutrition intervention can reduce the prevalence of undernutrition in home care populations. In a study of 417 free-living rural elders, 68 were found on screening to have undernutrition. Six months after nutrition intervention was provided as part of a comprehensive medical and social program, 38 percent were no longer at nutrition risk (Klein et al., 1997).
Many home health patients require nutrition counseling for a modified diet. A survey in the Chicago area found that more than 35 percent of patients 65 years or older were admitted to HHAs on a modified diet. After review of medical records by a dietitian, an additional 10 to 15 percent were found to need modified diets or to have their diet prescription changed (Gaffney and Singer, 1985).
Overly restricted diets may lead to low dietary intake and weight loss in older people (ADA, 1998b). For this reason it is important that a nutrition professional evaluate actual intake and make recommendations to patients and their families that address only the most important medical issues. These recommendations must be sensitive to customary food patterns, meet nutritional needs, and prevent a decrease in food intake.
Patients in the care of HHAs also require monitoring of enteral and parenteral nutrition. In 1992, it was estimated that as many as 40,000 Medicare patients received parenteral nutrition and 152,000 received enteral nutrition at home (Howard et al., 1995). Thus nutritional care of Medicare patients at home to appropriately monitor and evaluate the nutritional needs are significant.
The Nutrition Professional in Home Health Agencies
There is no mention of a nutrition professional in the Code of Federal Regulations for HHAs, either in the sections related to personnel or to conditions of participation (CFR, 1998). The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards for HHAs require that each patient be evaluated for nutrition risk, and if nutrition problems are related to the reason for HHA referral, the program must provide the services (JCAHO, 1998b). However, most examples given in the JCAHO standards imply that health care providers other than a nutrition professional would provide these services. This is most likely related to the omission of the nutrition professional from HCFA regulations.
A small proportion of nutrition professionals work in home health settings. The most recent survey of work sites for dietitians (Bryk and Soto, 1999) indicates that only 399 (1.4 percent of the respondents) listed their primary employment in home health care. This small number be-
comes even more modest given a report that dietitians in the home care industry work a limited number of hours (Arensberg and Schiller, 1996). This potential work force shortage is greater for dietitians credentialed as entry-level nutrition support practitioners. Responses from 1,237 certified nutrition support dietitians revealed that 53 percent spent no time in home health, and only 61 practitioners (approximately 5 percent) were employed full-time in HHAs (Professional Testing Corporation, 1997).
The practice of the dietitian in home care has been described (Arensberg and Schiller, 1996). Dietitians who worked in home care were experienced, but new to the home care environment. They worked on average less than 10 hours per week, and typically for organizations that served between 100 and 500 patients. Most dietitians made no home visits, but provided consultation to other professionals. They also provided services to the patient by telephone. When home visits were made by the dietitian, most were for patients with diabetes and cancer. Even though a substantial number of patients enrolled in home health care were receiving nutrition support, dietitians reported making at most one visit per week to these patients.
The above study found that the greatest obstacle to providing or expanding nutrition services in home care was “lack of reimbursement.” The following are areas in which dietitians did not provide services but felt capable of doing so: monitoring nutrition support, conducting home visits, providing counseling for nutrition therapy, and assessing nutrition risk. In most cases, there was no separate billing to third-party payers for nutrition services. When third-party billing was initiated, only 28 percent received reimbursement and nearly half of charges submitted received 25 percent or less of the amount billed.
In another descriptive survey (Schiller et al., 1998), administrators of HHAs recognized that patients had a high prevalence of nutrition problems and that nutrition therapy was an important form of treatment. More than half of the administrators surveyed did not have, but would like, a dietitian as a nutrition consultant for nutrition assessments, the development of nutrition care plans, nutrition therapy for specific conditions, and staff training. While in most cases a nurse provided nutrition services (Schiller et al., 1998), home care nurses demonstrated a deficit in nutrition knowledge, even though they felt it was an important part of their practice (Caie-Lawrence et al., 1995). HHA administrators stated that the main deterrent to having a dietitian provide nutrition services was lack of reimbursement by third-party payers and lack of physician request (Schiller et al., 1998).
