While the transition to value-based care has taken longer than expected, the inertia behind the shift is decades old and unlikely to cease regardless of governmental policy.
This content is sponsored by Abbott Nutrition
The American healthcare system has pushed toward better outcomes and lower costs since the introduction of managed care and capitation under health maintenance organizations (HMOs) in the mid-1990s. After ACA came into effect, failure to optimize outcomes could cause a range of fiscal penalties. For example, Centers for Medicare and Medicaid Services (CMS) penalized 2,573 hospitals in October 2017 for having too many Medicare patients readmitted within 30 days.
In 2007, the Institute for Healthcare Improvement (IHI) created a framework under which hospitals could optimize financial performance and improve outcomes — the Triple Aim. The revolutionary IHI guideline calls for improving the patient experience, reducing per capita costs and making patient populations healthier. According to the health services researcher, Wm. Thomas Summerfelt, PhD, one widely overlooked quality improvement initiative capable of vastly improving the performance of a hospital per the tenets of the Triple Aim is nutrition supplementation.
Nutrition — Healthcare's blind spot
During a workshop at Becker's Hospital Review 9th Annual Meeting on April 12 in Chicago, Dr. Summerfelt, former vice president of research and innovation with Downers Grove, Ill.-based Advocate Health Care and current president of the North American office of health IT company Convergence CT, cited a number of studies that established a link between patient malnutrition and increased length-of-stay, greater care cost, and higher mortality rates as well as likelihood of pressure ulcers and readmission rates.
Dr. Summerfelt placed a particular emphasis on findings from a comprehensive study published in the American Journal of Managed Care in 2013, which included 11 years of data from 44 million patients treated at 460 hospitals. The study's authors found an oral nutritional supplement ordered during a hospital stay was associated with a length-of-stay reduction of 2.3 days and a 6.7 percent decrease in the risk of 30-day readmission.
"The fact of the matter is there's all this literature, yet the [nation's] healthcare system has not implemented or integrated nutrition into its clinical care delivery system," Dr. Summerfelt said.
During his time at Advocate, Dr. Summerfelt spearheaded a research initiative to identify the potential benefits of improved nutrition among Advocate hospital patients. Dr. Summerfelt's department began looking into patient malnutrition after hearing from Advocate nutritionists and dietitians that the organization could do better.
"Nutrition gets compromised during hospital stays," Dr. Summerfelt said. "We do really well with pneumonia, we do great with minimally invasive surgeries, we do awesome with cardiovascular disease, but [patient] nutrition was not in the foundational fabric of our organization in particular, and I would venture to say that's not uncommon among hospitals in the United States."
Dr. Summerfelt, along with a team of researchers from Advocate and global healthcare company Abbott, launched a study to determine if oral nutritional supplementation could make an impact on patient malnutrition and care outcomes. Four of Advocate's 12 hospitals were tapped to participate in the research initiative, and the research team decided partnering with an industry stakeholder would benefit the effort.
"Abbott accepted the invitation, became a partner, and that was very unique and has been a very unique collaboration," Dr. Summerfelt said, adding a prediction that future collaborations between industry and health systems "are going to be more and more important as we move forward and try to fulfill the Triple Aim" amid the rise of value-based care.
The Abbott-Advocate partnership
From Oct. 13, 2014, through Apr. 2, 2015, researchers enrolled 1,269 Advocate patients identified as at risk for malnutrition in the quality improvement program. The program included a validated screening tool that was integrated into the electronic medical record (EMR) at all four hospitals to trigger oral nutritional supplementation for patients at risk of malnutrition. Two of the participating hospitals implemented enhanced improvement initiatives that included immediate delivery of the nutritional supplements, as well as educational efforts for providers, patients and patient caregivers.
Researchers compared readmission rates, length-of-stay and costs among patients who participated in the nutrition care program and 4,611 patients treated in 2013 who had a diagnosis of malnutrition. Researchers also looked at the readmission rates of 1,319 patients treated over the same six months as the intervention, a year before implementation of the nutrition care program.
Advocate researchers conducted the analysis, which revealed an association between the enhanced nutrition program and a 29 percent decrease in all-cause 30-day readmissions and a 26 percent decrease in length-of-stay compared to established benchmarks, which showed that implementing the nutrition program could save more than $4.8 million from reducing readmission rates and shortening a patient's length-of-stay.
"This was enough to get people's attention, it certainly got my attention" Dr. Summerfelt said. "What Advocate discovered was this is a potent way to take care of patients, especially if you're on the hook for population health management. They really worked on hardwiring all of this initiative into the system and looked at unique and innovative ways to get patients to continue taking nutritional supplements [beyond discharge]."
One of the unique methods implemented by Advocate was giving coupons to patients who received oral nutritional supplements during their hospital stay. Providers at Advocate also conducted post-discharge phone calls with patients to check up on nutritional knowledge and habits.
A basic element of care
The results seen at Advocate were driven by malnutrition risk-screening at admission, staff education, EMR utilization and, perhaps most importantly, cultural change. Under the initiative, it became second nature for frontline providers to educate patients about the importance of healthy eating and nutritional supplementation.
"Nutrition is a basic element of caring for human beings," Dr. Summerfelt said. "It's great that we have all the technology and medical innovations that we have, but if we don't feed our patients adequately, then we really can't have hopes for optimum [care] outcomes."
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