7/11/2013 CONWAY, MARY ELLEN. Improving Home Health Outcomes with Nutrition Intervention. Mary Ellen Conway, RN, BSN. Learning Objectives

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1 Improving Home Health Outcomes with Nutrition Intervention Mary Ellen Conway, RN, BSN President, Capital Healthcare Group 2012 Abbott Laboratories LITHO IN USA /August Mary Ellen Conway, RN, BSN Mary Ellen Conway, RN, BSN President, Capital Healthcare Group Bethesda, MD 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. 2 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 3 1

2 When the Medicare Benefit Was Created In 1965 Average life expectancy was 70.2 years In 1996 it was 79.1 years In 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 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 Davis MH, Burner ST. Three decades of Medicare: what the numbers tell us. Health Affairs Winter;14(4): Americans are aging and living longer US Population, Adults 55 + (MM) Average Life Expectancy in the US (Years) Women Men 2010 Everyday, for the next 18 years, 8,000 baby boomers will be turning 65. In 2010, overall life expectancy in the US increased to ~79 years +. +CDC 2010 preliminary data _ Older patients suffer from one or more chronic diseases 33 Hypertension Disease Prevalence Among 18 Age 55+ (%) Sarcopenia (Loss of lean body mass) Diabetes Osteoporosis Heart Disease COPD Alzheimer s Cancer US Census Bureau. December 2009; Timely Data Resources, Inc. Disease incidence: a prevalence database, December 2009; Iconoculture: Consumer Outlook Health and Wellness

3 Post Acute services are becoming increasingly more important in driving improved patient outcomes for hospitals Discharge Is now going to Transition 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. Accessed October 18, There is a connection between the top 15 leading causes of death, nutrition, and home care Rank Cause 1 Diseases of heart of the heart 2 Malignant neoplasms 3 Chroniclower lower respiratory disease 4 Cerebrovascular disease 5 Accidents 6 Alzheimer s disease 7 Diabetesmellitus mellitus 8 Nephritis, nephrotic syndrome, nephrosis nephrosis 9 Influenza and and pneumonia 10 Intentional self harm 11 Septicemia 12 Chronic liver liver disease and and cirrhosis cirrhosis 13 Essential hypertension and and hypertensive renal renal disease disease 14 Parkinson s disease 15 Pneumonitis due due to to solids solids and and liquids liquids 12 have a nutritional connection 7 of the 12 have nutritional and home health connections CDC. Deaths: Preliminary Data for National Vital Statistics Reports, Vol. 60, No. 4 The National Association for Home Care & Hospice. Basic Statistics about Home Care. Updated Patients are admitted into home health in nutritionally compromised states Major nutritional issues impacting home health clients: Malnutrition 1 Affects 13 21% of home care patients 51% at risk 3 Loss of Lean Body Mass 2 * Affects ~25% of home care patients *Statistic is from community-dwelling older adults 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 Iannuzzi-Sucich M et al. J Gerontol A Biol Sci Med Sci 2002; 57: M772- M Yang Y et al. J Am Med Dir Assoc 2011; 12:

4 Nutrition could be the missing link to support the home health mission Home Health Mission: Decrease Costs 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. 10 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); Malnutrition is caused by the unique characteristics of older adults Socioeconomic Status Body Composition Changes Cognitive Impairment Multiple Comorbidities Inadequate Food & Fluid Intake Malnutrition Psychosocial Challenges Physical Impairments Polypharmacy Fuhrman MP. Nutr Clin Pract 2009; 24:

5 Key challenges among nutritional intake and access to nutrition exacerbate problem of malnutrition Inadequate Food & Fluid Intake Physical Impairments Socioeconomic Status 93% had at least one problem with eating and digestion 50% required assistance with shopping and food preparation Soini H, et al. J Gerontol Nurs. 2006; 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; Poor nutrition in adults managing a chronic condition leads to exorbitant healthcare costs 2004 Adult All-Cause Re-Hospitalizations Healthcare Costs 1 2.3M $17B Malnourished patients are significantly more likely than well-nourished patients to experience re-hospitalizations Jencks SF, et al. NEJM. 2009; 360(14): 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 Mudge A, et al. J Hosp Med. 2011;6: Friedmann J, et al. Am J Clin Nutr. 1997; 65: Vecchiarino P, et al. Heart Lung. 2004;33:

6 Patient s nutritional status and lean body mass becomes progressively compromised as they travel through the continuum of care Upon Admission to the Hospital 30% to 50% are malnourished upon admission 1,2 During Hospital Stay 37% of patients hospitalized for 1-2 days have lean body mass loss 3 Post-discharge Many patients continue to lose weight after discharge 4 1. Schiesser M, et al. Surgery. 2009;145(5): Naber THJ, et al. Am J Clin Nutr. 1997;66: Pichard C, et al. Am J Clin Nutr. 2004;79(4): Beattie AH, et al. Gut. 2000;46(6): Home health patients often suffer from multiple drivers of muscle mass loss Aging & Bed Rest (decreased activity) Loss of Lean Body Mass Illness & Injury (Inflammation) Demling RH. Eplasty. 2009;9: Progressive loss of lean body mass is a natural part of aging Average loss of muscle mass with age 1-6 Average loss of lean body mass with aging Grimby G, Saltin B. Clin Physiol. 1983;3: ; 2. Janssen I. J Appl Physiol. 2000;89:81-88; 3. Grimby GB, et al. Acta Physiol Scand. 1982;115: ; 4. Larsson L, et al. J Appl Physiol. 1979;46: ; 5. Flakoll P, et al. Nutrition. 2004;20: ; 6. Baier S, et al. JPEN J Parenter Enteral Nutr. 2009;33:

