April 2020 Issue
Malnutrition in Hospitalized Older Adults
By Wendy Phillips, MS, RD, CD, CNSC, CLE, NWCC, FAND
Vol. 22, No. 4, P. 22
An Evaluation of This Dire Diagnosis and How MQii Is Turning the Tide
For many years, malnutrition was noted as an “imbalance of nutrients” and wasn’t well defined.1,2 International nutrition organizations focused efforts over the past two decades to more clearly identify malnutrition clinical characteristics that can be objectively measured and that characterize the presence and degree of malnutrition.1,3 The goals are to predict which patients are most likely to be malnourished and the nutrition interventions that can be applied on an individual and societal level to decrease the incidence of malnutrition.4
Hospitals in the United States incur more than $49 billion per year in expenses for hospital stays involving malnutrition. A government report showed that the cost in 2016 for an individual hospital stay for a malnourished patient averaged $25,600 vs $13,900 for a nonmalnourished patient, reflecting both direct and indirect costs. Direct costs include dietitian and nurse labor, food and supplements, and other supply costs. Indirect costs related to malnutrition include the following5:
• an extended length of hospitalization, reported to be on average an extra 6.2 days per hospitalization; and
• higher likelihood of unplanned readmission within 30 days (23.2% for malnourished patients compared with 14.9% for nonmalnourished patients).
Perhaps most importantly, patients with malnutrition are more likely to experience infections,6,7 poor wound healing,8-11 falls,12 and a lower quality of life (QOL).13,14 According to Maureen Janowski, RD, LDN, CSG, FAND, director of clinical support for Morrison Healthcare in Atlanta, “Physical function is probably the biggest influence on QOL in older adults. Those that have good mobility and functional status have a much better QOL than the frail older adult.” Poor functional status, and therefore a lower QOL, is related to malnutrition. The highest prevalence of malnutrition occurs in the 85 and older age group, and the second highest prevalence in the 65–84 age group.15-17 In fact, almost 7 in 10 hospitalized adults aged 65 and older are malnourished.2
Malnutrition Quality Improvement Initiative
In recognition of both the enormous financial burden on the health care system and the high potential for poor QOL for older adults and their caregivers, the Defeat Malnutrition Today (DMT) coalition was established in 2015; the Academy of Nutrition and Dietetics (the Academy) and Avalere Health lead this effort with more than 100 partner organizations.18
The DMT coalition primarily has focused its efforts on preventing and treating malnutrition in older adults due to the high prevalence in this population.1 The DMT coalition released “National Blueprint: Achieving Malnutrition Care for Older Adults” in 2017, which provides guidance for malnutrition care throughout the Nutrition Care Process and in acute and postacute care and community settings.4 The goal is to improve health outcomes for older adults by standardizing nutrition care, quality improvement, and public policy recommendations for patients, caregivers, and health care providers, as well as facility, community, state, and national policymakers.
According to Terese Scollard, MBA, RDN, LD, FAND, owner of MySurgeryPlate LLC, based in Beaverton, Oregon, “each patient has a right to nutrition care that prevents malnutrition when hospitalized or in ambulatory settings.”19 As the immediate past chair of the Clinical Nutrition Management Dietetic Practice Group, Scollard partners with other RDs to advocate for improvements in health care infrastructure and accountability and mentor future dietitians to continue the work to remove malnutrition as a concern in health care.
In addition to the National Blueprint, the DMT coalition published a comprehensive Malnutrition Quality Improvement Initiative (MQii) Toolkit in 2016 to address the gaps in older adult malnutrition care.18 Development of the MQii was based on extensive literature reviews, stakeholder interviews, and pilot studies.
Despite clear evidence that malnutrition affects health outcomes and that targeted interventions can ameliorate those effects, few malnutrition-specific quality reporting measures existed within health care facilities.20 Therefore, the MQii includes electronic clinical quality measures, as listed in Table 1; these are recommended for use in quality reporting and payment programs such as the Inpatient Quality Reporting measures and Qualified Clinical Data Registries for eligible providers, including RDs, to satisfy requirements for the Merit-based Incentive Payment System for ambulatory services.20,21
The Academy and Avalere Health also are testing a Global Malnutrition Composite Score, which combines these four malnutrition care steps into one quality measure.20 RDs and facilities can sign up for the MQii Learning Collaborative to learn more and receive assistance to implement the MQii.22 Access the full toolkit and accompanying resources at http://malnutritionquality.org.
