12
Nutrition Services in Post-Acute, Long-Term Care and in Community-Based Programs

Previous chapters have described the strength of evidence supporting the relationship between nutritional status and morbidity, the provision of nutrition therapy for certain chronic diseases, and the nutrition services provided in ambulatory and acute care. This chapter addresses the nutrition services and food assistance programs needed in post-acute care, long-term care, and in community-based programs. The following programs are discussed:

  • Post-acute care

    • Skilled nursing facilities (SNF) or hospital-based sub-acute units

    • Home health agencies (HHA)

  • Long-term care

    • Institutions

    • Programs of All Inclusive Care for the Elderly (PACE)

  • Food assistance for elders in the community

    • Congregate feeding and home delivered meals.

During the last decade, the most rapid growth in Medicare costs has occurred in the area of post-acute care (Clark, 1998; Freedman, 1999; Jackson and Doty, 1998; Liu et al., 1999; NCHS, 1999). Many forces have fueled this growth, including the change to a capitated, prospective payment system (PPS) in acute care, legal actions by patients who were denied care in SNF and HHA programs, the shift to more aggressive reimbursement strategies by Medicare providers, and (to a smaller extent)



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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population 12 Nutrition Services in Post-Acute, Long-Term Care and in Community-Based Programs Previous chapters have described the strength of evidence supporting the relationship between nutritional status and morbidity, the provision of nutrition therapy for certain chronic diseases, and the nutrition services provided in ambulatory and acute care. This chapter addresses the nutrition services and food assistance programs needed in post-acute care, long-term care, and in community-based programs. The following programs are discussed: Post-acute care Skilled nursing facilities (SNF) or hospital-based sub-acute units Home health agencies (HHA) Long-term care Institutions Programs of All Inclusive Care for the Elderly (PACE) Food assistance for elders in the community Congregate feeding and home delivered meals. During the last decade, the most rapid growth in Medicare costs has occurred in the area of post-acute care (Clark, 1998; Freedman, 1999; Jackson and Doty, 1998; Liu et al., 1999; NCHS, 1999). Many forces have fueled this growth, including the change to a capitated, prospective payment system (PPS) in acute care, legal actions by patients who were denied care in SNF and HHA programs, the shift to more aggressive reimbursement strategies by Medicare providers, and (to a smaller extent)

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population changing demographic, economic, and sociological characteristics of the elderly population in the United States. EMERGING TRENDS Both federally funded programs and private payers are evaluating innovative ways to provide services across the continuum of care while attempting to use the least expensive and least intensive care that is appropriate (Cohen, 1998). Examples of such innovation include privately funded social health maintenance organizations (SHMOs) and programs of all inclusive care for the elderly (PACE). SHMOs are demonstration projects that combine community care services and short-term nursing home care with Medicare’s basic services. PACE is a new Medicare benefit; these programs accept the risk of providing all forms of care needed by nursing home-eligible clients for a capitated Medicare fee. When possible, these services are provided while recipients remain in their homes (HCFA, 1998). Another trend is that traditional nursing homes are expanding “up” to include more complex services, such as subacute care, and “down” to provide less complex services, such as home care and assisted living (Evashwick et al., 1998; Lehrman and Shore, 1998). However, the largest number of elders are still being cared for by informal caregivers such as family and friends (AoA, 1998; Cutler and Sheiner, 1993). Both federally and privately funded health insurance plans are moving from a fee-for-service system to a partially or fully capitated (PPS) in all areas of care, including skilled nursing, home care, and outpatient services. Future trends will be affected by longer lifespans and the desire of older people to remain independent as long as possible (Economics and Statistics Administration, 1995; Hawes et al., 1999; Manard and Cameron, 1997). Increased longevity has significant cost implications. The precise impact on Medicare expenditures is unknown and depends on evolving Medicare policies and social practices, changing medical technology, and the prevalent morbidities within the older population. As health care shifts from acute care to community and home-based programs, provided by a mix of health professionals, paraprofessionals, and informal caregivers, effective nutrition services and food assistance programs are likely to become especially important. However, the present system of including nutrition services in overall administrative costs, rather than direct reimbursement, creates a financial disincentive to address the nutrition problems of older people. If nutritional status and food security diminish as a result of this inattention, the older person may develop subsequent illnesses that require more acute and expensive care

