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7/11/2013
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Improving Home Health Outcomes with Nutrition Intervention
Mary Ellen Conway, RN, BSN
President, Capital Healthcare Group
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©2012 Abbott LaboratoriesLITHO IN USA82720.001/August 2012
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Mary Ellen Conway, RN, BSN
Mary Ellen Conway, RN, BSNPresident, Capital Healthcare GroupBethesda, MD301-896-0193www.capitalhealthcaregroup.com
Mary Ellen Conway is the President of Capital Healthcare Group (CHG), a healthcare consulting provider assisting hospitals, managed care organizations, ACOs, TCOs, home care and hospice providers, durable medical equipment suppliers and physician practices nationwide. As a former Home Care and DME Administrator and legal practice based consultant, Mary Ellen and her team assist health care organizations throughout the continuum to meet their regulatory requirements, create and provide cutting edge programs to manage patient populations, and provide both proactive and reactive responses to ZPIC and RAC audits.
Additionally, CHG assists with new business start-up as well as due diligence for acquisitions and mergers.
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Learning Objectives
Understand the connection between nutrition and home health outcomes
Review case study demonstrating how a home health agency elevated role of nutrition in patient care
Identify and implement new approaches to improve outcomes and ultimately reduce cost of care
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When the Medicare Benefit Was Created In 1965
Average life expectancy was 70.2 yearsIn 1996 it was 79.1 yearsIn 2025 it is expected to be 82.6 years
The benefit package was patterned after the products most commonly provided by private insurance companies
The system was not designed to handle today’s patients with more complex illness and greater needs- new medications/treatments/technologies
8,000 - 10,000 “baby boomers” retiring every day—not being replaced by that number in the workforce = reduced Medicare contributions
Davis MH, Burner ST. Three decades of Medicare: what the numbers tell us. Health Affairs. 1995 Winter;14(4):231-43.4
The American healthcare system is clearly in trouble - primarily a result of attempting to manage long-term chronic conditions in a system that was
designed for short-term acute care
Americans are aging and living longer
2030
2020
2010
Average Life Expectancyin the US (Years)
US Population, Adults 55+ (MM)
Everyday, for the next 18 years, 8,000 “baby boomers” will be turning 65.
+CDC 2010 preliminary data _040912http://www.aarp.org/personal-growth/transitions/boomers_65/ 5
In 2010, overall life expectancy in the US increased to ~79 years+.
Women
Men
Older patients suffer from one or more chronic diseases
US Census Bureau. December 2009; Timely Data Resources, Inc. Disease incidence: a prevalence database, December 2009; Iconoculture: Consumer Outlook Health and Wellness 2008-2009.
Osteoporosis Diabetes
COPD
Heart Disease
Alzheimer’s Cancer
Hypertension
Sarcopenia(Loss of lean body mass)
Disease Prevalence
Among Age 55+ (%)
33
28
23
18
13
8
3
2011 2015 2020 2025
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Post Acute services are becoming increasingly more important in driving improved patient outcomes for hospitals
Hospitals must pay much more attention to the transition of patient care into post acute / community
Transition of care has not historically been their responsibility
– Increased attention on follow-up care
– Greater opportunity for active involvement of home health care
Denniston L. New Final HHS Rules on Readmissions. http://connect.curaspan.com/articles/new-final-hhs-rules-readmissions. Accessed October 18, 2011.
http://www.gpo.gov/fdsys/pkg/FR-2011-08-18/html/2011-19719.htm
TransitionDischarge Is now going to
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There is a connection between the top 15 leading causes of death, nutrition, and home care
Rank Cause1 Disease of heart
2 Malignant neoplasms
3 Chronic lower respiratory disease
4 Cerebrovascular disease
5 Accidents
6 Alzheimer’s disease
7 Diabetes mellitus
8 Nephritis, nephrotic syndrome, nephrosis
9 Influenza and pneumonia
10 Intentional self harm
11 Septicemia
12 Chronic liver disease and cirrhosis
13 Essential hypertension and hypertensive renal disease
14 Parkinson’s disease
15 Pneumonitis due to solids and liquids
12 have a nutritional connection
1 Diseases of the heart
2 Malignant neoplasms
3 Chronic lower respiratory disease
4 Cerebrovascular disease
6 Alzheimer’s disease
7 Diabetes mellitus
8 Nephritis, nephrotic syndrome, nephrosis
9 Influenza and pneumonia
12 Chronic liver disease and cirrhosis
13 Essential hypertension and hypertensive renal disease
14 Parkinson’s disease
15 Pneumonitis due to solids and liquids
1 Diseases of the heart
2 Malignant neoplasms
3 Chronic lower respiratory disease
6 Alzheimer’s disease
7 Diabetes mellitus
13 Essential hypertension and hypertensive renal disease
14 Parkinson’s disease
7 of the 12 have nutritional and home health connections
CDC. Deaths: Preliminary Data for 2010. National Vital Statistics Reports, Vol. 60, No. 4
The National Association for Home Care & Hospice. Basic Statistics about Home Care. Updated 2010
Patients are admitted into home health in nutritionally compromised states
Major nutritional issues impacting home health clients:
Malnutrition1
Affects 13–21% of home care patients
51% at risk3
Loss of Lean Body Mass2*
Affects ~25% of home care patients
1. Tackling Malnutrition: Oral nutritional supplements as an integrated part of patient and disease management in hospital and in the community. Medical Nutrition International Industry. July 2010.