While the MQii was developed for use with older adults in hospitals, the principles of quality improvement and malnutrition care throughout the Nutrition Care Process remain the same regardless of age group or health care setting.23 The DMT coalition is working with RDs to expand the malnutrition quality improvement tools throughout each step of the Nutrition Care Process to inpatient rehabilitation facilities and long term care (LTC) facilities, as some steps of the Nutrition Care Process may be implemented differently in these settings (such as nutrition screening and care plan development and monitoring/evaluation).
Rya K. Clark, RDN, LD, CNSC, clinical nutrition manager at TIRR Memorial Hermann in Houston, describes her experience with the MQii at her inpatient rehabilitation facility: “MQii empowers participants with three key elements to address older adult malnutrition: current literature on the impact of malnutrition in this vulnerable population; validated performance improvement measures; and support to collect meaningful internal data. The data we have collected allowed us to define prevalence of malnutrition, which is 26% present on admission, and make meaningful correlations to our current performance measures, such as functional independence, discharge to community, and length of stay.”
Nutrition Care Process for Malnutrition
RDs can help prevent and treat this costly and burdensome disease through application of the Nutrition Care Process for malnourished individuals.
While older adults admitted to an LTC or inpatient rehabilitation facility may be more likely to receive a nutrition assessment due to state and federal facility licensing rules and longer average lengths of stay,24,25 hospitals and ambulatory clinics usually don’t staff enough RDs to complete a nutrition assessment and care plan for all admitted patients.26,27 There must be a system to identify which patients are at the highest nutrition risk and in need of a nutrition referral to an RD.
The first step in this process is usually the completion of a nutrition screening tool with a predetermined list of questions to identify nutrition risk.28 Nursing staff members or their designees usually complete this during the admission or clinic intake process. The use of a validated nutrition screening tool that’s appropriate for the patient population served in that health care setting is recommended; the Evidence Analysis Library® from the Academy should be consulted to choose the appropriate tool.29
Nutrition assessment involves obtaining, verifying, and interpreting the data needed to identify nutrition diagnoses, along with their causes and significance.28 At minimum, older adults identified to be at nutrition risk using a validated nutrition screening tool, regardless of care setting, should be assessed using the following components:
• nutrition-focused physical exam, including hydration status and signs and symptoms of macro- or micronutrient deficiency;
• skin integrity and wound healing progress, as applicable;
• anthropometric changes;
• biochemical tests;
• nutrition-related medication interactions and effects; and
• diet history, including current and usual intake and macro- and micronutrient dietary adequacy.
An evidence-based set of criteria then should be used to evaluate the presence and degree of malnutrition.30 The malnutrition clinical characteristics for adult malnutrition, published as a consensus statement by the Academy and the American Society for Enteral and Parenteral Nutrition (ASPEN) in 2012, are the recommended criteria to be used in the United States.1
A validation study is underway to determine the ability of these criteria to predict health outcomes associated with malnutrition.31,32 While the Academy/ASPEN consensus statement criteria are appropriate for use in the United States, the need remained to identify characteristics that could be measured, compared, and reported throughout the world. The Global Leadership Initiative on Malnutrition (GLIM) includes several of the major international clinical nutrition societies, including the US Academy and ASPEN.
In 2018, GLIM published a set of core diagnostic criteria that can be used to determine the presence and degree of malnutrition in adults throughout the world. Clinicians are encouraged to document the patient-level data included in the GLIM malnutrition diagnostic criteria in discrete fields in the medical record so they can be used for data reporting, but the country-specific criteria is what should be used to determine the presence of and degree of malnutrition. In the United States, older adults should be evaluated using the Academy/ASPEN criteria.33
Malnutrition is one of many nutrition diagnoses that a patient may exhibit.34 Based on the nutrition assessment, RDs can assign malnutrition as a nutrition diagnosis, and then should communicate the following information to the licensed independent practitioner who has medical diagnostic privileges35:
• degree of malnutrition (severe or nonsevere);
• context of malnutrition (acute, chronic, or social/environmental);
• etiology of malnutrition;
• signs/symptoms indicating malnutrition; and
• nutrition interventions that will treat the nutrition diagnoses, including malnutrition.
Once the licensed independent practitioner has documented the malnutrition as a medical diagnosis, the medical coder should translate that documentation to the appropriate diagnostic code to be included on the billing claim form. This malnutrition coding process has been a focus of quality improvement efforts in US hospitals over the past five to 10 years because of the potential for significantly higher Medicare reimbursements through the Inpatient Prospective Payment System (IPPS).36
In 2019, the LTC facility payment model switched to the Patient Driven Payment Model, and for the first time a malnutrition diagnosis can influence payment in this care setting.37 This will provide an important focus on malnutrition care in LTC facilities, where the majority of the population is older adults.