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population (Cornoni-Huntley et al., 1991; Frisoni et al., 1995; Gray-Donald, 1995; Mowé et al., 1994). SKILLED NURSING FACILITIES AND NURSING HOMES Skilled nursing facilities (SNF) are defined as health facilities that provide the following basic services: 24-hour inpatient care that includes medical, nursing, dietary, and pharmaceutical services, and an activity program. Other services such as rehabilitation and social work, not regularly needed by all residents, may be contracted (CFR, 1998). Many SNFs provide subacute care or have special units for dementia, rehabilitation, and human immunodeficiency virus/acquired immune deficiency syndrome. Residents in these special care units often have more complex nutrition needs. SNFs are usually part of a free-standing nursing home that provides long-term care for chronically ill, frail elders. There may also be SNF units in acute care facilities. Medicare Funding Medicare covers 100 days of SNF care per benefit period, but it must follow a 3-day hospital stay; days 21 through 100 are subject to a copayment by supplemental insurance or by the patient.1 Until 1998, SNFs received retrospective, cost-based reimbursement. Medicare began the transition to a PPS in 1998, and phase-in is expected to be completed by 2001. This system is based on encounter with the patient rather than on an episode, such as an admission for a specific diagnosis as in acute care facilities. In the PPS system, SNFs are paid an all-inclusive, predetermined, federal per diem rate regardless of actual costs of patient care. The rate is adjusted for the SNF’s case mix, based on resource use; the case mix components that affect costs are nursing and rehabilitation use. Billing for Part A along with the services that were covered under Medicare Part B in the past, such as contracted services with rehabilitation personnel, are consolidated. Other Part B services, such as physicians’ care, are still billed separately (Congressional Research Service, 1998; House Ways and Means Committee, 1996). When a person no longer needs skilled nursing care, she or he may continue to reside in a nursing home for chronic care. In this case, Medicare payments for Part B-covered services (except physicians’ services) are made directly to the nursing facility, whether the services are pro- 1   A “benefit period” lasts for 60 consecutive days; it commences on the first day of admission to a hospital and ends on discharge from the SNF. Benefit periods can be renewed.

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population vided by an employee of the nursing home or by an outside person who contracts with the nursing home. The rest of the costs of nursing care are borne by the patient, supplemental insurance, or Medicaid. In both the old retrospective payment system and the new PPS system, nutrition services are considered part of the per diem rate and not reimbursed directly, as are rehabilitation services. Use of a dietitian is mandated by both licensing and accreditation standards (CFR, 1998; JCAHO, 1998a). However, as SNFs face more financial risk with the new PPS, there is increased potential for cost containment of basic services (Grimaldi, 1999). Need for Nutrition Services and the Role of the Nutrition Professional Even though SNFs and nursing homes are required to have a dietitian, the amount of time dietitians actually spend in these facilities varies. The time budgeted for a dietitian in a facility often depends on state requirements, the severity of patients’ conditions, nutrition interventions needed, results of previous licensing and accrediting surveys, and economic factors within the SNF and the community. State requirements for licensing of SNFs include the minimum level of dietitian coverage; although it varies, 8 hours per month is not uncommon. Little can be accomplished when nutrition problems are identified at this level of service. When a dietitian works part-time, there must be a full-time person in the facility to provide daily oversight of the food and nutrition services. This is usually a certified dietary manager. Identifying Nutrition Problems In 1986, the Institute of Medicine (IOM) Study on Nursing Home Regulation (IOM, 1986) recommended the use of a uniform, comprehensive and outcome-oriented assessment procedure for nursing home residents. The Omnibus Budget Reconciliation Act (OBRA) of 1987 enacted many of the IOM recommendations, including the requirement that all Medicare and Medicaid-certified nursing facilities implement the recommended assessment instrument. This is now part of the statutory and regulatory requirements for long-term care facilities (CFR, 1998; USC, 1998). The Resident Assessment Instrument (RAI) was developed and validated at the Hebrew Rehabilitation Center for the Aged in Boston under a contract with the Health Care Financing Administration (HCFA) (Hawes et al., 1995; Morris et al., 1990) and updated to its present form, version 2.0, in 1995 (Allen, 1997). The RAI includes standardized procedures and forms for collecting data (Minimum Data Set [MDS]). Certain conditions