Identification of Patients Who Would Benefit from Nutrition Services
It was expected that home health services would reduce overall health care costs by decreasing the need for acute care admissions and preventing other costly interventions. However, this expectation has not been fully realized. Although HHAs provide significant benefits to acutely ill patients, these services are often used as complements of, not substitutions for, other forms of health care. There is limited evidence that home health services significantly reduce overall health care costs or reduce readmission to hospitals or nursing homes. However, it has been shown that readmissions are less likely if careful identification and specific interventions are focused on the problems that most often precipitate readmissions (Weissert et al., 1997).
For Medicare to provide reimbursement to nutrition professionals in home care settings, such services must be carefully targeted to ensure both cost-effectiveness and adequate coverage for individuals with the greatest need. The nutrition professional has to educate other health care professionals working in home health about how to give appropriate nutrition education and how to evaluate the effectiveness of nutrition interventions. Nutrition professionals should, however, provide the most complex nutrition care themselves.
One tool that may prove helpful in identifying patients with complex nutrition problems is the Outcomes Assessment and Information Set (OASIS) (Sperling and Humphrey, 1999). Home health agencies began using this in July 1999 for Medicare patients needing skilled care. OASIS includes several questions that attempt to assess nutrition status, food security, and the patient’s implementation of any prescribed dietary modifications. When the patient is experiencing problems, a referral to the dietitian is recommended. At the time of this report however, to the committee’s knowledge there have been no published studies validating the effectiveness of the OASIS system in identifying and addressing nutrition problems.
Who Should Receive the Services of a Nutrition Professional in the Home Health Setting?
Patients seen in the home care setting are often the most frail, undernourished group of elders in the health care system and, because they are homebound, have no ability to use nutrition services that may be available in other ambulatory settings. Box 12.1 summarizes conditions that were identified as requiring services provided by a nutrition professional. In certain instances, these services may be delivered telephonically; however, the effectiveness may depend on the socioeconomic, cultural, and educational characteristics of patients (Short and Saindon, 1998).
Coverage for Home or Ambulatory Enteral and Parenteral Nutrition Support Services
There is an inequity in Medicare coverage for enteral and parenteral nutrition in the home care or ambulatory setting compared to the hospital or skilled nursing setting. Although a physician, nurse, and pharmacist are typically involved in the care of the home or ambulatory patient receiving nutrition support, the nutrition professional is often absent. Medicare beneficiaries who remain on nutrition support following hospitalization or begin it in the ambulatory or home care setting are often at high risk and could benefit from the care of a nutrition professional. The nutrition professional is also knowledgeable about how and when to transition patients to other, often less costly forms of nutrition support.
In addition to the lack of consultation by a nutrition professional, many beneficiaries need home enteral or parenteral interventions that are not reimbursed by Medicare. These people may require tube feedings or parenteral interventions that are projected to last for less than 90 days; they may also be able to take some food by mouth, but not enough to meet nutrient or energy needs. Few individuals are able to pay for this therapy on their own, and the lack of reimbursement for nutrition support puts these Medicare beneficiaries at nutritional risk. People who are unable to maintain adequate nutritional status are more likely to experience adverse outcomes, including premature readmission to the hospital, functional compromise, and mortality (Sullivan, 1992).
HHAs are required to have specialized nutrition expertise in order to be Medicare certified. However, HCFA regulations do not specifically include the nutrition professional in the list of mandated participants, and there is no provision to pay for these services, other than as administrative costs. It is unclear if the costs of the services of a nutrition professional are included in these administrative costs, particularly since HCFA did not list the nutrition professional in its regulations. This oversight encourages HHAs to use other untrained professionals or to budget so little for the nutrition professional that adequate services cannot be provided. Another way that HHAs have obtained nutrition services is to request help from dietitians in hospitals or in outpatient clinics, with or without remuneration. Yet staffing in hospitals is limited by the capitated PPS and in the outpatient setting because there is no reimbursement for nutrition services.