2. Iannuzzi-Sucich M et al. J Gerontol A Biol Sci Med Sci 2002; 57: M772-M777.
3. Yang Y et al. J Am Med Dir Assoc 2011; 12: 287-294.
*Statistic is from community-dwelling older adults
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Nutrition could be the missing link to support the home health mission
Home Health Mission:
DecreaseCosts
Center for Medicare and Medicaid Services (CMS) is tasking providers to better manage healthcare expenditures by
shifting care to new cost effective channels of care.
What Is Malnutrition?
A state of nutrition in which
a deficiency, excess, or
imbalance of energy, protein,
and other nutrients causes
measurable adverse effects on body function
and clinical outcome.
Elia M, ed. Guidelines for Detection and Management of Malnutrition: A Report of the Malnutrition Advisory Group. Maidenhead, UK: British Association for Parenteral and Enteral Nutrition (BAPEN); 2000.
Malnutrition is caused by the unique characteristics of older adults
Malnutrition
BodyComposition
Changes
MultipleComorbidities
CognitiveImpairment
Polypharmacy
PsychosocialChallenges
SocioeconomicStatus
InadequateFood & Fluid
Intake
PhysicalImpairments
Fuhrman MP. Nutr Clin Pract 2009; 24:196-205.
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Key challenges among nutritional intake and access to nutrition exacerbate problem of malnutrition
93% had at least one problem with eating and digestion
Soini H, et al. J Gerontol Nurs. 2006;12-17.
50% required assistance with shopping andfood preparation
InadequateFood & Fluid
Intake
PhysicalImpairments
SocioeconomicStatus
Patients who suffer from malnutrition will also have a loss of lean body mass
Wardlaw GM, Kessel M. Perspectives in Nutrition. 5th ed. New York, NY: McGraw-Hill; 2002.
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Poor nutrition in adults managing a chronic condition leads to exorbitant healthcare costs
$17B2.3M
2004Healthcare
Costs1
2004Adult All-Cause
Re-Hospitalizations1
Malnourished patients are significantly more likely than well-nourished patients to experience re-hospitalizations.2-5
1. Jencks SF, et al. NEJM. 2009; 360(14): 1418-1428. 2. ”Tackling Malnutrition: Oral Nutritional Supplements as an integrated part of patient and disease management in hospital and the community. A summary of the evidence base.” Medical Nutrition International Industry, July 2010. 3. Mudge A, et al. J Hosp Med. 2011;6:61-67. 4. Friedmann J, et al. Am J Clin Nutr. 1997; 65:1714-1720. 5. Vecchiarino P, et al. Heart Lung. 2004;33:301-307.
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Patient’s nutritional status and lean body mass becomes progressively compromised as they travel through the continuum of care
161. Schiesser M, et al. Surgery. 2009;145(5):519-526. 2. Naber THJ, et al. Am J Clin Nutr. 1997;66:1232-1239.3. Pichard C, et al. Am J Clin Nutr. 2004;79(4):613-618. 4. Beattie AH, et al. Gut. 2000;46(6):813-818.
30% to 50% are malnourished
upon admission1,2
Upon Admissionto the Hospital
37% of patients hospitalized for
1-2 days have lean body mass loss3
DuringHospital Stay
Many patients continue to lose
weight after discharge4
Post-discharge
Home health patients often suffer from multiple drivers of muscle mass loss
Demling RH. Eplasty. 2009;9:65-94.