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population trigger further assessment, based on standard Resident Assessment Protocols (RAP). The final step is to develop a comprehensive resident care plan based on the MDS and RAP information. The following aspects of nutritional care are evaluated in the MDS: oral problems, height and weight, weight change, nutrition problems (altered taste, hunger, uneaten meals), approaches to nutritional care (nutrition support, mechanically altered food, therapeutic diets), and food intake. In addition, other aspects of care that affect or are affected by nutrition are also evaluated: dental care, skin condition, and hydration. There are specific RAPs for nutritional status, feeding tubes, dehydration/fluid maintenance, dental care, and pressure ulcers that provide guidelines for the clinician’s assessment, treatment, and evaluation. Existing research provides mixed reports on the success of the RAI. Some reports indicate improvement in the identification of and intervention for nutrition problems in the nursing home (Blaum et al., 1997; Rantz et al., 1999), whereas others report continued problems. In 1998, the Senate heard testimony regarding the persistence of nutrition problems in California nursing homes, despite the federal regulations requiring assessment, intervention, and monitoring (GAO, 1998). Because of the complexity of the RAI screening and planning process, documentation and the actual care of nursing home residents may not be linked (Rantz et al., 1999). In one descriptive observational study (Kayser-Jones et al., 1997), dietary intake as recorded by the certified nursing assistant (CNA) was significantly different from actual food consumption; in some cases the CNA was observed recording food intake data before the resident actually ate a meal or consistently recording an intake of more than 75 percent, irrespective of the resident’s actual consumption (less than 75 percent food intake is the trigger on the RAP for further evaluation for poor food intake). Nutrition Problems in Nursing Homes Pressure Sores The relationship between nutrient intake and pressure sores illustrates the complexity of nutrition research in the older nursing home resident. Advanced age, chronic disease, multiple and varying levels of treatment, poor nutrient intake, immobility, and cognitive impairment all contribute to unclear conclusions in studies. In all nutrition studies, three aspects have to be addressed: (1) the contribution of undernutrition to morbidity and mortality, (2) how the disease or condition alters nutrient and energy needs, and (3) the role of nutrition intervention in reversing the disease or condition.

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population Does Undernutrition Contribute to the Development of Pressure Sores? Undernutrition is a frequently cited risk factor for the development, presence, and inadequate healing of pressure sores (Finucane, 1995). The prevalence of pressure sores among frail, bedridden patients may be as high as 20 percent (Barbenel et al., 1977), and treatment of these wounds can prolong hospital stay and consume considerable health care resources. Data linking recognized measures of nutritional status with pressure sores in the acute, rehabilitation, or chronic care settings are limited. Observational studies with older people have yielded mixed findings. Poor nutrient intake has been related to the development of pressure sores (Bergstrom and Braden, 1992; Berlowitz and Wilking, 1989) or to their failure to respond to treatment (Allman et al., 1986; Gorse and Messner, 1987). However, an association with nutrient intake has not been consistently observed. Sullivan and Walls (1994) studied 350 geriatric rehabilitation patients prospectively. Twenty-six percent developed complications, including 42 pressure sores of Grade II or higher. There was no association between average daily nutrient intake and these complications. Are Nutrient Needs Altered in Those with Pressure Ulcers? Breslow and coworkers (1991) described observations of 26 nursing home residents who received tube feedings. Most of the patients were immobile, incontinent, and mentally impaired. The needs and nutrient intake of 14 people who had pressure sores were compared to those who did not. Those with pressure sores were slightly older and had lower body mass indices than those who did not have sores. The investigators concluded that those with pressure sores had higher nutrient requirements than those who did not, based on the energy and protein needed to gain weight or restore serum proteins to normal levels. They also concluded that energy and nutrient needs were being underestimated in patients who had pressure sores. Does Nutrition Intervention Play a Part in Healing Pressure Sores? There have been few prospective, controlled trials studying the role of nutrition intervention as an independent variable in the prevention or treatment of pressure sores. Myers and colleagues (1990) randomized patients with pressure sores either to usual care or to special nutrition support consisting of nutrition assessment and prescribed intervention. Even though subjects in the intervention arm were excluded from analysis if they did not receive prescribed energy intake and supplements, the intervention was ineffective in improving pressure sore status. Breslow and coworkers

