Hospital to home outreach for malnourished elders (HHOME): A feasibility pilot

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Journal of Aging Research & Clinical Practice©
Volume 1, Number 2, 2012
HOSPITAL TO HOME OUTREACH FOR MALNOURISHED
ELDERS (HHOME): A FEASIBILITY PILOT
A.M. Mudge1,2, A.M. Young1,3, L.J. Ross1, E.A. Isenring2,4, R.A. Scott1, A.N. Scott1, L. Daniels3, M.D. Banks1,3
Introduction
Malnutrition is common in older patients hospitalised
for medical illness, and associated with poor outcomes
including longer hospital stays, increased mortality and
increased readmissions (1). Considerable resources are
devoted to identification and management of
malnutrition in hospital. However, barriers to improving
nutritional intake in hospital, and shorter hospital stays,
mean that opportunities to make a meaningful difference
to malnutrition in the course of the acute illness may be
limited (2, 3). Nutritional deficits associated with acute
illness and hospitalisation may take months to recover
(4). An alternative approach is to view hospitalisation as
an opportunity to identify a vulnerable patient group and
institute longer term management of malnutrition (5).
However, in Australia, dietetic resources in the
community are limited and service coordination between
hospitals and the community is often poor due to
differing funding structures and service priorities.
Two recent studies have examined the benefits of an
individual post-hospital nutrition care plan for
malnourished older patients (6, 7). Care planning was
undertaken by a dietitian and focussed on enriched diets
and/or liquid nutritional supplements, supported by
home visits and/or telephone follow-up. These studies
reported promising improvements in mortality (6) and
functional status (7) but highlighted the complex social
and logistical challenges faced by recently-discharged
and chronically ill older patients. Discharge planning and
early post-hospital outreach support are of benefit in
older medical patients (8), and have been widely
adopted. Discharge planning nurses have expertise in
needs assessment and service coordination which may
have a valuable role in addressing some barriers to
adequate nutrition(4), but nutrition-related needs are not
routinely and explicitly targeted in discharge planning
processes (9).
We propose that combining the skills and expertise of
discharge planning nurses and dietitians in an
1. Royal Brisbane and Women’s Hospital; 2. University of Queensland;
3. Queensland University of Technology; 4. Princess Alexandra Hospital
Corresponding Author: Alison M Mudge, Royal Brisbane and Women's Hospital,
Internal Medicine and Aged Care, Butterfield St, Herston, Brisbane, Queensland
4029, Australia, 0402162252, Alison_Mudge@health.qld.gov.au;
Abstract: Objectives: Malnutrition is common in older hospitalised patients, and barriers to adequate intake in hospital limit the
effectiveness of hospital-based nutrition interventions. This pilot study was undertaken to determine whether nutrition-focussed
care at discharge and in the early post-hospital period is feasible and acceptable to patients and carers, and improves nutritional
status. Design: Prospective cohort study. Setting: Internal medicine wards of a tertiary teaching hospital in Brisbane, Australia.
Participants: Patients aged 65 and older admitted for at least 3 days, identified as malnourished or at risk of malnutrition using Mini
Nutritional Assessment (MNA). Interventions: An interdisciplinary discharge team (specialist discharge planning nurse and
accredited practicing dietitian) provided nutrition-focussed education, advice, service coordination and follow-up (home visits and
telephone) for 6 weeks following hospitalisation. Measurements: Nutritional intake, weight, functional status and MNA were
recorded 6 and 12 weeks after discharge. Service intensity and changes to care were noted, and hospital readmissions recorded.
Service feedback from patients and carers was sought using a brief questionnaire. Results: 12 participants were enrolled during the
6 week pilot (mean age 82 years, 50% male). All received 1-2 home visits, and 3-8 telephone calls. Four participants had new
community services arranged, 4 were commenced on oral nutritional supplements, and 7 were referred to community dietetics
services for follow-up. Two participants had a decline in MNA score of more than 10% at 12 week follow-up, while the remainder
improved by at least 10%. Individualised care including community service coordination was valued by participants. Conclusion:
The proposed model of care for older adults was feasible, acceptable to patients and carers, and associated with improved
nutritional status at 12 weeks for most participants. The pilot data will be useful for design of intervention trials.