Nutrition Intervention, Monitoring, and Evaluation
Nutrition interventions must be individualized to address the patient’s own nutrition-related goals and should be targeted to address the etiology of the malnutrition.38 Resolution of the signs and symptoms of malnutrition during the monitoring and evaluation steps of the Nutrition Care Process will indicate whether the interventions are appropriate.
When allowed to do so by state and facility rules and regulations, RDs should seek privileges to write nutrition orders to treat malnutrition. According to Kate Willcutts, DCN, RD, CNSC, clinical nutrition director at the University of Virginia Health System, “Once the RDNs were given the ability to write nutrition orders per a facility-approved protocol, their workflow and the providers’ workflow was streamlined to allow quicker implementation of nutrition interventions to all patients, including older adults. It has also allowed improved overall work efficiency, so more time can be spent with patients.”
Transitions of Care
Discharge planning isn’t a distinct step of the Nutrition Care Process. Rather, discharge needs should be assessed and a plan developed throughout each step of the Nutrition Care Process.31 Patients are likely to readmit to the hospital due to at least the three following factors39:
• inadequate risk assessment, such as failing to recognize food insecurity issues;
• communication or education breakdowns, such as inadequately communicating tube feeding instructions or failure to provide written education materials in the language the patient prefers; and/or
• false assumptions made by care providers, such as presumptions made about the patient’s literacy level and comprehension.
Therefore, increased focus should be placed on hands-off communication, education, and other factors related to improving these transitions of care. RDs can execute clinical nutrition interventions as part of the interdisciplinary transition of care plan. A best practice for malnourished older adults includes a documentation section in the electronic health record (EHR) titled “Discharge Nutrition Plan” or “Transitions of Care Plan,” as the regulatory accreditation bodies such as The Joint Commission require comprehensive discharge planning services.40
Table 2 provides example nutrition discharge planning documentation. The goal is to provide safe, quality care for patients as they transition through health care settings, including home.
Janowski shares her experience working with older adults transferring from hospitals to LTC facilities. “At best, the discharge planning process would include the RDNs’ full nutrition assessment,” she says. “If the EHR or facility communication plan does not support this, there should at least be a short paragraph from the RDN about the patient’s nutritional status, which would include a nutrition diagnosis of malnutrition, if applicable. It is also important to include the interventions currently being used to help improve the patient’s nutritional status.”
A key component of interdisciplinary transition of care planning includes the “Present on Admission (POA)” indicator for diagnoses.41 When a medical diagnosis is added as a code to the billing claim form, the coder must indicate whether it was POA. This can influence the insurance reimbursement for the stay and is another reason the malnutrition diagnosis should be communicated appropriately between care settings.42 The potential to increase payment in the IPPS and the Patient Driven Payment Model helps to provide this necessary focus.37,42
Conversely, malnutrition diagnoses don’t influence inpatient rehabilitation facility admission eligibility, nor do they influence Medicare payment for the inpatient rehabilitation facility stay.43 RDs such as Clark and groups such as the DMT are using the MQii to help advocate for a change in payment and quality measure criteria for inpatient rehabilitation facilities to improve prioritization of malnutrition diagnoses. This can promote appropriate communication of malnutrition diagnoses in this important transitional care setting.
Regardless of the payment status, the malnutrition diagnosis, when present, should be documented by the RD as a nutrition diagnosis and by the licensed independent provider as a medical diagnosis, and the medical coder should include it in the claim form. This will help ensure nutrition interventions continue when needed and help coders more accurately indicate whether the diagnosis was POA.
RDs can partner with other health care team members and the patient and caregiver(s) to prevent and/or treat malnutrition using the MQii throughout the Nutrition Care Process. RDs should review the National Blueprint, the MQii Toolkit, the Academy’s clinical malnutrition resource page at www.eatrightpro.org/malnutrition, and ASPEN’s Malnutrition Solution Center at www.nutritioncare.org/guidelines_and_clinical_resources/Malnutrition_Solution_Center. Janowski recommends resources available from the dietetic practice groups Dietitians in Health Care Communities and Healthy Aging, as well as the book Nutrition Care of the Older Adult: A Handbook for Nutrition Throughout the Continuum of Care, 3rd edition.44 RDs are the expert providers to develop malnutrition programs in every care setting.
— Wendy Phillips, MS, RD, CD, CNSC, CLE, NWCC, FAND, is a regional vice president for Morrison Healthcare. During her 20 years as a dietitian, she has worked to promote RDs as the nutrition experts to identify and treat malnutrition, including championing national reform efforts for order writing privileges for RDs.
