Julie Stefanski MEd, RDN, CSSD, LDN, CDE

What if you had the potential to save your facility thousands of dollars?

A growing body of evidence is demonstrating that significant revenue is lost when malnutrition goes undiagnosed and untreated.

Up to 50% of hospitalized patients are at risk for or already have malnutrition, but only 7% actually receive a diagnosis and treatment.1,2  Malnutrition can significantly impact Medicare reimbursement and the case mix index for a facility.

Our new interdisciplinary continuing education course Malnutrition Alert! How to Improve Patient Outcomes for nurses, dietitians, and physicians is designed to help you recognize the role that protein-calorie malnutrition plays in adult morbidity and mortality and to focus on the tasks required of the interprofessional team in preventing, diagnosing, and treating malnutrition.

Written by Terese Scollard, MBA, RDN, LD, FAND, a leading expert in malnutrition, and a member of the Academy of Nutrition and Dietetics work group that in 2012 designed and released the Consensus Statement on malnutrition, this course provides the guidelines you need to tackle this important condition.

Patients who are malnourished may not only have longer lengths of stay of up to 4 to 6 days, but hospital costs are on average twice as high for patients with malnutrition.2,3

Malnutrition can also lead to:

  • An increased risk of adverse events and complications
  • A 54% higher likelihood of hospital 30-day readmission4
  • Up to a 5 times more likely in-hospital death than a non-malnourished patient2

Prior to 2012 it was difficult to diagnose malnutrition in the past as there were no widely accepted characteristics that clinicians could use to classify this condition consistently throughout all care settings.  That all changed with the publication of the Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Consensus Statement on identifying and diagnosing malnutrition.5

Registered Dietitian Nutritionists and their colleagues should be aware of the guidelines and working as a team to treat malnutrition.  A study which assessed the impact of an interdisciplinary malnutrition treatment program in several hospitals within a large accountable care organization (ACO) reduced 30-day readmission rates by 27% and the average length of stay in the hospital by almost two days for patients with malnutrition.6

The impact of these appropriate interventions to address malnutrition has the potential for significant savings for a healthcare system. A similar study from Advocate Health Care resulted in a $4.8 million cost reduction after implementation of a nutrition-focused quality improvement program at four Chicago facilities.  The savings of approximately $3,800 per patient was attributed to decreased readmission rates and shorter length of stay.7 Some facilities have been able to increase staffing hours for registered dietitians as justified by the missed revenue when malnutrition is not diagnosed and addressed.8

A successful malnutrition treatment program requires an interdisciplinary team to assess, document and prioritize interventions that improve the nutritional status of those under our care.  From the ED to the ICU, it’s vital that all healthcare providers document malnutrition characteristics accurately.  When a physician automatically clicks “Appears well nourished,” in the electronic medical record when the patient actually isn’t, facilities risk ignoring a condition that increases costs, length of stay, and even the patient’s chance of readmission.

Wendy Phillips MS, RD, CNSC, CLE, NWCC, FAND, Division Director of Clinical Nutrition for Morrison Healthcare and Chair-Elect of the Clinical Nutrition Managers Dietetic Practice Group of the Academy of Nutrition & Dietetics explained, “RDNs should read all medical record documentation from other healthcare practitioners, including physicians and other licensed independent practitioners, physical therapists, and nurses. Be on the lookout for seemingly innocuous phrases such as “appears well nourished” or other comments made during a physical exam. This commonly happens in emergency department documentation that will become part of the medical record if the patient is later admitted. A healthcare provider may not put a lot of thought into this phrase and is likely making a general reference to the person’s body mass index rather than their nutritional status. If a RDN later documents this person as malnourished, there is an automatic conflict in the documentation that is difficult to explain and reconcile if the chart is audited. RDNs can take the lead in their facilities to educate other providers to take more care in their evaluation and documentation as it relates to malnutrition.”

What Can You Do to Address Malnutrition?

  • Recognize that malnutrition can have a significant impact on healing, length of stay, and readmission rates
  • Utilize the malnutrition guidelines of the Consensus statement to standardize your nutrition assessment and documentation
  • Communicate your concerns with the primary care providers for your patient
  • Educate the clinicians you work with to help improve consistency of documentation
  • Work with the medical coding professionals at your facility to address practices and denials
  • Implement strategies and interventions to address and prevent malnutrition in your patients

References

  1. Wells JL, Dumbrell AC. Nutrition and Aging: Assessment and treatment of compromised nutritional status in frail elderly patients. Clin Interv Aging. 2006; 1(1):67-69.
  2. Weiss AJ, Fingar KR, Barrett ML, et al. Characteristics of hospital stays involving malnutrition, 2013. HCUP Statistical Brief #210. Rockville, MD: Agency for Healthcare Research and Quality. Available at: http://www.hcup-us.ahrq. gov/reports/statbriefs/sb210-Malnutrition-Hospital-Stays-2013.pdf.
  3. Barker LA, Gout BS, and Crowe TC. Hospital malnutrition: Prevalence, identification, and impact on patients and the healthcare system. Int J of Environ Res and Public Health. 2011;8:514-527.
  4. Fingar KR, Weiss AJ, Barrett ML, et al. All-cause readmissions following hospital stays for patients with malnutrition, 2013. HCUP Statistical Brief #218. December 2016. Agency for Healthcare Research and Quality, Rockville, MD. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb218-Malnutrition-Readmissions-2013.pdf
  5. White JV, Guenter P, Jensen G, et al; Academy of Nutrition and Dietetics Malnutrition Work Group; A.S.P.E.N. Malnutrition Task Force; A.S.P.E.N. Board of Directors. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet. 2012;112(5):730–738.
  6. Sriram K, Sulo S, VanDerBosch G, et al. A comprehensive nutrition-focused quality improvement program reduces 30-day readmissions and length of stay in hospitalized patients. JPEN J Parenter Enteral Nutr. 2017;41(3):384-391.
  7. Sulo S, Feldstein J, Partridge J, et al. Budget impact of a comprehensive nutrition-focused quality improvement program for malnourished hospitalized patients. Am Health Drug Benefits. 017;10(5):262-270.
  8. Drapeaux BD, Robertson D. Malnutrition: Making the case for more dietitians.  Support Line. 39(3):10-12.