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population (1993) studied the effect of dietary protein on the healing of pressure sores in malnourished patients. They found that pressure sores healed in those patients receiving a high protein intake (24 percent of total kilocalories) and adequate kilocalories to prevent weight loss. However, their results were confounded by small sample size, nonrandom assignment to groups, and other forms of treatment. A more recent trial by Hartgrink and colleagues (1998) contrasted pressure sore outcomes in 129 hip fracture patients randomized to receive either nocturnal tube feedings or no supplemental feedings. They excluded patients with pressure sores of Grade II or higher on admission. In the treatment group, only 40 percent of subjects tolerated placement of a nasogastric feeding tube for more than 1 week and 26 percent of the subjects for more than 2 weeks. The subjects randomized to the tube feeding group had a greater overall energy and protein intake, but no significant differences in serum albumin levels or the development and severity of pressure sores at 1 and 2 weeks were found. There was also no impact on the development or severity of pressure sores in the subset of subjects who actually received the tube feeding. There are multiple causes of pressure sores, but poor nutritional status is probably a contributing factor. Energy and nutrient requirements seem to be increased in patients with pressure sores. Although it follows that nutrition intervention should have an effect on reversing pressure sores, confounding variables such as an inadequate understanding of the nutrient and energy needs in this condition, problems with study design, and inadequate research methods do not permit this conclusion. More research is needed to develop better methods for assessing nutrition status, as well as the relationship between nutrient intake and the development and reversal of pressure sores. Hydration Inadequate fluid intake among nursing home residents has been reported in a number of studies and can lead to increased morbidity and hospitalizations (Chidester and Spangler, 1997; Gaspar, 1999; Kayser-Jones et al., 1999). Ensuring adequate water intake is particularly important because elders often have a decreased sense of thirst. They may also be dependent on caregivers for help in consuming liquids and food. A nursing protocol has recently been published that helps identify and address dehydration (Mentes and The Iowa Veterans Affairs Nursing Research Consortium, 1998). The American Dietetic Association has also developed a nutrition protocol that describes assessment and intervention strategies (Vogelzang, 1999).

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population Dysphagia A substantial number of nursing home residents have problems with dysphagia, which if not addressed may result in aspiration pneumonia and undernutrition. This condition illustrates the interdependence of the nutrition professional and speech pathologists, occupational therapists, nurses, and physicians in providing appropriate nutrition care to the nursing home resident. In one study (Kayser-Jones and Pengilly, 1999), a bedside swallowing evaluation was done: 45 out of 82 nursing home residents were found to have some degree of dysphagia, yet only 10 of these 45 residents had been referred to a speech pathologist or occupational therapist for a previous evaluation. Once dysphagia is recognized, aspects of feeding such as positioning the resident during meals, consistency of foods, size of bites, and feeding techniques can be altered. Groher and McKaig (1995) studied 740 nursing home residents. They found that 36 percent were on mechanically altered diets. Following an evaluation for dysphagia, it was determined that almost all of these residents could tolerate diets at a higher level than they were receiving. For example, the majority of residents receiving tube feedings or pureed foods could tolerate mechanically soft diets. Undernutrition Chapter 4 describes commonly used markers and syndromes of undernutrition. Some of the important issues from that chapter are repeated here. In a review of studies evaluating nutritional intake in chronically institutionalized older people, 5 to 18 percent of nursing home residents had energy intakes below need (Rudman et al., 1989). Twenty-six percent met the MDS criterion for poor oral intake. A more recent study reported that 9 percent of nursing home residents met the MDS criterion for hunger (Blaum et al., 1997). Weight loss has been shown to predict mortality in older people (French et al., 1999; Losonczy et al., 1995; Wallace et al., 1995; White et al., 1998). However, it is a relatively insensitive predictor in nursing homes because food intake may decrease several weeks before routine weight measurements (often monthly) are taken. Low serum albumin levels have been reported to predict mortality in residents of long-term care facilities (Abbasi and Rudman, 1993; Henderson et al., 1992; Rudman et al., 1987; Woo et al., 1989). Using the first National Health and Nutrition Examination Survey (NHANES) data, 14 risk factors were identified that were related to a low serum albumin (Reuben et al., 1997). People with six or more of these factors had an odds ratio of 6.44 of having a serum albumin level less than 3.8 g/dL. Among these factors were being 65 or more years old, having conditions that interfered with eating, being edentu-