Key words: Malnutrition, discharge planning, interdisciplinary care.
Received October 20, 2011
Accepted for publication December 1, 2011 131
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interdisciplinary discharge planning and outreach model
could improve nutritional intake and nutritional status in
older patients in the early post-hospital period, and
thereby improve clinical outcomes such as functional
status, mortality and hospital readmissions. This small
pilot study was designed to test the feasibility,
acceptability and effect of this new model on nutritional
status in order to inform design of a future trial of efficacy
and cost-effectiveness.
Methods
The pilot study was conducted in the internal medicine
department of a large metropolitan teaching hospital in
Brisbane, Australia. This department has a well
established system of interdisciplinary inpatient care and
early discharge planning (10). Specifically, each of the
four medical units includes one half-time accredited
practising dietitian who undertakes nutritional
assessment and inpatient care of patients at risk of
malnutrition identified on routine nursing admission
screening or clinical assessment, and a nursing case
manager who coordinates discharge care. Each team also
has access to a specialist discharge facilitation nurse to
assist complex discharges.
Participants were enrolled over a 6 week period
November 2010-January 2011. Patients were eligible for
the study if they were aged 65 years or older; admitted
for 3 days or more; were discharged home to live in the
community; lived in northern Brisbane; and were able to
consent to participate. Patients were excluded if they
were assessed as well nourished (score 12 or above)on the
Mini Nutritional Assessment short form (MNA-SF, the
screening component of MNA) (11), were being cared for
with palliative intent, or had tube feeding or parenteral
nutrition. The study was approved by the hospital
Human Research Ethics Committee and written informed
consent was obtained from all participants.
The intervention team consisted of an accredited
practicing dietitian and an experienced discharge
facilitation nurse (each working 20 hours per week on the
project), who worked in close liaison with the four
inpatient interdisciplinary teams. All participants
received a full nutritional assessment to identify their
nutritional status and requirements, and the intervention
dietitian formulated an individualised post-hospital
nutrition care plan, which was discussed with the
participant and relevant family and/or carers. Specific
verbal and written advice were provided to improve
nutritional intake (e.g. sample meal plans), supported by
brochures providing information on supermarket
locations, budgeting suggestions, lists of nutrient-dense
snacks and easy to prepare recipes. The intervention staff
identified potential barriers to adequate nutrition
following discharge and worked with the inpatient team
to address these barriers (eg arranging shopping
support).
The intervention nurse visited participants at home
within one week of discharge. This visit reinforced in-
hospital education regarding adequate nutrition,
addressed misperceptions (eg unnecessary food
restrictions), allowed assessment of food storage and
preparation facilities, and ensured that planned services
were in place, acceptable and sufficient. Primary care
services (general practitioner, domiciliary nursing, other
community services) were contacted as required. Further
advice and service coordination were provided by
fortnightly telephone support over the following 6 weeks.
The intervention dietitian telephoned or visited
participants at 4 weeks to reassess their nutritional intake
and requirements, and modified their nutrition care plan
as appropriate. Telephone contact details for the
intervention team were provided to participants to allow
ready access to advice and support throughout the
intervention.
Baseline data collected at enrolment included age, sex,
primary diagnosis and comorbidities (from the medical
record), nutritional assessment using MNA (12) (where a
score of <17 indicates malnutrition, 17-23.5 indicates
malnutrition risk and ≥24 indicates well nourished) , self-
reported functional status, and existing community
services (13). Weight was measured using a single set of
calibrated scales (Tanita HD351, accurate to 0.1kg) and
height using a stadiometer (SECA 213, accurate to 1cm).
Details of family carers, general practitioner and other
primary care services were recorded, and a home visiting
safety check completed.