Program of All-Inclusive Care for the Elderly
The Program of All-Inclusive Care for the Elderly (PACE) is a new capitated benefit for Medicare beneficiaries authorized under the Balanced Budget Act of 1997 (HCFA, 1998). PACE is modeled from the On Lok Senior Health Services program in San Francisco. Participants continue to live in their homes while receiving a comprehensive array of services. The program is delivered through services provided at adult day health centers, homes, and inpatient facilities. Elders receive all services provided by Medicare and, at a minimum, 16 other services including nutrition counseling and meals. A multidisciplinary team, which includes a dietitian, provides or coordinates the provision of services.
PACE providers receive a monthly capitated Medicare rate. Providers receive an additional monthly premium from those participants who are not also receiving Medicaid. However, there is no deductible, coinsurance, or other cost sharing. The rate is a per capita cost calculated by HCFA for reimbursement of HMOs and adjusted for frailty factors. The rate is fixed for each contract year regardless of the changes in the participant’s health status (Congressional Research Service, 1998; HCFA, 1998).
Dietitians in the San Francisco-based PACE perform quarterly nutrition assessments for each client. They identify and provide for nutrition needs or coordinate provision through other community programs such as Title III–VI Elderly Nutrition Programs. Dietitians employed by PACE may be experiencing some of the same cost containment problems as
those in the acute care setting (Frances Chan, R.D., On Lok Senior Health Service, San Francisco, California, personal communication, 1999).
There is no common definition of Assisted Living (AL) facilities. In most cases they include some combination of housing and services in a residential environment. The programs strive to maximize individual functioning and autonomy (Gramann, 1999; Hawes et al., 1999). Some of these facilities are part of a larger complex that also provides other forms of care, such as adult day health, skilled nursing, or acute care.
A classic feature of AL is an attempt to let residents age-in-place. However, as residents age, the acuteness of their condition increases, increasing the cost as well as the potential for inappropriate or inadequate service, particularly in free-standing units (Manard and Cameron, 1997). There are no consistent national criteria for when residents should be transitioned to higher levels of care, such as skilled nursing facilities.
Most AL facilities are expensive and, therefore, serve middle- to upper-income elders. Demographic trends show the need for more affordable AL as the population ages and wants to remain independent longer.
Medicare does not reimburse for this form of elder care and most likely will not in the near future. However, residents of AL complexes receive Medicare benefits in other settings, such as acute care, ambulatory care, or home health care in AL facilities. Other federally funded programs, such as congregate feeding and home-delivered meals, may also be used by residents of some AL facilities.
Role of Nutrition Services
The focus of nutrition services for residents of AL complexes should be on disease prevention and maintenance of independence. Programs should emphasize good nutrition and activity. In this setting, elders are able to use nutrition services that may be available from local outpatient clinics, HHAs, or community-based education programs, when available.
Congregate Feeding or Home Meals
The Elderly Nutrition Program (ENP) is the largest community nutrition program provided for older people in the United States. Title III of the Older Americans Act provides services for the general elderly popula-
tion, and Title VI provides services to the Native American population. Both programs are administered by the Administration on Aging (AoA) of the Department of Health and Human Services. Both provide congregate feeding and home-delivered meals. The AoA provides 37 percent of the funding for congregate feeding and 23 percent for home-delivered meals. The rest of the cost is borne by state, local and private funds; donations; and volunteer time (AoA, 1998; Ponza et al., 1996).
Participants in the programs must be 60 years of age or older. Low-income groups are targeted. Many participants face moderate or high nutritional risk and have functional disabilities. Meals served must provide at least one-third of the relevant recommended dietary allowances (IOM, 1994), and the programs must employ dietitians.
In one study, the vast majority of individuals attending meal sites were at moderate (42 percent) or high risk (39 percent) of malnutrition as assessed by the Determine Your Nutritional Health Checklist (Reuben et al., 1996). In a recent comprehensive evaluation of Title III–VI programs (Ponza et al., 1996), participants had a significantly better nutrient intake than those not receiving services; programs were shown to target high-risk populations. In addition to meals, more than half of the participants received nutrition education, screening, and counseling. Programs have long waiting lists, and funding from the federal government may not be meeting the increased need for services (Ponza et al., 1996).