7 Bed rest, age, and disease increase loss of muscle Loss of Lean Leg Mass (lbs.) all measurements represent single leg loss Healthy Young (26-46 years of age) 28 Days Inactivity 1 Approx 1.0 lb Healthy Older Adults (67 years of age) 10 Days Inactivity 2 Approx 2.2 lbs Elderly Inpatients ( 65 years of age) 3 Days Hospitalization 3 Approx 2.2 lbs. 1. Paddon-Jones D, et al. J Clin Endocrinol Metab. 2004;89(9): ; 2. Kortebein P, et al. JAMA. 2007;297(16): ; 3. Paddon-Jones D. Presented at: 110th Abbott Nutrition Research Conference; June 23-25, 2009; Columbus, OH. 19 Malnutrition and loss of lean body mass leads to many complications Increased complications Decreased wound healing Decreased recovery 1. Collins, CE et al. Nutr. 2005;21: ; 2. Milne AC, et al. Cochrane Database Syst Rev. 2005;(2)CD Stratton RJ et al. Disease-related malnutrition: an evidence based approach to treatment. Wallingford; CABI Publishing: Botella-Carretero, J et al. Clin Nutr. 2010;29: Norman K et al. Clin Nutr. 2008; 27(1): Volkert D 20 et al. Clin Nutr. 2006;25: Loss of lean body mass loss leads to difficulty performing ADLs 1 Demling RH. Eplasty. 2009;9: Paddon-Jones D, Sheffield- Moore M, Cree MG, et al. J Clin Endocrino Metab. 2006;91: Paddon-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: Engelen MP, Schols AM, Baken WC, et al. Eur Respir J. 1994;7: Evans WJ, Morley JE, Argilés J, et al. Clin Nutr. 2008;27:

8 Malnutrition and loss of lean body mass can seriously impact patients outcomes % of Loss of Total Lean Body Mass 10% Loss 20% Loss 30% Loss Associated Complications Impaired Immunity (Infections) Decreased Healing Wounds If lean body mass loss reaches 40%, your patients are at risk of death usually from pneumonia Demling RH. Eplasty. 2009;9: 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 = 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 Objective To identify the association between baseline nutritional status and subsequent health service utilization and mortality Population N = 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:

9 Early nutrition intervention with oral nutritional supplements (ONS) has been clinically shown to help you achieve your goals Patients Agency Increased wound healing Decreased complications Increased recovery Reduced chronic disease complications Increased Quality Decreased hospitalizations Decreased treatment length Decreased Cost 1. Collins, CE et al. Nutr. 2005;21: ; 2. Milne AC, et al. Cochrane Database Syst Rev. 2005;(2)CD Stratton RJ et al. Disease-related malnutrition: an evidence based approach to treatment. Wallingford; CABI Publishing : Botella-Carretero, J et al. Clin Nutr. 2010;29: Norman K et al. Clin Nutr. 2008;27(1): Volkert D et al. Clin Nutr. 2006;25:

10 28 29 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 10

11 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 32 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 Educated patients and caregivers on importance of adherence patients 33 11

12 FIND clients at risk using a validated nutrition screening assessment at SOC FIND Identify patients at risk through your nutritional risk screen performed at the start of care (SOC) assessment 34 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 12

13 Bayada was slightly below the National Average ACH rate at the start of the pilot National Average Bayada Average* 26% 24.3% All-Cause Hospitalization Rate medicare.gov/homehealthcompare/search.aspx (data as of 10/11) *For 7 participating locations (AZ, MA, NJ) The pilot program shows a trend toward reduced hospitalizations with nutrition intervention National Average 26% Bayada Average* 24.3% Bayada Pilot Average* 8.7% The keys to success: Collaboration Awareness through education and training Plan of action Client self-management Efficiency All-Cause Hospitalization Rate medicare.gov/homehealthcompare/search.aspx (data as of 10/11) *For 7 participating locations (AZ, MA, NJ) 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 13

14 You can do this too by implementing simple FIND, FEED, FOLLOW in your agency to improve outcomes FIND FEED FOLLOW Identify at risk clients Incorporate nutrition intervention into care Drive patient selfmanagement through education 40 Summary Malnutrition and loss of lean body mass are common in home care patients and are associated with poor outcomes Nutrition intervention, particularly oral nutritional supplements, can improve patient outcomes and decrease hospitalizations 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 14