Aging & Bed Rest (decreased activity)
Loss of Lean Body
Mass
Illness & Injury(Inflammation)
Progressive loss of lean body mass is a natural part of aging
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1. Grimby G, Saltin B. Clin Physiol. 1983;3:209-218; 2. Janssen I. J Appl Physiol. 2000;89:81-88;
3. Grimby GB, et al. Acta Physiol Scand. 1982;115:125-134; 4. Larsson L, et al. J Appl Physiol. 1979;46:451-456;
5. Flakoll P, et al. Nutrition. 2004;20:445-451; 6. Baier S, et al. JPEN J Parenter Enteral Nutr. 2009;33:71-82.
Average loss of muscle mass with age1-6Average loss of lean body mass with aging1-6
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Bed rest, age, and disease increase loss of muscle
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Healthy Older Adults
(67 years of age)10 Days’
Inactivity2
Healthy Young (26-46 years of age)
28 Days’ Inactivity1
Lo
ss o
f L
ea
n L
eg
Ma
ss (
lbs.)
all
measu
rem
ents
repre
sent si
ngle
leg lo
ss
Elderly Inpatients (≥65 years of age)
3 Days’ Hospitalization3
–2.0
–1.5
–1.0
0
–2.5
–0.5
1. Paddon-Jones D, et al. J Clin Endocrinol Metab. 2004;89(9):4351-4358; 2. Kortebein P, et al. JAMA. 2007;297(16):1772-1774; 3. Paddon-Jones D. Presented at: 110th Abbott Nutrition Research Conference; June 23-25, 2009; Columbus, OH.
Approx
2.2 lbs.
Approx
1.0 lb
Approx
2.2 lbs
Malnutrition and loss of lean body mass leads to many complications
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1. Collins, CE et al. Nutr. 2005;21:147-155.;
2. Milne AC, et al. Cochrane Database Syst Rev. 2005;(2)CD003288.
3. Stratton RJ et al. Disease-related malnutrition: an evidence based approach to treatment. Wallingford; CABI Publishing:2003.
4. Botella-Carretero, J et al. Clin Nutr. 2010;29:574-579.
5. Norman K et al. Clin Nutr. 2008; 27(1):48-56.
6. Volkert D et al. Clin Nutr. 2006;25:330-360.
Decreased wound healing
Decreased wound healing
Decreased recovery
Decreased recovery
Increased complications
Increased complications
Loss of lean body mass loss leads to difficulty performing ADLs
1 Demling RH. Eplasty. 2009;9:65-94. 2 Paddon-Jones D, Sheffield-Moore M, Cree MG, et al. J Clin Endocrino Metab. 2006;91:4836-4841. 3Paddon-Jones D. In: Gussler J, ed. The Role of Nutrition in Accretion, Retention, and Recovery of Lean Body Mass. Report of the 110th Abbott Nutrition Research Conference: Selected Summaries. Columbus, Ohio: Abbott Nutrition; 2009:9-14. 4 Engelen MP, Schols AM, Baken WC, et al. Eur Respir J. 1994;7:1793-1797. 5 Evans WJ, Morley JE, Argilés J, et al. Clin Nutr. 2008;27:793-799.
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Malnutrition and loss of lean body mass can seriously impact patients’ outcomes
22Demling RH. Eplasty. 2009;9:65-94.
% of Loss of Total Lean Body Mass Associated Complications
Decreased Healing
Impaired Immunity (Infections)
Wounds
If lean body mass loss reaches 40%, your patients are at risk of death – usually from pneumonia
10% Loss
20% Loss
30% Loss
Poor nutrition leads to rehospitalizations as measured by refrigerator content
Objective
Measure outcomes associated with refrigerator contents of elderly patients (nutrition in home)
Population
N = 132 adults aged 65+ who received home visits at least 1 month after hospital discharge
Key Findings
Elderly people without adequate refrigerator content were more frequently readmitted (P = 0.032) and admitted 3 times sooner (34 vs. 100 days); P = 0.002 compared to those who did not have an empty refrigerator
Boumendjel N et al. Lancet 2000; 356: 563.
Patients "at risk" are more likely to experience ER visits and rehospitalizations
ObjectiveTo identify the association between baseline nutritional
status and subsequent health service utilization and mortality
PopulationN = 198 older adults receiving Medicare home health
services for 1 year
Key Findings 12% were malnourished and 51% were at risk Those who were malnourished or at risk
at initial assessment were more likely to experience (6 months, 1 year):– Subsequent Hospitalization (P=.040)– Number of Hospital Admissions (P=.045)– ER Visit (P=.047)– Mortality (6 months, P=.001; 1 year, P=.031)
Yang Y et al. J Am Med Dir Assoc 2011; 12: 287-294.
