Nadine Sahyoun, PhD, RD University of Maryland. September 10, 2013

Transcription

1 Nadine Sahyoun, PhD, RD University of Maryland September 10, 2013

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3 Tufts University USDA HNRC on Aging

4 B12 decrease in stomach acid and pepsin makes it difficult to split B12 from food protein Calcium/Vitamin D decreased ability to absorb calcium, less time spent in the sun, skin less able to produce vit D with sun exposure Nutrient Density - important as energy needs decrease but nutrient needs increase or remain the same. Vitamin B6 need increases with age

5 Cognitive Function Depression Oral Health Food Security Physical Function Social Support Food Safety Dietary Intake Genomics Nutritional Status Anthropometry Biochemical Clinical Health Outcome Health Care Costs & Quality of Life

6 Booth et al. Nutrition Reviews", Vol. 59, No. 3

7 Food security exists when all people, at all times, have physical, social and economic access to sufficient, safe, and nutritious food which meets their dietary needs and food preferences for an active and healthy life 6 million seniors at risk of hunger -11.4% of seniors Marginally food insecure are much more likely than fully food secure seniors to have ADL limitations.

8 Sarcopenia Osteoporosis Arthritis Heart disease Cognitive problems

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10 Low protein intake Reduced physical activity Hormones: GH, androgens 9/30/

11 About 45% of older adults develop sarcopenia About 1.5% of health care expenditure totaling 18.5 billion dollars attributed to sarcopenia Study results (2013) : Doubling the Daily Allowance of Protein Intake With Diet and Exercise Protects Muscle Loss (Source: FASEB Journal

12 Cardiovascular disease improving lipid profile can reduce CHD by 45% for over 65 Better diet tied to fewer deaths after heart attack (Source: JAMA Internal Medicine, 2013) Hypertension dietary control in over 65 -prevention of CHD 20% in men: 30% in women Osteoporosis - calcium and vitamin D reduce incidence Sarcopenia protein, micronutrient intake helps maintain muscle mass (Rivlin, 2007)

13 Malnutrition is common at hospital admission and at discharge wide range of prevalence (range 12-70%) (Heersink and colleagues)

14 16 Average length of stay in days and over2004 Data Source: The National Hospital Discharge Survey

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16 Medicare hospital readmission rate: 30 days 19.5% 3 months 34.0% 6 months 44.8% 1 year 56.1% Cost of rehospitalization (2004) $17 Billion in the Medicare population Jencks et al. N Engl J Med 2009

17 Funded by AOA in and conducted in collaboration with MOWAA Objective: Study the feasibility to: Position OAANP as a core service within the continuum of care Develop partnerships with hospitals Establish partnerships with non-traditional community programs Demonstrate that these partnerships result in referrals from hospitals and additional services to clients Examine health status of participants over a 5-month period. Sahyoun et al. J Nutr Elderly

18 Hawkeye Valley Area Agency on Aging Syracuse Department of Aging and Youth Area Agency on Aging Christian Senior Services Lutheran Senior Services Meals on Wheels of Stark & Wayne Central Louisiana County Area Agency on Aging 18

19 Demonstration sites had to develop a model approach for partnership with healthcare and community organizations Obtain referrals from hospitals Conduct assessment and provide meals to hospital-discharged individuals within 48 hours or at 2 weeks (control) after discharge Provide other social services in addition to meals 19

20 MOU signed with hospital administrators Hospital discharge planners, administrators, social workers served as referral agents Participants had to be Hospital-discharged individuals returning to their primary residence Short-term acute care No terminal disease No severe dementia/alzheimer s disease 20

21 Percent (%)

22 100 Percent (%) CC POMP National 22

23 Percent (%) CC National 23

24 1 impairments 3 impairments Percent (%) CC POMP National 24

25 100 Early Delayed 80 Percent (%) Fruit Vegetables Meat Milk 25

26 Characteristics CC % Fair/poor self-assessed appetite 39 Frequently eat alone 55 Have difficulty shopping for food 81 Have difficulty preparing meals 80 26

27 Presence of high levels of nutrition risk, physical and emotional dysfunction, and social isolation among the hospital discharged population. This population with short-term acute health conditions may be missed by the HDM due to poor coordination of efforts between the medical health care and community care system. 27

28 Resistance from hospitals Communications/need champion Heavy burden on case managers/social workers Incorrect perceptions of HDM by case managers/social workers Greater referrals from community organizations and social services vs. hospitals Difficult sustaining interest and enthusiasm for project Takes a long time to establish partnerships Policy Change/Insurance companies 28

29 Now: Reducing rehospitalization important element of financing health care reform Affordable Care Act includes penalties for hospitals with high readmission rates for 3 health conditions (MI, HF, pneumonia) expanded to 6 health conditions (COPD, vascular procedures) in 2015 Hospitals are motivated to identify patients at high risk for readmission and to employ evidence-based interventions

30 Affordable Care Act funded pilot programs for improving care transitions for high risk Medicare beneficiaries 82 models were funded Funding for 5 years beginning April 2011 Aim: Improve transitions Improve quality of care Reduce readmissions for high risk beneficiaries Document measureable savings

31 Several evidence-based programs share the following elements: Interdisciplinary Transitional Care staff Patient/Participant centered Patient Follow-up from hospital to home

