Is nutrition on your company’s plate?
Ounces of prevention yield pounds of outcomes
Have you ever thought of nutritional interventions as a competitive advantage? With payers beginning to look long and hard for faster-healing and better outcomes overall, a company-wide nutrition focus may be your ticket to more business and happier and healthier customers, according to Rosanna Gibbons, MS, RD, LN, director of Nutrition — The Best Prescription, a Sparks, MD-based consulting firm. Gibbons is also a practicing home care nutritionist.
According to Gibbons, nutrition gets a bad rap in home care. Although it is one of the building blocks of healing and continued well being, "providers think of it as a non-essential service," she says. "I’m trying to dispel the paradigm that it’s a nicey-nice thing."
"It makes a tremendous impact," agrees Lisa LaChapelle, RN, executive case manager in the Baltimore office of Mid Atlantic Medical Services (MAMSI), one of the largest managed care companies in the mid-Atlantic region. "If patients are not nutritionally in good shape, you can’t get them stable. But I’ve not been seeing enough home care intervention recently."
One reason providers may have sidestepped more extensive nutrition services in the past is lack of funding, from both insurers and patients. That may not be the obstacle that it once was, according to Gibbons. "Insurance companies are becoming proactive, and many now preauthorize nutrition consultations based on diagnosis."
Patients privately paying for services still may not be willing or able to afford a nutritionist, but it is possible to improve nutritional assessment and care coordination without sending a dietitian on home visits, she advises.
Even in instances where a dietitian is needed but reimbursement is limited, the dollars spent now may save money and improve outcomes down the road. "It takes $5,000 to $40,000 to treat one pressure ulcer. But if the patient is not receiving appropriate protein to grow new cells, it will never get well," Gibbons says.
For organizations seeking maximum patient outcomes with lower costs, Gibbons advocates turning paraprofessionals into malnutrition detectives through concentrated nutritional training.
"They are good ambassadors to the rest of the organization for what’s happening. You can maximize their abilities as providers of primary care and identify unsafe situations," she says.
Train paraprofessional staff to spot patients at highest risk of nutrition backsliding with these actions:
• Offer basic nutrition training.
The good old food pyramid remains the foundation of nutrition education. Reinforce basic dietary information with policy and procedures, and co-visits to help identify any food preparation problems and strengthen caregivers’ assessment skills, Gibbons recommends. Caregivers should also learn techniques to help clients make better food choices. For example, they can help clients who regularly eat take-out or delivered food focus on the most nutritional menu items.
• Assess risk.
Nutrition deficits can affect nearly all patients, but they are much more common in the elderly, according to Gibbons. One good way to identify those at highest risk is to use a nutritional status-screening tool. Consider the "Determine Your Nutritional Health" checklist developed by the Nutrition Screening Initiative, a collaboration between the American Academy of Family Physicians, the American Dietetic Association, and the National Council on Aging. (See checklist, p. 34.) This simple questionnaire was designed as a self-test, so caregivers could easily incorporate it in their assessments, Gibbons suggests.
Socioeconomic status is the No. 1 risk factor for poor nutritional status. Another key indicator is dietary restrictions. "Over 85% of the elderly have some kind of chronic condition for which there are dietary restrictions. But we know that if a person has more than three diet restrictions, their compliance goes down to 20%," Gibbons explains.
Client comments about the cost of medications or not being able to buy certain foods are also signals of increased risk.
• Spot physical signs of malnutrition.
Train caregivers who help clients bathe or dress to notice signs of wasting, such as poor skin turgor and loose-fitting clothes. Sudden or unexplained weight loss is also an indicator. Consider training staff to calculate body mass index (BMI) or provide a conversion chart that translates height and weight into BMI. "Elderly patients with a BMI less than 22 have higher emergency readmission rates, longer length of care, and an increased frequency of primary care," Gibbons reports.
Other physical events should also clue caregivers into possible nutrition deficits. For example, clients who need more assistance with transferring and toileting overtime may be experiencing weakness as a result of inadequate nutrition. Also, patients who cough or drool during meals may suffer dysphagia.
• Assess food stocks.
Paraprofessionals with limited incomes may themselves not have a bursting pantry, so it is important that they know when some becomes too little. Clients should at least have basic provisions such as milk, eggs, and bread and enough staples to "put a meal together," Gibbons advises.
• Assess food safety and sanitation.
More than 9,000 people die every year from food-borne illnesses, according to Gibbons. Although most of the victims of salmonella and other such maladies are senior citizens and children, the elderly often mistake their symptoms for influenza and simply never report the problem. Yet "they are so frail, one bout of dysentery will throw them into dehydration," she notes.
With such severe consequences, preventing food-borne illnesses is critical, yet the elderly often compromise food safety. "With their limited functionality, they are less conscientious about restoring food. They have a tendency to let things sit out when they come home from the grocery, or if people bring things over.
Foods left for more than one hour between 40 degrees and 140 degrees Fahrenheit are potentially unsafe, Gibbons advises.
• Provide support materials.
Another way to make good use of scarce nutritionists’ time is to have them prepare patient education materials and helpful support materials for paraprofessionals, such as a standard shopping list for diabetics or 50 quick, easy, and nutritious meals.
• Know when to refer.
Above all, home health aides and homemakers should know when to call for reinforcements. "If you’ve done all the right things, and the patient’s still floundering, it’s time to refer," says Gibbons. Making the referral early is terribly important. "There’s so much complexity in nutrition, it’s a long hard uphill battle to bring functionality back once it’s gone," she says.
Although paraprofessionals can uncover many nutrition problems, sometimes only the dietitian’s expert eye can find the exact cause of a patient’s nutritional decline. "It’s not a one visit thing. Sometimes it takes two to three times to have an impact. You have to pull things out of the cabinet, examine foods and patient dietary habits," says LaChapelle.
Once the nutritionist becomes involved, it is important that they document any patient progress. "I capture every piece of data that shows improvement. That is the key to getting services authorized," says Gibbons. Even small changes count. For example, a patient who can climb half a flight of stairs instead of two steps, or a drop in diabetics’ fasting blood sugar from the high to low 200s is good. "You don’t have to wait for glycated hemoglobin results to show you’ve had an impact," she notes.
In addition to thorough documentation, case managers also expect good communication, according to LaChapelle. "I want an honest answer. Tell me if they don’t understand what they’re eating, and not have visit after visit with a CHF [congestive heart failure] patient increasing Lasix or increasing weight."
Editor’s note: Copies of the Determine Your Nutritional Health checklist are available from the Nutrition Screening Initiative at (202) 625-1662.
Sources
• Rosanna Gibbons, MS, RD, LN, Director, Nutrition — The Best Prescription, 1112 Lower Glencoe Road, Sparks, MD 21152. Telephone: (410) 472-3274.
• Lisa LaChapelle, RN, Executive Case Manager, Mid Atlantic Medical Services Inc., 2 E. Rolling Cross Road, Suite 155, Baltimore, MD 21228. Telephone: (410) 869-7447.
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