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AgencyPatients
Early nutrition intervention with oral nutritional supplements (ONS) has been clinically shown to help you achieve your goals
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1. Collins, CE et al. Nutr. 2005;21:147-155.; 2. Milne AC, et al. Cochrane Database Syst Rev. 2005;(2)CD003288..
3. Stratton RJ et al. Disease-related malnutrition: an evidence based approach to treatment. Wallingford; CABI Publishing :2003.
4. Botella-Carretero, J et al. Clin Nutr. 2010;29:574-579. 5. Norman K et al. Clin Nutr. 2008;27(1):48-56.
6. Volkert D et al. Clin Nutr. 2006;25:330-360.
Increased wound healing
Decreased complications
Increased recovery
Reduced chronic disease complications
IncreasedQuality
Decreased hospitalizations
Decreased treatment length
DecreasedCost
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Opportunity to assess and intervene with Home Health patients at the start of care
Previous research has shown a connection between nutrition intervention in certain patient populations
No research examined broad populations of home health clients across diagnoses
Next step — Elevate the role of nutrition in patient care
– to determine if nutrition screening, education and access to oral nutritional supplements help reduce hospitalizations in a typical home health population
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Success with formal nutrition program has also been demonstrated to improve agency and patient outcomes
Profile:
Bayada Nurses provide nursing, rehabilitative, therapeutic, hospice, and personal home health services
Employs more than 14,000 nurses, home health aides, therapists, and social workers
The Situation:
76% of rehospitalizations were identified as preventable
Malnutrition can impact patient outcomes and cause more rehospitalizations
Identified opportunity to elevate role of nutrition in standard of care
A nutrition FIND, FEED, FOLLOW program was implemented in seven Bayada offices throughout the US
Implementation Plan includes:
Trained clinicians
Completed a nutrition screen at the initial patient assessment
Applied appropriate intervention for at-risk patients
Educated patients and caregivers on importance of adherence
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FIND clients at risk using a validated nutrition screening assessment at SOC
Identify patients at risk through your nutritional risk screen performed at the start of care (SOC) assessment
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FIND
FEED: Provide Patient education and product to improve patient adherence to nutrition plan
Bayada’s nutrition screen at start of care helped identify at risk clients that required nutrition intervention
Sample Size: 1,259 clients screened
332 clients (26.4%) identified as moderate to high risk for nutritional compromise
76.8% (n=255) received nutritional education
58.7% (n=195) received free samples of ONS
14.5% (n=48) purchased additional ONS
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National Average†
Bayada Average*
All-Cause Hospitalization Rate
† medicare.gov/homehealthcompare/search.aspx (data as of 10/11)
*For 7 participating locations (AZ, MA, NJ)
26%24.3%
Bayada was slightly below the National Average ACH rate at the start of the pilot
National Average†
Bayada Average*
Bayada Pilot Average*
All-Cause Hospitalization Rate
The keys to success:
• Collaboration
• Awareness through education and training
• Plan of action
• Client self-management
• Efficiency
† medicare.gov/homehealthcompare/search.aspx (data as of 10/11)
*For 7 participating locations (AZ, MA, NJ)
26%24.3%
8.7%
The pilot program shows a trend toward reduced hospitalizations with nutrition intervention
Pilot results lead to a company-wide roll out of formalized nutrition interventions for clients
Nutrition Assessment within EMR
– HomeCare HomeBase
– Risk level identified and clinician notified at SOC
Clinician MUST document plan for clients at risk
– Option for ONS samples (sent directly to client)
– Custom designed care plans that address nutrition
Disease / condition specific– Falls/Frailty/Hip Fracture – Ortho Musculoskeletal
– Wounds – Non-surgical/Surgical/Chronic
– Diabetes
– CHF/MI – Cardiovascular
– Pneumonia/Respiratory
– Malnutrition (Impaired Nutrition)
– Obesity
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You can do this too by implementing simple FIND, FEED, FOLLOW in your agency to improve outcomes
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FIND
Identify at risk clients
FEED
Incorporate nutrition intervention into care
FOLLOW
Drive patient self-management
through education
Summary
Malnutrition and loss of lean body mass are common in home care patients and are associated with poor outcomes
Professional collaboration between Home Health Agency and Abbott Nutrition addresses client’s nutritional status to improve outcomes
Initial outcomes and metrics of the Quality Improvement initiative show improved outcomes, including decreased readmission rates
Nutrition intervention, particularly oral nutritional supplements, can improve patient outcomes and decrease hospitalizations
CONWAY, MARY ELLEN