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population lous or having poor dentition, having little or no exercise, and having a low sodium diet prescription. All of these factors are common in nursing home residents. Nutrition Interventions in Nursing Homes Use of Modified Diets Diets that are overly restricted in sodium and fat or do not contain familiar foods may result in a decrease in food intake and weight loss (Buckler et al., 1994). The American Dietetic Association has taken the position that there should be careful assessment of patient needs prior to using modified diets (ADA, 1998b). This assessment should include medical, psychosocial, and quality-of-life issues. Menus and dining experiences should accommodate food preferences, preserve residents’ dignity, and emphasize their joy in eating (ADA, 1998a). A liberalized diet, with only moderate changes in sodium, fat, and sugar, has been shown to meet the majority of nursing home residents’ needs (Aldrich and Massey, 1999). Feeding Nursing Home Residents Many nursing home residents have physical or cognitive impairments that affect their ability to feed themselves. Observational studies, which include both qualitative and quantitative methods, describe the effects of feeding-related care on the intake of nursing home residents (Porter et al., 1999; Steele et al., 1997). When family and nursing home staff demonstrated positive, caring feeding techniques, residents’ food intake often improved or did not worsen. Other residents observed, however, failed to receive the needed help with feeding. In some cases, cognitively impaired residents were fed forcibly in violation of best-practice care. Studies have also reported inadequate nutrient intake (Porter et al., 1999) and inappropriate vitamin and mineral supplementation (Porter et al., 1999; Rudman et al., 1995) in nursing home residents. Use of Liquid Dietary Supplements Liquid dietary supplements are frequently prescribed when food intake is poor. The role of these supplements in the nutritional care of nursing home residents is not well understood. Retrospective studies, as well as prospective controlled trials, have shown that liquid supplements resulted in improvements in nutrient intake, weight, and some serum markers (Elmståhl and Steen, 1987; Johnson et al., 1993; Turic et al., 1998). However, other descriptive studies which have included observation of

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population the actual feeding practices in nursing homes reported that supplements were sometimes ordered inappropriately and, when ordered, were not consumed by the resident all of the time. Frail residents did not always receive help opening containers, other patients and staff members consumed supplements, or supplements were consumed in place of meals (Kayser-Jones et al., 1998; Porter et al., 1999). It remains unclear as to what role liquid supplements play in the nutritional care of the long-term care resident. Use of Tube Feedings The 1987 OBRA regulations and guidelines state that a comprehensive assessment of a patient’s ability to eat must be done before tube feedings are used. The facility must also document that it is unable to maintain or improve the resident’s nutrition status through oral intake. The regulations also recognize the patient’s autonomy to refuse tube feeding (Thomas et al., 1998). Tube feedings have been shown to benefit some nursing home residents (Morley and Silver, 1995). There was shortened rehabilitation time and/or decreased morbidity and mortality in residents who received supplementary tube feedings following femoral neck fractures and chronic pulmonary disease (Bastow et al., 1983; Delmi et al., 1990; Whittaker et al., 1990). Although short-term use of tube feeding that addresses specific reversible feeding problems may be appropriate, it is questionable if long-term tube feeding in the old, severely demented resident is appropriate (Mitchell et al., 1997, 1998; Peck et al., 1990). It is important that residents, their families, and a multi-disciplinary team, including the nutrition professional, consider the outcome and consequences prior to initiation of tube feedings. Reasons for Problems Many factors affect food intake in the elderly nursing home resident. Changes in taste and smell, the effects of chronic disease and multiple medications, depression, and a decreased basal metabolic rate and activity all may cause a decreased appetite and desire to eat (Abbasi and Rudman, 1994). Some studies have shown that investigation into causes of poor food intake is disorganized. Even when nurses and dietitians alerted physicians to feeding and weight problems, the physician seldom investigated the causes, such as swallowing disorders, poor oral health, anorexia, or depression (Johnson et al., 1993; Kayser-Jones et al., 1997, 1998).

