Bridging the Gap from Hospital to Home: Implementation of a Malnutrition Transitions of Care Program

Abstract

Background: Using the electronic medical record, a clear discharge nutrition plan was established, as well as a mechanism to refer patients to the clinical outreach RDN and order the discharge food box for food insecure patients. The clinical outreach RDN contacts the patients to schedule a visit in their home. During the visit, the RDN ensures that the nutritional plan of care is understood, identifies other nutrition-related issues, and connects patients with community resources as needed for continued optimization of the patients’ nutritional status. Methods: Readmission data is obtained using a web-based business intelligence tool. Improvements in the patients' nutritional status will be evaluated by comparing the patients’ nutritional status at the time of the RDN home visit to what was recorded by the RDN during hospitalization. This included Nutrition Focused Physical Exam results as well as changes in weight and PO intake. An enterprise analytics report measures utilization and associated cost with emergency department (ED) visits and inpatient admissions before and after the in-home nutrition intervention. Results / Outcomes: 30-day malnutrition readmission rates for February 2019 are down 24% from February 2018.30-day malnutrition readmission rates are down 17.5% from January 2019 (pre-intervention) to February 2019 (post-intervention) and have decreased another 12.8% in March 2019. Utilization rates have declined across all categories when comparing patients pre and post-intervention. Data shows the intervention group with 11.4% less ED visits, 9% lower ED associated charges, 12% less inpatient admissions, 3% lower inpatient associated charges, and 8% lower average total length of stay, when compared to a control group of patients with a diagnosis of malnutrition that did not receive the clinical outreach RDN home visit. Conclusions: An RDN in a transitions of care role, providing in-home post-acute care to malnourished and sometimes food insecure patients, is a unique opportunity for RDNs to make profound impacts within organizations and communities. The belief is that initial goals will be met as well as other unintended outcomes will be seen, such as improved patient satisfaction and RDN engagement. [ABSTRACT FROM AUTHOR]