1. White JV, Guenter P, Jenson G, et al. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet. 2012;112(5):730-738.
2. What is malnutrition? World Health Organization website. https://www.who.int/features/qa/malnutrition/en/. Published July 8, 2016. Accessed December 23, 2019.
3. Mehta NM, Corkins MR, Lyman B, et al. Defining pediatric malnutrition: a paradigm shift toward etiology-related definitions. JPEN J Parenter Enteral Nutr. 2013;37(4):460-481.
4. Avalere Health; Defeat Malnutrition Today. National blueprint: achieving quality malnutrition care for older adults. https://defeatmalnutrition.today/sites/default/files/documents/MQC_Blueprint_web.pdf. Published March 2017.
5. Barrett ML, Bailey MK, Owens PL; Healthcare Cost and Utilization Project. Non-maternal and non-neonatal inpatient stays in the United States involving malnutrition 2016. https://www.hcup-us.ahrq.gov/reports/HCUPMalnutritionHospReport_083018.pdf. Published August 30, 2018. Accessed December 13, 2019.
6. Thibault R, Makhlouf AM, Kossovsky MP, et al. Healthcare-associated infections are associated with insufficient dietary intake: an observational cross-sectional study. PLoS One. 2015;10(4):e0123695.
7. Schneider SM, Veyres P, Pivot X, et al. Malnutrition is an independent factor associated with nosocomial infections. Br J Nutr. 2004;92(1):105-111.
8. Tsaousi G, Stavrou G, Ioannidis A, Salonikidis S, Kotzampassi K. Pressure ulcers and malnutrition: results from a snapshot sampling in a university hospital. Med Princ Pract. 2015;24(1):11-16.
9. Brito PA, de Vasconcelos Generoso S, Correia MI. Prevalence of pressure ulcers in hospitals in Brazil and association with nutritional status — a multi-center, cross sectional study. Nutrition. 2013;29(4):646-649.
10. Banks M, Bauer J, Graves N, Ash S. Malnutrition and pressure ulcer risk in adults in Australian health care facilities. Nutrition. 2010;26(9):896-901.
11. Shahin ES, Meijers JM, Schols JM, Tannen A, Halfens RJ, Dassen T. The relationship between malnutrition parameters and pressure ulcers in hospitals and nursing homes. Nutrition. 2010;26(9):886-889.
12. Julius M, Kresevic D, Turcoliveri M, Cialdella-Kam L, Burant CJ. Malnutrition as a fall risk factor. Fed Pract. 2017;34(2):27-30.
13. Nguyen HT, Collins PF, Pavey TG, Nguyen NV, Pham TD, Gallegos DL. Nutritional status, dietary intake, and health-related quality of life in outpatients with COPD. Int J Chron Obstruct Pulmon Dis. 2019;14:215-226.
14. Rojas-Loureiro G, Servín-Caamaño A, Pérez-Reyes E, Servín-Abad L, Higuera-de la Tijera F. Malnutrition negatively impacts the quality of life of patients with cirrhosis: an observational study. World J Hepatol. 2017;9(5):263-269.
15. Tobert CM, Mott SL, Nepple KG. Malnutrition diagnosis during adult inpatient hospitalizations: analysis of a multi-institutional collaborative database of academic medical centers. J Acad Nutr Diet. 2018;118(1):125-131.
16. Weiss AJ, Fingar KR, Barrett ML, et al. Characteristics of hospital stays involving malnutrition, 2013. Healthcare Cost and Utilization Project website. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb210-Malnutrition-Hospital-Stays-2013.jsp. Published September 15, 2016.
17. Corkins MR, Guenter P, DiMaria-Ghalili RA, et al. Malnutrition diagnoses in hospitalized patients: United States, 2010. JPEN J Parenter Enteral Nutr. 2014;38(2):186-195.
18. McCauley SM, Mitchell K, Heap A. The Malnutrition Quality Improvement Initiative: a multiyear partnership transforms care. J Acad Nutr Diet. 2019;119(9S2):S18-S24.
19. Scollard T. Commentary: the concept of malnutrition prevention and integration in the ambulatory care setting. Future Dimens. 2019;38(2):22-25.
20. McCauley SM, Khan M, D’Andrea C. Academy of Nutrition and Dietetics: quality measures for malnutrition. J Acad Nutr Diet. 2019;119(9):1541-1544.
21. CMS approves inclusion of Malnutrition Quality Measures. Academy of Nutrition and Dietetics website. https://www.eatrightpro.org/news-center/in-practice/quality-and-coverage/cms-approves-inclusion-of-malnutrition-quality-measures. Published December 21, 2019. Accessed December 23, 2019.
