Screening homecare patients and giving them oral nutrition supplements can reduce rehospitalization and save costs, according to a recent study published in the Journal of Parenteral and Enteral Nutrition. Those are things that home health agencies can do more proactively and rigorously, said Katie Riley, vice president and chief nursing officer for the post-acute division of AdvocateAurora Health (AHC) and the study’s lead author.
The study, published in May, was a follow-up to one completed earlier in hospital settings; it tracked patients in two branches of AdvocateAurora’s Illinois-based home health agency (HHA).
“We realized that any time those patients are discharged to home, there are a certain number that are discharged to homecare, so we wanted to follow them for a longer period of time,” said Riley.
They put a portion of the study’s participants on a nutrition-focused quality improvement program, prescribing them oral supplements, and then followed them 90 days after their treatment. They found that rehospitalization rates were reduced by more than 20% for those on the program.
Here are four takeaways from the study, which ran in 2016 and 2017:
1. More patients may be malnourished than you think.
As many as half of all patients entering the hospital are malnourished—and that is even more likely for older adults, according to previous studies. And a 2013 study found that around a quarter of U.S. adults receiving in-home care were at moderate to high risk of poor nutrition.
“When you think of malnutrition, one goes in their head to a very thin-looking person from the third-world. It’s not just that,” Riley said.
Of the 5,688 patients screened in the study, 2,206—38%—were identified as being at risk of malnutrition, and 1,546 were put on the nutritional program. Their average age was 76.8 years.
Patients were eligible to be included in the study if they were discharged from an AHC hospital or outpatient clinic or from an affiliated skilled nursing facility. They weren’t included, however, if they had a feeding tube or weren’t able to consume food and drink on their own.
2. Use a standard tool to evaluate nutritional risk.
HHAs already use clinical assessment tools to score fall risk, skin breakdown and other factors that may affect a patient’s treatment outcomes or send them back to the hospital. Caregivers should approach nutrition the same way, Riley said.
“You can’t just look at somebody and say, ‘Oh, they have poor nutrition,’” Riley said. Instead, home health providers need to quantify how often someone eats, what they eat, whether alcohol or medications might interfere with nutrient absorption and more. “But when you go through a true validated tool, you’ll see those patients qualified as malnourished because of these things.”
For the study, screening was completed by the admitting nurse or physical therapist, who was trained on the Nutritional Health Screen (NHS), a tool used by Medicare-certified HHAs and built into the system’s electronic medical record (EMR). NHS uses 15 questions to calculate a story of good, moderate or high nutrition risk.
“We are now seeing the value of the difference you can make by doing that screening and doing interventions according to the results of the screening,” Riley said.
3. Trust a supplement.
In the study, patients with moderate to high risk who were flagged for intervention had a nutrition plan set in their EMR. The admitting clinician ordered oral nutrition supplements for them according to their needs, either standard (Ensure), diabetes-specific (Glucerna) or renal-specific (Nepro). Patients were allowed to pick their own flavors and were educated on the importance of drinking the supplements, both initially and on follow-up visits.
Why use a supplement instead of just regular food when a patient is at home?
“It’s the short-range plan for those patients, who, when they come home, perhaps their appetite hasn’t returned or they’re not mobile enough or don’t feel well enough to get into the kitchen to get a well-rounded meal,” Riley said. “It’s always great when they can get their nutrition from meats and fruits and vegetables and carbohydrates they can take in, but sometimes all they can really take in are liquids, and you want a liquid that has good nutrition in it.”
4. Small changes can save big money.
Over the course of 90 days, the study found total savings of $2.3 million; the net savings per treated patient was $1,500. That’s based on an estimate that a return to the hospital for an inpatient stay after homecare costs about $12,000 per person on average.
“The value that came with it was a nice surprise,” Riley said. “It was great to see the results. I don’t know that we had necessarily projected they’d be to such a degree.”
For the next step, Riley said, the team plans to look at one more level of the continuum of care: the physician’s office.
Meanwhile, the results so far should encourage HHAs to take a more proactive approach to nutrition when it comes to caring for patients, Riley said. Recommend supplements and give patients options in terms of flavors and also how they take them—perhaps as a shake or even poured over ice cream, if their dietary needs allow.
“Don’t just cross your fingers and hope,” Riley added. “It’s better that they get this supplement because it’s fully loaded with the nutrition and vitamins that they need.”
