almost empty cereal bowl
Know what questions to ask your clients & their families
by Amy Rogers

Health care spending in the United States is projected to reach $6.2 trillion by 2028. While the Centers for Medicare & Medicaid Services (CMS) increasingly recognizes the vital role nutrition plays in the health of patients and its ability to reduce costs, malnutrition is often under-recognized due to the snowballing pressures front line caregivers face. Industry data shows that up to half of all hospitalized patients in the U.S. are malnourished, resulting in significant care challenges as they transition home.   

In addition to malnutrition impacting institutionalized patients, 45 million Americans living in their homes experienced food insecurity in 2020 as the country faced its first year of the pandemic. This can significantly impact health care spending, as studies show that chronic conditions are strongly associated with food insecurity.

Factors Affecting Focus

In talking with health care providers, the following factors are mentioned as impacting home health’s focus on nutrition:

  • Homecare staff often assume the patient has control of their nutrition or that their family makes sure they do, so nutrition is often not incorporated into the care transition plan and patients don’t receive essential education.
  • The patient may not look undernourished, so a nutrition screening is rushed through or skipped entirely, resulting in undiagnosed malnutrition becoming more severe and costly.
  • It can be difficult to measure nutrition improvement because weight is highly variable and historic parameters generally are not good markers.
  • Homecare agencies do not get reimbursed specifically for oral nutrition supplements (ONS), so resources are put toward educating clinicians to identify nutrition issues. This leaves patients financially responsible for obtaining their own ONS, which can be burdensome.

All of these reasons are valid, but focusing on nutrition can positively impact a home health agency’s bottom line. A study published in the Journal of Parenteral and Enteral Nutrition examined the results of a nutrition-focused program for more than 1,500 home health patients.

The program focused on individualized treatment, including the overall coordination of care with patients’ health care providers. They were first screened for malnutrition risk with the Nutritional Health Screen, a tool used by Medicare-certified home health agencies, and patients with moderate or high risk were flagged for intervention. The customized care plan included ONS and was generated in the electronic medical record. The plan was reviewed at each patient visit, and nutrition status was documented in the patient’s chart. Patients were educated on the importance of nutrition and the benefits of ONS. The study found that prioritizing nutrition care reduced costs by roughly $1,500 per patient over 90 days, for a total of more than $2.3 million.

While nutrition plays an essential role in the holistic approach to a patient’s health, it is not always easy to directly correlate nutrition to the improvement of a patient’s health. However, nutrition is an underlining factor for health issues and malnutrition can have a negative impact on wound healing.

Incorporating Nutrition into Skin Health

When thinking about wound care, providers should take a holistic approach to healing. This means focusing on healing the whole person and not just the wound. This starts with a comprehensive assessment that should look at the patient’s nutrition status. For example, lower extremity chronic ulcers are often dominant in individuals who are diabetic and over 65 years old. Their age and the loss of essential nutrients from the ulcer’s drainage puts them at risk for malnutrition.

All wounds, regardless of the type, need more protein. The National Pressure Injury Advisory Panel (NPIAP) recommends 1.2 to 1.5 grams of protein per kilogram of body weight per day and a calorie intake of 30 to 35 kilocalories per kilogram of body weight per day for acute and chronic wounds. If an individual has a stage two, three or four pressure injury, calories, protein, arginine, zinc and antioxidants are essential. Below are two patient scenarios where nutrition is a critical component of wound care.

Incorporating Nutrition into Skin Health Examples:

1. The patient is a 65-year-old female with a spinal cord injury and stage three sacral pressure injury. She is in a bed or chair all day and is incontinent, has poor nutritional intake and the amount of drainage and incontinence is requiring changes three to four times per day.

Her stage three pressure injury requires additional protein, calories and micronutrients to help heal. Knowing that she is eating poorly, offering a high protein and high calorie ONS fortified with arginine, zinc and vitamin C will help her meet her increased nutrition requirements and offset the protein lost from the wound drainage.

2. The patient is a 54-year-old male with a diabetic foot ulcer who was transferred from an acute care facility with infection to his left lateral foot. He has a long history
of diabetes.

He could be at risk for malnutrition since it’s very common for nutritional status to decline in the hospital setting. Since he has diabetes, caregivers will need to get his blood glucose under control and increase protein in his diet to help heal the wound from within.

Tips for Putting Nutrition First

Perhaps your home health organization already wants to put a greater focus on nutrition, or maybe you are starting from the bottom and need to get your staff on board. Regardless of where you are currently, here are tips to help make prioritizing nutrition a success:

1. Continue educating staff.

Whether part of a big or small organization, educating staff plays a critical role in driving empowerment in delivering high quality care. For example, Medline recently introduced complimentary skin health boot camp courses for post-acute health care providers across the country. Hosted by the company’s clinical services team, the boot camps connect the dots on nutrition’s impact on skin health.

2. Incorporate patient & family education.

With the average care visit from clinicians lasting less than an hour, collaboration is critical between home health clinicians, their patient and the patient’s family. It is essential for home health clinicians to spend time educating clients on what type of oral nutritional supplements work best for the patient’s individual care needs and what malnutrition signs to look out for, and to check in with the patient and their family caregivers every few weeks. Some questions to ask include:

  • What is the patient’s appetite like? People with poor appetite may have trouble consuming larger volume ONS. Low volume with high concentrated protein makes it easier for the person to be compliant with their supplement.
  • Is the ONS recommended financially feasible for the patient to purchase out of pocket?
  • Has the patient experienced unintentional weight loss or a decrease in appetite? A yes to either should prompt you to further investigate their nutrition challenges and implement interventions, which can be as simple as recommending an ONS between meals. If the patient or family does not know, you can ask if the patient’s clothes are fitting more loosely.
  • Asking less traditional questions such as “Do you struggle to buy groceries every week?” can reveal a challenge with food insecurity. Providing contact information for area food banks and other community organizations already working to address food insecurity can help optimize the patient’s food intake and nutrition status.

3. Leadership must demonstrate support.

Caregivers are spread thin and often have conflicting priorities. For staff to take nutrition seriously, they need to be reassured that they have leadership support to invest in initiatives that can help enhance best practices, like education.

Nutrition is a proven and cost-effective intervention. When caregivers arm themselves, their patients and patients’ families with tools to identify malnutrition early, providers can help intervene in time to optimize a patient’s nutrition care plan, leading to faster recovery times and overall decreases in the cost of treatment.

Amy Rogers, RN, BSN, is the senior clinical resource manager for Medline’s nutrition team.