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population Elders may also experience problems related to chewing and swallowing, manual dexterity, and altered cognition that make them dependent on others for feeding. However, staffing levels and skills may affect the quality of feeding assistance received. There are often too few CNAs to help with feeding, especially at the evening meal. There are also not enough registered nurses and dietitians to oversee and train CNAs about appropriate feeding techniques and to ensure the maintenance of a pleasant dining environment (Kayser-Jones and Schell, 1997; Porter et al., 1999). Licensing agencies need to develop more effective oversight with respect to feeding, supervision of staff, and other nutrition-related issues. In response to Senate hearings on California nursing homes (GAO, 1998), HCFA has drafted investigative protocols to better evaluate the outcome of care related to pressure sores, weight loss, hydration, and dining and food service, including the way CNAs and others are trained and supervised in feeding nursing home residents. The American Dietetic Association has also responded by developing risk assessment tools (ADA, 1998a; Vogelzang, 1999). HOME HEALTH AGENCIES HHAs are defined as private or public organizations that provide or arrange for the provision of skilled nursing services to people who are unable to leave their temporary or permanent place of residence. According to the National Association of Home Care, there are more than 20,000 providers of home care services to some 8 million people who require services for acute illness, long-term health conditions, permanent disability, or terminal illness. Medicare certifies approximately half of the home care programs (NAHC, 1999). Unlike skilled nursing facilities, Medicare does not require a 3-day acute care stay prior to coverage of home health care services. HHAs are required to provide preventive treatment and rehabilitative services for the specific problems related to the physician’s referral. The treatment provided through HHAs must be consistent with standards of practice for the discipline involved and the person providing the care must be registered, licensed, or certified to provide the service (CFR, 1998). Medicare Funding Medicare beneficiaries pay nothing out-of-pocket for covered home health visits. Medicare currently reimburses HHAs on an interim payment system (IPS), although a PPS is currently under development. A 4-year transition to the PPS system of reimbursement began in late 1999. The appropriate unit of service and the number, type, and duration of

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population FUTURE AREAS OF RESEARCH Additional research is needed on the role of liquid dietary supplements and tube feedings in maintaining adequate nutritional status in the nursing home setting. There also should be continued investigation of nutritional assessment techniques and the relationship between nutrient intake and conditions common to nursing home residents (e.g., pressure sores). More work is needed on the development and validation of tools that would help identify people at nutritional risk who are being seen in home health agencies. Continued research on how best to communicate with homebound clients in both urban and rural areas is needed. Specific attention should be paid to the potential applications of teleconferencing, particularly when used to provide information about food and nutrition to the client who has communication problems (hearing, speech, other languages, etc.). SUMMARY There has been a rapid growth in the use of skilled nursing, home health, and long-term care services over the last decade. Patients receiving these services often are undernourished due to chronic disease or its treatment. It is important that there are viable nutrition services and food assistance programs in these settings. As Medicare reimbursement moves to a capitated prospective payment system, it is imperative that nutrition services are not compromised. Much of what is known about existing services in nursing homes comes from qualitative and quantitative observational studies. It is unclear if the OBRA-mandated screening and intervention tools have improved clinical care. Specifically, substantial problems with aspects of nutrition care persist, such as the quality of the food service, feeding techniques used for impaired patients, and the use of supplements and tube feedings. Physicians do not always carefully evaluate the causes of nutrition problems prior to prescribing liquid dietary supplements or tube feedings. Even though HHAs are required to have specialized nutrition expertise to be Medicare certified, there is no specific requirement for a nutrition professional in HCFA regulations or JCAHO standards. Staffing for nutrition professionals is often inadequate and HHAs commonly turn to dietitians in hospitals for help, with or without remuneration. Descriptive studies have concluded that there is an inadequate work force of nutrition

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population professionals in the home care setting due in part to insufficient reimbursement for these services. Research in HHAs indicates that it is important to carefully identify patients who need services and that services should aim to prevent hospital admissions, when possible, and to restore health and function. The new OASIS system for assessing patient needs has not been validated for its ability to identify nutrition problems. If this system proves cumbersome or insensitive, another screening system must be developed and validated. To be most cost-effective, care by the nutrition professional should be provided to those who need the most complex services. Follow-up care should be supervised by the nutrition professional, but could be provided by others going into the home. Use of the telephone and other communications technologies should be investigated, particularly when the patient and provider do not speak a common language or the patient has hearing or speech disabilities. It is unclear from the literature when and for whom this technology is most useful. Reimbursement for parenteral and enteral nutrition support in the home care setting and ambulatory setting is inadequate in the following areas: coverage for the nutrition professional to assess and monitor tolerance to nutrition support or to transition patients to less costly forms of nutrition intervention; and coverage for patients who need nutrition support for less than 90 days in order to meet energy and nutrient needs, whether or not they are eating (patients who are unable to meet nutrient and energy needs with food alone). Other forms of care, such as PACE, AL, and informal caregiving, depend on the complementary services of other government-funded community programs, such as congregate feeding and home-delivered meals. Recent studies indicate that these programs are an effective, integral part of the government’s services to the elderly, but that funding may not match need. Older individuals in PACE, in assisted living facilities, or cared for by family and friends also need access to viable nutrition services in ambulatory care settings or through home care services. If these services are not available, there is an increased likelihood that nutrition-related disorders will not be addressed. The lack of good food assistance and nutrition programs may lead to increased disability and to the use of more expensive services.