22. About the MQii. Malnutrition Quality Improvement Initiative website. http://malnutritionquality.org/about-mqii.html. Accessed December 23, 2019.
23. Nutrition Care Process. Academy of Nutrition and Dietetics, Evidence Analysis Library website. https://www.andeal.org/ncp. Accessed December 23, 2019.
24. Phillips W, Janowski M. RDN productivity benchmarks for long term care settings. J Acad Nutr Diet. 2017;117(9 Suppl):A47.
25. Centers for Medicare & Medicaid Services. State Operations Manual: appendix PP — guidance to surveyors for long term care facilities. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf. Updated November 22, 2017. Accessed December 23, 2019.
26. Phillips W, Janowski M, Brennan H, Leger G. Analyzing registered dietitian nutritionist productivity benchmarks for acute care hospitals. J Acad Nutr Diet. 2019;119(12):1985-1991.
27. National Academies of Sciences, Engineering, and Medicine. Examining access to nutrition care in outpatient cancer centers: proceedings of a workshop. https://www.nap.edu/read/23579/chapter/1. Published 2016. Accessed December 23, 2019.
28. Academy of Nutrition and Dietetics. Academy of Nutrition and Dietetics definition of terms list. https://www.eatrightpro.org/-/media/eatrightpro-files/practice/scope-standards-of-practice/20190910-academy-definition-of-terms-list.pdf. Published September 10, 2019. Accessed December 23, 2019.
29. Nutrition screening adults. Academy of Nutrition and Dietetics, Evidence Analysis Library website. https://www.andeal.org/topic.cfm?menu=5382. Accessed December 23, 2019.
30. Academy of Nutrition and Dietetics, Electronic Nutrition Care Process Terminology website. http://www.ncpro.org. Accessed December 24, 2019.
31. Hand RK, Murphy WJ, Field LB, et al. Validation of the Academy/A.S.P.E.N. malnutrition clinical characteristics. J Acad Nutr Diet. 2016;116(5):856-864.
32. Malnutrition clinical characteristics validation and staffing optimization study (MCC study). ClinicalTrials.gov website. https://clinicaltrials.gov/ct2/show/NCT03928548. Updated April 26, 2019. Accessed June 17, 2019.
33. Jensen GL, Cederholm T, Correia MITD, et al. GLIM criteria for the diagnosis of malnutrition: a consensus report from the global clinical nutrition community. JPEN J Parenter Enteral Nutr. 2019;43(1):32-40.
34. NCP step 2: nutrition diagnosis. Academy of Nutrition and Dietetics, Electronic Nutrition Care Process Terminology website. https://www.ncpro.org/pubs/encpt-en/page-036. Accessed December 24, 2019.
35. Phillips W. Coding for malnutrition in the adult patient: what the physician needs to know. Pract Gastroenterol. 2014;39:52-60.
36. Phillips W. Accurate documentation of malnutrition diagnosis reflects increased healthcare resource utilization. Nutr Clin Pract. 2015;30(5):604-608.
37. Patient Driven Payment Model. Centers for Medicare & Medicaid Services website. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html. Updated February 11, 2020.
38. NCP step 3: nutrition intervention. Academy of Nutrition and Dietetics, Electronic Nutrition Care Process Terminology website. https://www.ncpro.org/pubs/encpt-en/page-050. Accessed December 24, 2019.
39. The Joint Commission. Transitions of care: the need for a more effective approach to continuing patient care. https://www.jointcommission.org/-/media/deprecated-unorganized/imported-assets/tjc/system-folders/topics-library/hot_topics_transitions_of_carepdf.pdf?db=web&hash=CEFB254D5EC36E4FFE30ABB20A5550E0. Published June 2012. Accessed December 25, 2019.
40. Joint Commission Accreditation. Comprehensive Accreditation Manual 2019: CAMH for Hospitals. Oakbrook Terrace, IL: The Joint Commission; 2019.
41. Coding. Centers for Medicare & Medicaid Services website. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Coding. Updated February 11, 2020.
42. Centers for Medicare & Medicaid Services; Medicare Learning Network. Acute care hospital Inpatient Prospective Payment System. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AcutePaymtSysfctsht.pdf. Published February 2019. Accessed December 25, 2019.
43. Phillips W. Identifying and documenting malnutrition in inpatient rehabilitation facilities. J Acad Nutr Diet. 2019;119(1):13-16.
44. Niedert KC, Carlson MP, eds. Nutrition Care of the Older Adult: A Handbook for Nutrition Throughout the Continuum of Care. 3rd ed. Chicago, IL: Academy of Nutrition and Dietetics; 2016.