32 Adequate Dietary Intake Essential to recovery and rehabilitation at hospital and post discharge Contributes to improvement/maintenance of good health status of individuals with chronic conditions

33 Yet: Nutrition is provided as a service as needed and in some programs upon patient request Nutrition services are often not coordinated or comprehensive Multidisciplinary team approach needed which requires the involvement of the dietitian as a member of the team

34 How do we leverage, collaborate, coordinate, and integrate nutrition services as seamlessly as possible into a comprehensive and coordinated home and community based service system? 34

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36 Awarded September 2011 to Meals On Wheels Association of America Goals: Strengthen support of nutrition services Demonstrate the value of nutrition services Modernize nutrition service provision

37 Outcome: Build the future of Older Americans Act Nutrition Services through increased knowledge, understanding, and application at all levels of the aging services network

38 Providing the Nutrition Positioning System (NPS)

39 Planning Performance Evaluation Operations Funding Resource Streams Collaboration Coordination/ Coalition Integration Business Capacity & Acumen

40 Strategic planning: where are you going & how are you getting there.

41 More older people More healthy older people More frail older people More minorities More HCBS, less nursing home care

42 Long Term Services and Supports (LTSS) Home and Community Based Services (HCBS) Health Care/Care Transitions Accountable Care Organizations Medicaid LTSS- Managed Care

43 Services Methods of production/delivery - Meals Methods of development/delivery other services Steps necessary to provide to provide the product (meal, nutrition education, etc.) and services Capacity, expertise, human resources

44 Older Americans Act Service System Home & Community Based Service System Public Health System Health Care System Food Assistance System, Programs Funded by USDA Private Pay Systems Private Industry State Units on Aging, Area Agencies on Aging, Local Nutrition Service Providers Part of a comprehensive & coordinated home and community based service system Medicaid Waiver Programs, Managed Care Organizations State/county funded systems & services State/county/city health departments Chronic disease self management programs, BRFSS Food safety & sanitation, nutrition & health education Direct Health Care system, physicians, hospitals, nursing homes, rehabilitation centers, Transition care, Medical Nutrition Therapy SNAP, SNAP-ED, TEFAP, CSFP, CACFP, SFMNP Food stamps, food banks/pantries, soup kitchens, community gardens Fee for Service based on fair market value Insurance companies, managed care companies Private case management Restaurants, carryout, fast food, healthy fast food Frozen /other packaged meals, grocery stores, home delivery by post

45 Understand your market Identify your network s product line(s) Articulate your value/business case Forge relationships/ partnerships Organizational culture change Establish legal structure Determine your pricing/capital/cash flow Build or buy your business/it infrastructure Determine & ensure volume & scalability Sell your services/negotiate your contract

46 Time Service location or place Restaurant voucher programs Café style service Menu, more than 1 menu Food item choice More than 1 meal/day Fee for service/3rd part y & private pay options Customer service emphasis

47 Service needs Quality Services Appropriate services: cultural, religious, therapeutic Choice HCBS Services Diversity

48 Older Americans Act Title III (C1, C2, NSIP), V, VI Other Federal Social services or community service block grants State support varies

49 Participant contributions Fund raising Third party payments & insurance Medicaid Waiver-From fee for service to managed care Transition Care Grants

50 Social Entrepreneurship Catering Nutrition Services Nutrition Counseling Grocery Shopping Other Program Opportunities USDA Child Nutrition Programs

51 Competition for limited dollars Relook at for pay options Other services Tiered services Expanded services

52 $1.40 $1.20 $1.00 $0.80 $0.60 $0.40 $1.15 $1.14 $0.77 $0.68 $1.05 $1.01 $0.62 $0.60 $ Congregate Contribution/Meal $ Home Delivered Contribution/Meal $0.20 $ State Program Reports

53 Self Pay Increase client incomes to pay for services Health insurance & 3 rd party pay Donations-Ask & you will receive Investing wisely in volunteers In-kind support Funding & Sustainability, NCOA

54 Performance Measurement Has the program achieved its objectives as expressed by measurable standards Answers the questions: what, how Performance Measurement & Evaluation: Definitions & Relationships. GAO SP.May,

55 Program Evaluation Broader range of information & context Examines aspects of program operations or factors in program environment that contribute/impede success Estimates what might occur without the program Compares effectiveness of alternative programs with the same objective Provides an in-depth examination of the program performance & context to improve results Answers the question why Performance Measurement & Evaluation: Definitions & Relationships. GAO SP.May,

56 Website: Proceedings of Perspectives on Nutrition and Aging: A National Summit Online Resource Library Resources and Tools for Nutrition Programs Momentum Series and Topic Guides Other Nutrition and Aging Network Trainings

57 Momentum Webinar Series Good Nutrition Is a Key to Health: A Conversation with Kathy Greenlee, Assistant Secretary for Aging Components of a Quality Nutrition Program- Part s1&2 Identifying the Actual Cost of a Meal What is the Importance for Nutrition Programs Understanding and Calculating Meal Costs

58 Upcoming Topics Role of Nutrition Services in the LTSS System and Healthcare Continuum Collaborations and Partnerships Within the Parallel Nutrition Systems Funding Sources for Sustainability Performance and Evaluation Measurement

59 Website: