Conway Mary Ellen Abbott - c.ymcdn.comc.ymcdn.com/sites/ · Mary Ellen Conway, RN, BSN ... Review...

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7/11/2013 1 Improving Home Health Outcomes with Nutrition Intervention Mary Ellen Conway, RN, BSN President, Capital Healthcare Group 1 ©2012 Abbott Laboratories LITHO IN USA 82720.001/August 2012 2 Mary Ellen Conway, RN, BSN Mary Ellen Conway, RN, BSN President, Capital Healthcare Group Bethesda, MD 301-896-0193 www.capitalhealthcaregroup.com 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. 3 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 CONWAY, MARY ELLEN

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Improving Home Health Outcomes with Nutrition Intervention

Mary Ellen Conway, RN, BSN

President, Capital Healthcare Group

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©2012 Abbott LaboratoriesLITHO IN USA82720.001/August 2012

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Mary Ellen Conway, RN, BSN

Mary Ellen Conway, RN, BSNPresident, Capital Healthcare GroupBethesda, MD301-896-0193www.capitalhealthcaregroup.com

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.

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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

CONWAY, MARY ELLEN

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When the Medicare Benefit Was Created In 1965

Average life expectancy was 70.2 yearsIn 1996 it was 79.1 yearsIn 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

Davis MH, Burner ST. Three decades of Medicare: what the numbers tell us. Health Affairs. 1995 Winter;14(4):231-43.4

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

Americans are aging and living longer

2030

2020

2010

Average Life Expectancyin the US (Years)

US Population, Adults 55+ (MM)

Everyday, for the next 18 years, 8,000 “baby boomers” will be turning 65.

+CDC 2010 preliminary data _040912http://www.aarp.org/personal-growth/transitions/boomers_65/ 5

In 2010, overall life expectancy in the US increased to ~79 years+.

Women

Men

Older patients suffer from one or more chronic diseases

US Census Bureau. December 2009; Timely Data Resources, Inc. Disease incidence: a prevalence database, December 2009; Iconoculture: Consumer Outlook Health and Wellness 2008-2009.

Osteoporosis Diabetes

COPD

Heart Disease

Alzheimer’s Cancer

Hypertension

Sarcopenia(Loss of lean body mass)

Disease Prevalence

Among Age 55+ (%)

33

28

23

18

13

8

3

2011 2015 2020 2025

CONWAY, MARY ELLEN

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Post Acute services are becoming increasingly more important in driving improved patient outcomes for hospitals

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. http://connect.curaspan.com/articles/new-final-hhs-rules-readmissions. Accessed October 18, 2011.

http://www.gpo.gov/fdsys/pkg/FR-2011-08-18/html/2011-19719.htm

TransitionDischarge Is now going to

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There is a connection between the top 15 leading causes of death, nutrition, and home care

Rank Cause1 Disease of heart

2 Malignant neoplasms

3 Chronic lower respiratory disease

4 Cerebrovascular disease

5 Accidents

6 Alzheimer’s disease

7 Diabetes mellitus

8 Nephritis, nephrotic syndrome, nephrosis

9 Influenza and pneumonia

10 Intentional self harm

11 Septicemia

12 Chronic liver disease and cirrhosis

13 Essential hypertension and hypertensive renal disease

14 Parkinson’s disease

15 Pneumonitis due to solids and liquids

12 have a nutritional connection

1 Diseases of the heart

2 Malignant neoplasms

3 Chronic lower respiratory disease

4 Cerebrovascular disease

6 Alzheimer’s disease

7 Diabetes mellitus

8 Nephritis, nephrotic syndrome, nephrosis

9 Influenza and pneumonia

12 Chronic liver disease and cirrhosis

13 Essential hypertension and hypertensive renal disease

14 Parkinson’s disease

15 Pneumonitis due to solids and liquids

1 Diseases of the heart

2 Malignant neoplasms

3 Chronic lower respiratory disease

6 Alzheimer’s disease

7 Diabetes mellitus

13 Essential hypertension and hypertensive renal disease

14 Parkinson’s disease

7 of the 12 have nutritional and home health connections

CDC. Deaths: Preliminary Data for 2010. National Vital Statistics Reports, Vol. 60, No. 4

The National Association for Home Care & Hospice. Basic Statistics about Home Care. Updated 2010

Patients are admitted into home health in nutritionally compromised states

Major nutritional issues impacting home health clients:

Malnutrition1

Affects 13–21% of home care patients

51% at risk3

Loss of Lean Body Mass2*

Affects ~25% of home care patients

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 2010.