Participants were reassessed by a research dietitian 6
and 12 weeks after discharge. Assessments included
nutritional intake by multiple pass 24 hour recall (14),
weight using the same scales and nutritional status using
MNA . Food intake was converted to energy and protein
intake using AUSNUT 2007 food composition database in
Foodworks software (version 3.02, Xyris, Brisbane
Australia 2004). Weight changes at 6 and 12 weeks were
described as percentage of inpatient (baseline) weight
change, with 5% weight loss regarded as clinically
significant. Changes in MNA were described as
percentage of baseline MNA change, with 10% change
considered clinically significant. A brief questionnaire
was administered at 12 weeks which included 7
statements about the perceived helpfulness of various
intervention components (brochures, meal plans,
community service coordination, etc) and 3 questions
about current cooking, shopping and eating compared to
pre-illness. Participants were asked to rate these
statements using a 4 point Likert scale, which were then
dichotomised for analysis (strongly agree/ agree vs not
sure/disagree). They could also offer comments or
suggestions regarding the service.
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JOURNAL OF AGING RESEARCH AND CLINICAL PRACTICE©
Results
Over the enrolment period, 94 medical patients aged
65 years or older were discharged to the local community
after a hospital stay of at least 3 days. Of these, 34 had
cognitive or language impairment or terminal illness, 3
had tube feeding, 10 were discharged before review and
17 were assessed as well nourished on the MNA-SF,
leaving 30 eligible participants. Of these, 15 consented to
involvement, but 3 withdrew from the study prior to the
first follow-up, leaving 12 participants. One participant
did not attend 12 week follow-up. Characteristics of
participants are shown in table 1.
Table 1
Participant characteristics (n=12)
Age, mean years (SD) 82 (7)
Male, n (%) 6 (50)
Live alone, n (%) 6 (50)
Primary diagnosis, n (%)
Cardiorespiratory disease 4 (33)
Neurological disease 3 (25)
Other 5 (42)
Comorbidities, median count (IQR) 2.5 (2,3)
BMI, median (IQR) 24 (22.5, 28)
MNA category, n (%)
“At risk” (17-23.5) 9 (75)
Malnourished (<17) 3 (25)
Length of stay, median days (IQR) 8 (6,9)
Dependent in 1 or more ADL at discharge, n (%) 2 (17)
Community services arranged at discharge, n (%) 6 (50)
SD: standard deviation; IQR: inter-quartile range; BMI: Body mass index (kg/m2);
MNA: Mini-Nutritional Assessment; ADL: Activities of Daily Living.
Inpatient assessments, education and discharge
communication required approximately 4 hours per
patient. All participants received a home visit from the
intervention nurse, and 10 also received a visit from the
dietitian, with mean home visit duration of 55 minutes.
Participants received an average of 5 phone calls (range
3-8), with a mean duration of 7 minutes per call. In
addition, 10 calls (relating to 7 patients) were made to
relatives, and 15 calls (relating to 4 patients) were made
to primary care providers. Four participants (33%) were
referred for new community services, four (33%) were
commenced on oral nutritional supplements, and 7 (58%)
were referred for continuing community dietetic follow-
up.
Mean reported energy intake at 6 weeks was 5800
kJ/day (SD 2000 kJ/day ) or 90 kJ/kg/day; and at 12
weeks it was 6000 kJ/day (SD 1900 kJ/day) or 95
kJ/kg/day. Mean protein intake was 61g/day (SD 25
g/day)or 0.9 g/kg/day at 6 weeks and 64g/day (or 1.0
g/kg/day) at 12 weeks.
Three participants (25%) lost more than 5% body
weight by 6 weeks, and one further participant lost
weight between 6 and 12 weeks. Two of these
participants had been admitted with symptomatic
congestive cardiac failure, and resolution of fluid
overload may have contributed to weight loss; one had
improved their MNA score by >10% by 12 weeks, but the
second failed to attend 12 week follow-up. Three of the
four participants who lost more than 5% of body weight
during follow-up had estimated energy intake of less
than 50 kJ/kg at the 6 week follow-up, but none received
liquid nutritional supplements. All had BMI >23 kg/m2
at baseline, and baseline MNA scores were 21-23.5. Of the
5 participants with initial MNA of 21 or less, all
maintained or improved their weight and improved
MNA score by 10% or more. Three of these (60%)
received liquid nutritional supplements during follow-
up, and ongoing community dietetics referral.
