Welcome to today’s discussion on improving malnutrition care. As some of you may know, malnutrition among hospitalized patients often leads to longer hospital stays, increased medical complications, higher morbidity and mortality, and increased readmissions—particularly for older adults. Unfortunately, malnutrition is often not diagnosed or effectively treated and thus represents a gap in quality healthcare. I am Kelsey Jones, a Director at Avalere Health and a contributor to the MQii. Joining me today to talk about the growing crisis of malnutrition care and its impact on patients is Karim Godamunne.
Karim is the Chief Medical Officer at North Fulton Hospital and is closely engaged with the Patient and Family Advisory Council there. He is a hospitalist and is actively involved in supporting quality improvement efforts with hospitalists around the country. He has served as the Society of Hospital Medicine’s national representative for malnutrition and chaired a malnutrition taskforce for an 85-hospital health system. He is also the author of the article “An emergency call to food! There’s a MALNUTRITION GAP IN HOSPITALS” and lead author of the Opinion Article, “Malnutrition and healthcare-acquired infections: the need for policy change in an evolving healthcare landscape” in the The Journal of Hospital Infection. Karim serves on the Malnutrition Quality Improvement Initiative Advisory Council and the Technical Expert Panel for the new MQii electronic clinical quality measures.
Moderator - Kelsey:
Karim, given the well documented fact that 1 in 3 hospitalized patients are malnourished and 4-19 million malnutrition cases are left undiagnosed yearly, as well as the fact that malnutrition can increase hospital cost up to 300%, what do you think are the most important next steps to address and improve malnutrition in our nation?
Thanks Kelsey. I think the answer is there is not one step, there’s several steps needed to address this. One in particular that comes to my mind is the need to have a systems based response to malnutrition. You know I’m a physician by background and I know when I’m in practice working as a hospitalist, it’s very hard to see and identify every single type of malnutrition. In fact, I’m sure I don’t. That’s just the reality and challenges of diagnosing malnutrition. What that means for me is there needs to be a systems approach to diagnosing malnutrition. Clearly, a physician has a critical role to play, but also the dietitian, maybe a coding documentation specialist and obviously the nurses as well – that could be the admitting nurse and the nurses providing day to day care. It really is a team approach. As I said, you need a systems approach to that care and delivery, but you also need to buttress that with good data – being clear on admissions, who’s being screened, who’s being accessed, who on depart needs their malnutrition continue to be addressed post discharge so that way you know there is a continuum of care being met across both in the hospital as they arrive and to continue it post discharge.
Again, malnutrition is not specific to the acute hospitals. We need to reach out to our post-acute care partners, we need to make sure they continue the nutrition intervention started in the hospital, also educate with our care providers in the community- cancer care providers for example whose patients are particularly at risk for to make sure that they address or be aware of this problem as their patient develops an acute illness, or has chronic malnutrition.
Taking that a step further, I would look at the data, the data analytics. There needs to be new tools to help us assess and quantify malnutrition as it is relevant to your healthcare system to make sure that data is transparent to the care provider. There is more and more and better quality data out there, i.e., big data tools. But they are is still comparatively siloed, meaning that they are not going into the hands of the end users – the physicians as the other providers that provide the care so that they are aware of what’s going on. I think that’s going to be fundamentally important to help us address malnutrition.
The other part of that us quality measures such as eCQM. Hopefully one day we can have eCQMs to help us address malnutrition. I believe that’s a tremendous way to do it. We’ve seen that work before in the past, it helps drive hospitals to change behaviors. Having the appropriate quality measures embedded, so to speak, through an eCQM-type process that’s basically an electronic quality measure – I think is really critical to help drive this to the next level. We’ve seen that done before for meaningful use, in electronic medical records. It’s successful, it works, it makes it much more transparent. I think the combo of the systems approach, eCQMs, education, and team approach all working together will make tremendous gains in addressing malnutrition.
What do you see as the major impact of malnutrition on your patients, and how do you think they can get involved in malnutrition care?
In terms of the major impact on patients with malnutrition – we know it’s substantial. There’s a tremendous amount of cost burden to the system because of under-treatment of malnutrition. We know there’s increased mortality, increased lengths of stay, increased readmissions, and many other impacts on patients – increased wounds, as an example. What we do see is many patients and families are not aware of this. They have not been educated around this and this is let alone for the care provider or physician. But, for the example using the Patient and Family Advisory Council (PFAC), they are a tremendous opportunity to help get that message out so to speak.
PFACs, which are present in many hospitals and growing, and some are actually state-mandated, like in the state of Massachusetts and here in North Fulton we have a PFAC, we find them to be tremendous advocates for the “voice of the patient.” They need to be educated on malnutrition so they understand the impact on patients, the burden it’s done to the community, how malnutrition can be addressed. And frankly, if you look at the mission statement for PFAC, it aligns very closely with what addressing malnutrition entails. They are very focused on improving outcomes, supporting hospitals mission for quality and safety, improving and promoting information sharing between the hospitals and patients, helping establish the organization of priority. I think a PFAC is a very effective mechanism that can help address malnutrition to help get the message out there.
Typically PFAC members can be patients or families, they are often community leaders, or they themselves have family members that get ill so they are a very powerful component to get the message out to the community. In addition, very commonly the PFAC has what I call the “ear” of the executive leadership in a hospital – it’s very important to have good data and active data about what’s going on with malnutrition, but sometimes having that voice of that patient or having that patient story is very, very powerful. And boy, I can tell you we had in our PFAC, when I did this presentation on malnutrition, we had one patient that underwent an extensive operating procedure and he was saying, “If I’d known I’d have been much more engaged to address my nutrition to make sure I’d eaten and done these things,” cause they just don’t understand and have not been educated around this – the importance of that.
I think from the hospital’s perspective the PFAC is a great way to target the patient-centeredness care that we need to do today. We are challenged to find ways to be better patient-centered, but a PFAC is a very effective way to do that. And there are charities and community-based organizations and hospital associations such as your state hospital association that can help you get that set up. If you do have a PFAC, I would really encourage you to get that message out there about malnutrition. Educate them, teach them about that so that’s one more way to get that powerful message out there of how we really need to address malnutrition.
That’s excellent. How do you think engaging patients in malnutrition care can then help advance the quality of care and outcomes patients experience while in – and even beyond – the hospital setting?
I think it’s very critical. The typical length of stay of a patient in a hospital is 4.1 days. We have patients with malnutrition who stay longer, but needless to say the majority of their care will be the outpatient setting care, it won’t be in the acute hospital. The acute hospital may be a great place to identify them and catch them, but after several days of acute hospital stay they will be discharged to either a long term care facility type situation, or to a nursing home, or as is most often the case, to home with some type of additional support or resources. So, I think it’s important that we engage patients in their malnutrition; they need to understand the impact it has to them on their recovery. And not just the patient, it should also be the family, they need to be understanding because a lot of the time the patient can’t be an advocate for themselves and the family can. So I think it’s very important that we advance this care beyond the boundaries of the hospital because that’s the reality of malnutrition whether it’s acute or chronic, or however you define – it is fundamental.