Most of the participants of Title III–VI programs also use Medicare-funded programs, such as acute care, ambulatory services, and home health agencies. Almost half of the referrals for Title III–VI programs come from hospitals or community-based organizations, indicating that ENPs function as part of a larger network of community systems, addressing the comprehensive long-term care needs of the elderly.
The majority of functionally disabled elders live in the community rather than in nursing homes. More than 7 million Americans provide informal care to approximately 4.2 million functionally disabled elders each week (AoA, 1998). More than 2 million elders need help with one or more activities such as eating, cooking, and shopping (AoA, 1998). Informal care plays a significant role in preventing or delaying the need for disabled elders to use more expensive services. Elders cared for by family and friends may also use congregate feeding or home-delivered meals. When needed, they could also use nutrition services in HHAs or ambulatory care if these were available and accessible.
FUTURE AREAS OF RESEARCH
Additional research is needed on the role of liquid dietary supplements and tube feedings in maintaining adequate nutritional status in the nursing home setting. There also should be continued investigation of nutritional assessment techniques and the relationship between nutrient intake and conditions common to nursing home residents (e.g., pressure sores).
More work is needed on the development and validation of tools that would help identify people at nutritional risk who are being seen in home health agencies. Continued research on how best to communicate with homebound clients in both urban and rural areas is needed. Specific attention should be paid to the potential applications of teleconferencing, particularly when used to provide information about food and nutrition to the client who has communication problems (hearing, speech, other languages, etc.).
There has been a rapid growth in the use of skilled nursing, home health, and long-term care services over the last decade. Patients receiving these services often are undernourished due to chronic disease or its treatment. It is important that there are viable nutrition services and food assistance programs in these settings. As Medicare reimbursement moves to a capitated prospective payment system, it is imperative that nutrition services are not compromised.
Much of what is known about existing services in nursing homes comes from qualitative and quantitative observational studies. It is unclear if the OBRA-mandated screening and intervention tools have improved clinical care. Specifically, substantial problems with aspects of nutrition care persist, such as the quality of the food service, feeding techniques used for impaired patients, and the use of supplements and tube feedings. Physicians do not always carefully evaluate the causes of nutrition problems prior to prescribing liquid dietary supplements or tube feedings.
Even though HHAs are required to have specialized nutrition expertise to be Medicare certified, there is no specific requirement for a nutrition professional in HCFA regulations or JCAHO standards. Staffing for nutrition professionals is often inadequate and HHAs commonly turn to dietitians in hospitals for help, with or without remuneration. Descriptive studies have concluded that there is an inadequate work force of nutrition
professionals in the home care setting due in part to insufficient reimbursement for these services. Research in HHAs indicates that it is important to carefully identify patients who need services and that services should aim to prevent hospital admissions, when possible, and to restore health and function.
The new OASIS system for assessing patient needs has not been validated for its ability to identify nutrition problems. If this system proves cumbersome or insensitive, another screening system must be developed and validated. To be most cost-effective, care by the nutrition professional should be provided to those who need the most complex services. Follow-up care should be supervised by the nutrition professional, but could be provided by others going into the home. Use of the telephone and other communications technologies should be investigated, particularly when the patient and provider do not speak a common language or the patient has hearing or speech disabilities. It is unclear from the literature when and for whom this technology is most useful. Reimbursement for parenteral and enteral nutrition support in the home care setting and ambulatory setting is inadequate in the following areas:
coverage for the nutrition professional to assess and monitor tolerance to nutrition support or to transition patients to less costly forms of nutrition intervention; and
coverage for patients who need nutrition support for less than 90 days in order to meet energy and nutrient needs, whether or not they are eating (patients who are unable to meet nutrient and energy needs with food alone).
Other forms of care, such as PACE, AL, and informal caregiving, depend on the complementary services of other government-funded community programs, such as congregate feeding and home-delivered meals. Recent studies indicate that these programs are an effective, integral part of the government’s services to the elderly, but that funding may not match need.
Older individuals in PACE, in assisted living facilities, or cared for by family and friends also need access to viable nutrition services in ambulatory care settings or through home care services. If these services are not available, there is an increased likelihood that nutrition-related disorders will not be addressed.