Two of the participants with weight loss also had a
decline in MNA score at 12 weeks. Each had an initial
MNA score of 23.5. Both required further medical review
(general practitioner review and/or hospital admission)
within 12 weeks for medical issues. The remaining
participants had all improved MNA score by at least 10%
by 12 week follow-up. Three participants (25%) were
readmitted to hospital during the 12 weeks follow-up.
Questionnaires were completed by 9 (75%) participants
and their carers, and are summarised in figure 1.
Personalised advice about food intake and community
services were particularly valued, while generic written
nutritional information and brochures were less valued.
Four participants (44%) agreed that they were eating
better than prior to the recent hospitalisation and 5 (55%)
reported managing better with cooking and shopping.
Only 2 participants reported spending more money on
food than usual. Additional comments by participants
confirmed that both telephone and home visits were
perceived as useful and acceptable, and that the
additional social and practical supports were particularly
valued.
Figure 1. Participant (n=9) perception of the usefulness of
specific strategies in improving eating in the post-hospital
period, based on questionnaire responses.
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Conclusions
The results demonstrate the vulnerability of this
patient group. Despite a high level of support, energy
and protein intakes were relatively poor, and one third of
patients lost weight, although this may have been partly
contributed to by appropriate oedema management in
two heart failure patients. Two of these participants had a
decline in their nutritional status (as measured by MNA)
at 12 weeks. Both were considered relatively low risk at
program entry by screening criteria (MNA 23.5).
Participants readily identified at high risk at admission to
the program (low BMI or MNA) were likely to receive
oral nutritional supplements and ongoing community
dietetics referral, and maintained or improved their
nutritional status during follow-up. These findings have
implications for targetting participants and designing
intervention protocols in future trials, where weight loss
may be an important independent criterion for
intervention as well as baseline nutritional status (6).
The proposed model was able to be delivered as
planned, and the main intervention components were
acceptable to the older participants and their carers. The
intervention identified a large number of unmet needs,
with initiation of additional community services in one
third of participants, and referral for ongoing community
monitoring of nutritional status in more than half; local
service data prior to the intervention suggested very few
medical patients (approximately 1 per month) were being
referred for community dietetics follow-up. Tailored
advice and practical supports were identified by
participants as greater value than generic nutrition
information , and were facilitated by experienced staff
who linked closely with inpatient teams and relevant
community services.
We recognise that this pilot study was very small and
lacked a concurrent control. Only about one third of
potential participants were eligible for logistical reasons,
and the consent and continuation rate (40%) reflect the
challenges enrolling aged, sick patients in intervention
trials. Limitations of the 24 hour recall method for
nutritional intakeare acknowledged, including the
potential variability in usual intake and a tendency for
adults to under-report intake (15). However, the use of
multiple pass methods may improve accuracy of
participant recall (16, 17). Furthermore, poor reported
intake at 6 weeks was observed to correlate with
measured weight loss at 6 and 12 weeks. Although the
MNA is recommended as a nutrition assessment
instrument(13), the minimal clinically significant
difference has not been well defined, and we chose a 10%
change for consistency with previous studies (4).
Despite these limitations, the pilot study provides
“proof of concept” for an integrated interdisciplinary
post-hospital nutritional management program to
provide a bridge between inpatient and community care.
The early post-hospital period is a vulnerable time (4)
when the fragile physiological state of recovery from
acute severe illness may be compromised by deficits in
service coordination, inconsistent information sharing
with patients and carers, and unexpected challenges
faced on return to functioning in the community. By
combining specific nutrition and service coordination
expertise, we anticipate that such an intervention will
address some of the barriers which have contributed to
disappointing results in previous nutrition-only
interventions in this patient group (18).
Acknowledgments and funding: This pilot study was funded by the Queensland
University of Technology Institute of Health and Biomedical Innovation Strategic
Research Grants.
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