2. Iannuzzi-Sucich M et al. J Gerontol A Biol Sci Med Sci 2002; 57: M772-M777.

3. Yang Y et al. J Am Med Dir Assoc 2011; 12: 287-294.

*Statistic is from community-dwelling older adults

CONWAY, MARY ELLEN

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Nutrition could be the missing link to support the home health mission

Home Health Mission:

DecreaseCosts

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.

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); 2000.

Malnutrition is caused by the unique characteristics of older adults

Malnutrition

BodyComposition

Changes

MultipleComorbidities

CognitiveImpairment

Polypharmacy

PsychosocialChallenges

SocioeconomicStatus

InadequateFood & Fluid

Intake

PhysicalImpairments

Fuhrman MP. Nutr Clin Pract 2009; 24:196-205.

CONWAY, MARY ELLEN

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Key challenges among nutritional intake and access to nutrition exacerbate problem of malnutrition

93% had at least one problem with eating and digestion

Soini H, et al. J Gerontol Nurs. 2006;12-17.

50% required assistance with shopping andfood preparation

InadequateFood & Fluid

Intake

PhysicalImpairments

SocioeconomicStatus

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; 2002.

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Poor nutrition in adults managing a chronic condition leads to exorbitant healthcare costs

$17B2.3M

2004Healthcare

Costs1

2004Adult All-Cause

Re-Hospitalizations1

Malnourished patients are significantly more likely than well-nourished patients to experience re-hospitalizations.2-5

1. Jencks SF, et al. NEJM. 2009; 360(14): 1418-1428. 2. ”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 2010. 3. Mudge A, et al. J Hosp Med. 2011;6:61-67. 4. Friedmann J, et al. Am J Clin Nutr. 1997; 65:1714-1720. 5. Vecchiarino P, et al. Heart Lung. 2004;33:301-307.

CONWAY, MARY ELLEN

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Patient’s nutritional status and lean body mass becomes progressively compromised as they travel through the continuum of care

161. Schiesser M, et al. Surgery. 2009;145(5):519-526. 2. Naber THJ, et al. Am J Clin Nutr. 1997;66:1232-1239.3. Pichard C, et al. Am J Clin Nutr. 2004;79(4):613-618. 4. Beattie AH, et al. Gut. 2000;46(6):813-818.

30% to 50% are malnourished

upon admission1,2

Upon Admissionto the Hospital

37% of patients hospitalized for

1-2 days have lean body mass loss3

DuringHospital Stay

Many patients continue to lose

weight after discharge4

Post-discharge

Home health patients often suffer from multiple drivers of muscle mass loss

Demling RH. Eplasty. 2009;9:65-94.

Aging & Bed Rest (decreased activity)

Loss of Lean Body

Mass

Illness & Injury(Inflammation)

Progressive loss of lean body mass is a natural part of aging

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1. Grimby G, Saltin B. Clin Physiol. 1983;3:209-218; 2. Janssen I. J Appl Physiol. 2000;89:81-88;

3. Grimby GB, et al. Acta Physiol Scand. 1982;115:125-134; 4. Larsson L, et al. J Appl Physiol. 1979;46:451-456;

5. Flakoll P, et al. Nutrition. 2004;20:445-451; 6. Baier S, et al. JPEN J Parenter Enteral Nutr. 2009;33:71-82.

Average loss of muscle mass with age1-6Average loss of lean body mass with aging1-6

CONWAY, MARY ELLEN

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Bed rest, age, and disease increase loss of muscle

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Healthy Older Adults

(67 years of age)10 Days’

Inactivity2

Healthy Young (26-46 years of age)

28 Days’ Inactivity1

Lo

ss o

f L

ea

n L

eg

Ma

ss (

lbs.)

all

measu

rem

ents

repre

sent si

ngle

leg lo

ss

Elderly Inpatients (≥65 years of age)

3 Days’ Hospitalization3

–2.0

–1.5

–1.0

0

–2.5

–0.5

1. Paddon-Jones D, et al. J Clin Endocrinol Metab. 2004;89(9):4351-4358; 2. Kortebein P, et al. JAMA. 2007;297(16):1772-1774; 3. Paddon-Jones D. Presented at: 110th Abbott Nutrition Research Conference; June 23-25, 2009; Columbus, OH.

Approx

2.2 lbs.