The lack of good food assistance and nutrition programs may lead to increased disability and to the use of more expensive services.
Skilled Nursing Facilities and Nursing Homes
As Medicare shifts to a prospective payment system of reimbursement for skilled nursing, nutrition services must not be compromised and must be improved beyond current practice. Internal quality improvement systems and accrediting and licensing agencies must monitor for adequate feeding techniques, the quality of food service, and the satisfaction of patients and their families with these services. Endeavors aimed at new feeding techniques, which would use staff time more efficiently, must be developed and tested. Staffing must be adequate, and staff members should be well trained and professionally supervised so that nursing home residents are fed sensitively and appropriately.
Prior to initiating supplements and nutrition support, there should be documentation by physicians that treatable causes of weight loss and poor food intake have been considered and evaluated, if appropriate.
Home Health Agencies
Many homebound elders need nutrition services to maintain health and functional status. Patients with complex nutrition problems require the services of a nutrition professional. Others could obtain needed services from another health care professional visiting the home, with oversight by the nutrition professional. A well-designed screening system is necessary to identify those patients who most need the more complex nutrition services. The new OASIS system must be validated to ensure that it identifies patients with the greatest need. If this system proves inadequate, another system should be developed.
Nutrition services would be most efficacious for patients who require counseling about altered energy and nutrient needs or dietary modifications. Services have to be designed so they address, at a minimum, the problems that would most likely cause hospital readmissions.
The efficacy of nutrition intervention in chronic disease has been covered in previous chapters. The committee has identified the following conditions as being most important for nutrition intervention in the HHA setting: newly diagnosed diabetes; poorly controlled diabetes when caused by other conditions that require skilled care; heart failure; problems following cancer treatment (surgery, radiation, chemotherapy) that result in food aversions, consistency modifications, or increased nutrient or energy needs; dysphagia; undernutrition or weight loss in the absence of remedial medical or psychiatric disorders; pre-end-stage renal failure
when dietary modification is complex; severe osteoporosis or hip fracture; and wound healing problems.
When there is evidence that nutrition services should be provided, they must be required and supported financially. Present HCFA regulations do not specifically describe a role for the nutrition professional. This needs to be clarified. Anecdotal evidence indicates that nutrition professionals in other settings (e.g., hospitals) help provide services to HHAs, with or without remuneration. Those who are planning for PPS reimbursement in HHAs should consider that both staffing and compensation for nutrition services are inadequate in the present system.
Nutrition Support in the Home Care and Ambulatory Setting
It is recommended that reimbursement be made available to the nutrition professional with specialized training in nutrition support. This person would provide consultation and follow-up as requested by a physician. Consultation would include the assessment of nutritional needs and recommendations for appropriate intervention(s) and monitoring for feeding tolerance and complications. It is specifically intended that the participating nutrition professional work with the referring physician to discontinue inappropriate interventions and facilitate the transition to oral or other feeding modalities when indicated. There is the potential for appreciable cost offsets by encouraging appropriate interventions. Inappropriate use of costly feeding interventions and complications related to their misapplication may otherwise result.
A major gap in coverage exists for undernourished patients who need home nutrition support for less than 90 days. It is recommended that this 90-day requirement for reimbursement be reevaluated to consider the option of reimbursement for shorter-term interventions and that the intervention include appropriate consultation and approval by the nutrition professional.
It is important that standards and expected outcomes for essential nutrition services are well defined so that if capitated programs face potential financial risk, these services are not jeopardized.
Medicare-funded programs and food assistance programs often serve the same clients; their services are complementary, not duplicative. Patients seen in HHAs or PACE, or cared for in assisted living facilities or by family and friends, may need community programs such as Title III– VI Elderly Nutrition Programs to provide food assistance and additional nutrition services. Adequate funding for food assistance programs is an
essential part of the government’s overall nutrition services for elders and may not be keeping up with need.
It is essential that comprehensive nutrition services are provided through HHAs, outpatient clinics, and other community programs so that people living in their homes or in assisted living facilities can maintain good health and functionality as long as possible. Essential nutrition services should be provided in a way that respects the role of the informal caregiver and the independence and functionality of the patient.
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