How Advocate Health Care is driving better outcomes with a focus on social determinants of health

Although malnutrition is rarely associated with developing countries like the United States, evidence suggests that one in two patients older than 65 years of age entering the hospital may either be malnourished or at risk of malnutrition. Some patients become malnourished in the hospital and continue to be malnourished after they return home.

This is troubling since malnutrition leads to longer hospitalizations, increased hospital stays, increased  risk of mortality and morbidity, and higher healthcare costs. At Becker's 8th Annual CEO & CFO Roundtable in Chicago in November, Abbott hosted an executive roundtable to explore how Downers Grove, Ill.-based Advocate Health Care, which includes Advocate Aurora Health in Milwaukee, has introduced effective nutrition intervention across different care settings.

Advocate's Nutrition Quality Improvement Program (QIP)

In recent years, Advocate's leadership began prioritizing nutrition as a social determinant of health critical to the wellbeing of its patients. The health system initially studied the impact of a comprehensive nutrition care model for malnourished hospital patients in its Phase 1 Nutrition Quality Improvement Program (QIP).

Next, the organization expanded its research into the post-acute care space and has most recently explored how nutrition programs could benefit patients in its clinics. Medicare Advantage patients are of particular interest. Kevin McCune, MD, CMO of Advocate Medical Group, explained, "Our medical group cares for about 30,000 Medicare Advantage patients. We are at full risk for this population, but we have the benefit of managing them throughout the continuum of care."

Advocate started the first phase of its Quality Improvement Program in the hospital setting. The project began with two large teaching hospitals and two community hospitals. All of the institutions used a standardized nutritional screening tool that was part of the EMR. If a patient had an identified nutritional need, nurses could immediately add oral nutrition supplementation to their treatment plan.

Once patients returned home, they were encouraged to continue with the oral supplement. Prior to discharge, the hospital staff provided additional education and high-value supplement coupons. After discharge, the team conducted follow-up calls to answer any nutrition-related questions that the patients had.

Katie Riley-Siwak, RN, post-acute CNO at Advocate Aurora Health, said, "We know that malnutrition is a vicious cycle and we wanted to break the cycle. In Phase 1 of the Quality Improvement Program, we saw all-cause readmission decrease by 29 percent, length of hospital stay decreased by 26 percent and the cost savings were $5 million over a six-month period of time."

Phase 2 of the Quality Improvement Project focused on providing oral nutrition supplementation to patients who were discharged to home health. Since Advocate Health Care has its own home health company, it was easy to track patients discharged from the hospital to home healthcare. QIP Phase 2 showed substantial benefits for patients, regardless of whether they were discharged to home health from the hospital or a skilled nursing facility.

QIP Phase 3 has focused on patients who came from group practices. Advocate Health screened any patient that entered the organization from anchor offices on the North and South sides of Chicago. Once patients were screened, they were asked if they would participate in the study. Individuals who agreed were given a 30-day supply of an oral nutritional supplement. These patients benefitted more over a 90-day period of time than patients in other QIP phases. These individuals also had a reduced risk for hospitalization after 30, 60 and 90 days, translating to $1500 in savings per patient.

Dr. McCune noted, "Among Medicare Advantage patients, we know that if we capture the Hierarchical Condition Category below 18.5, there is a real opportunity. Although we've tried to address food deserts through food pantries and other programs, our physicians appreciate the simplicity of a prescription of two bottles of oral nutrition supplementation per day."

Operationalizing a nutrition care program

Advocate's approach to nutrition care is a model that can be emulated by other health systems. An important part of the strategy is to identify patients before they are hospitalized. Another critical component is the ability to manage patients throughout their continuum of care. A key enabler is an EMR with a continuity of care record.

Advocate has created a model that electronically identifies patients coming in each day that have a body mass index of 18.5 or lower. In addition, the health system has created an interdisciplinary team to focus on the organization's most complex patients. Dr. McCune explained, "We bring together physicians, pharmacy, nutrition, spiritual care and care managers to identify each patient's key needs." The organization has also adopted a six-month, pre- and post-overall-cost-of-care evaluation.

The team at Advocate Health Care has identified six recommendations for implementing a nutrition care program:

1.       Leverage malnutrition risk screening for the entire patient population.

2.       Recognize that systematic nutrition interventions are effective for improving patient outcomes.

3.       Promote effective nutrition care across the care continuum, from the hospital setting to post-acute care and home care.

4.       Initiate interventions promptly; Advocate Health Care's physicians have appreciated the ability to offer a simple solution to patients.

5.       Provide continuous nutrition education support for patients, caregivers and staff.

6.       Encourage multidisciplinary teamwork.

Ms. Riley-Siwak underscored the importance of taking a holistic view of patient care and nutrition. She noted, "The more we continue to treat patients like silos, the more challenges we will have. We want to keep patients healthy in the community as much as possible."

Conclusion

Phase 2 and Phase 3 of Advocate's Quality Improvement Program demonstrate that nutrition care is scalable beyond the hospital. No matter what the caregiver setting is, oral nutrition supplementation delivers benefits to patients. The steps are the same: organizations must identify patients, empower them to take positive action and then follow them throughout the continuum of care.

Dr. McCune said, "We need to create an institutional culture that is mindful of social determinants of health. In particular, we must be concerned about malnutrition and redefine the clinician's role to include the patient's nutrition."

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