Approx

1.0 lb

Approx

2.2 lbs

Malnutrition and loss of lean body mass leads to many complications

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1. Collins, CE et al. Nutr. 2005;21:147-155.;

2. Milne AC, et al. Cochrane Database Syst Rev. 2005;(2)CD003288.

3. Stratton RJ et al. Disease-related malnutrition: an evidence based approach to treatment. Wallingford; CABI Publishing:2003.

4. Botella-Carretero, J et al. Clin Nutr. 2010;29:574-579.

5. Norman K et al. Clin Nutr. 2008; 27(1):48-56.

6. Volkert D et al. Clin Nutr. 2006;25:330-360.

Decreased wound healing

Decreased wound healing

Decreased recovery

Decreased recovery

Increased complications

Increased complications

Loss of lean body mass loss leads to difficulty performing ADLs

1 Demling RH. Eplasty. 2009;9:65-94. 2 Paddon-Jones D, Sheffield-Moore M, Cree MG, et al. J Clin Endocrino Metab. 2006;91:4836-4841. 3Paddon-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; 2009:9-14. 4 Engelen MP, Schols AM, Baken WC, et al. Eur Respir J. 1994;7:1793-1797. 5 Evans WJ, Morley JE, Argilés J, et al. Clin Nutr. 2008;27:793-799.

CONWAY, MARY ELLEN

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Malnutrition and loss of lean body mass can seriously impact patients’ outcomes

22Demling RH. Eplasty. 2009;9:65-94.

% of Loss of Total Lean Body Mass Associated Complications

Decreased Healing

Impaired Immunity (Infections)

Wounds

If lean body mass loss reaches 40%, your patients are at risk of death – usually from pneumonia

10% Loss

20% Loss

30% Loss

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 = 0.002 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

ObjectiveTo identify the association between baseline nutritional

status and subsequent health service utilization and mortality

PopulationN = 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: 287-294.

CONWAY, MARY ELLEN

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AgencyPatients

Early nutrition intervention with oral nutritional supplements (ONS) has been clinically shown to help you achieve your goals

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1. Collins, CE et al. Nutr. 2005;21:147-155.; 2. Milne AC, et al. Cochrane Database Syst Rev. 2005;(2)CD003288..

3. Stratton RJ et al. Disease-related malnutrition: an evidence based approach to treatment. Wallingford; CABI Publishing :2003.

4. Botella-Carretero, J et al. Clin Nutr. 2010;29:574-579. 5. Norman K et al. Clin Nutr. 2008;27(1):48-56.

6. Volkert D et al. Clin Nutr. 2006;25:330-360.

Increased wound healing

Decreased complications

Increased recovery

Reduced chronic disease complications

IncreasedQuality

Decreased hospitalizations

Decreased treatment length

DecreasedCost

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CONWAY, MARY ELLEN

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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

CONWAY, MARY ELLEN

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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

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 patients

Educated patients and caregivers on importance of adherence

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CONWAY, MARY ELLEN

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FIND clients at risk using a validated nutrition screening assessment at SOC

Identify patients at risk through your nutritional risk screen performed at the start of care (SOC) assessment

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FIND

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

CONWAY, MARY ELLEN

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National Average†

Bayada Average*

All-Cause Hospitalization Rate

† medicare.gov/homehealthcompare/search.aspx (data as of 10/11)

*For 7 participating locations (AZ, MA, NJ)

26%24.3%

Bayada was slightly below the National Average ACH rate at the start of the pilot

National Average†

Bayada Average*

Bayada Pilot Average*

All-Cause Hospitalization Rate

The keys to success:

• Collaboration

• Awareness through education and training

• Plan of action

• Client self-management

• Efficiency

† medicare.gov/homehealthcompare/search.aspx (data as of 10/11)

*For 7 participating locations (AZ, MA, NJ)

26%24.3%

8.7%

The pilot program shows a trend toward reduced hospitalizations with nutrition intervention

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

CONWAY, MARY ELLEN

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You can do this too by implementing simple FIND, FEED, FOLLOW in your agency to improve outcomes

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FIND

Identify at risk clients

FEED

Incorporate nutrition intervention into care

FOLLOW

Drive patient self-management

through education

Summary

Malnutrition and loss of lean body mass are common in home care patients and are associated with poor outcomes

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

Nutrition intervention, particularly oral nutritional supplements, can improve patient outcomes and decrease hospitalizations

CONWAY, MARY ELLEN