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population RECOMMENDATIONS Skilled Nursing Facilities and Nursing Homes As Medicare shifts to a prospective payment system of reimbursement for skilled nursing, nutrition services must not be compromised and must be improved beyond current practice. Internal quality improvement systems and accrediting and licensing agencies must monitor for adequate feeding techniques, the quality of food service, and the satisfaction of patients and their families with these services. Endeavors aimed at new feeding techniques, which would use staff time more efficiently, must be developed and tested. Staffing must be adequate, and staff members should be well trained and professionally supervised so that nursing home residents are fed sensitively and appropriately. Prior to initiating supplements and nutrition support, there should be documentation by physicians that treatable causes of weight loss and poor food intake have been considered and evaluated, if appropriate. Home Health Agencies Many homebound elders need nutrition services to maintain health and functional status. Patients with complex nutrition problems require the services of a nutrition professional. Others could obtain needed services from another health care professional visiting the home, with oversight by the nutrition professional. A well-designed screening system is necessary to identify those patients who most need the more complex nutrition services. The new OASIS system must be validated to ensure that it identifies patients with the greatest need. If this system proves inadequate, another system should be developed. Nutrition services would be most efficacious for patients who require counseling about altered energy and nutrient needs or dietary modifications. Services have to be designed so they address, at a minimum, the problems that would most likely cause hospital readmissions. The efficacy of nutrition intervention in chronic disease has been covered in previous chapters. The committee has identified the following conditions as being most important for nutrition intervention in the HHA setting: newly diagnosed diabetes; poorly controlled diabetes when caused by other conditions that require skilled care; heart failure; problems following cancer treatment (surgery, radiation, chemotherapy) that result in food aversions, consistency modifications, or increased nutrient or energy needs; dysphagia; undernutrition or weight loss in the absence of remedial medical or psychiatric disorders; pre-end-stage renal failure

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population when dietary modification is complex; severe osteoporosis or hip fracture; and wound healing problems. When there is evidence that nutrition services should be provided, they must be required and supported financially. Present HCFA regulations do not specifically describe a role for the nutrition professional. This needs to be clarified. Anecdotal evidence indicates that nutrition professionals in other settings (e.g., hospitals) help provide services to HHAs, with or without remuneration. Those who are planning for PPS reimbursement in HHAs should consider that both staffing and compensation for nutrition services are inadequate in the present system. Nutrition Support in the Home Care and Ambulatory Setting It is recommended that reimbursement be made available to the nutrition professional with specialized training in nutrition support. This person would provide consultation and follow-up as requested by a physician. Consultation would include the assessment of nutritional needs and recommendations for appropriate intervention(s) and monitoring for feeding tolerance and complications. It is specifically intended that the participating nutrition professional work with the referring physician to discontinue inappropriate interventions and facilitate the transition to oral or other feeding modalities when indicated. There is the potential for appreciable cost offsets by encouraging appropriate interventions. Inappropriate use of costly feeding interventions and complications related to their misapplication may otherwise result. A major gap in coverage exists for undernourished patients who need home nutrition support for less than 90 days. It is recommended that this 90-day requirement for reimbursement be reevaluated to consider the option of reimbursement for shorter-term interventions and that the intervention include appropriate consultation and approval by the nutrition professional. All Programs It is important that standards and expected outcomes for essential nutrition services are well defined so that if capitated programs face potential financial risk, these services are not jeopardized. Medicare-funded programs and food assistance programs often serve the same clients; their services are complementary, not duplicative. Patients seen in HHAs or PACE, or cared for in assisted living facilities or by family and friends, may need community programs such as Title III– VI Elderly Nutrition Programs to provide food assistance and additional nutrition services. Adequate funding for food assistance programs is an

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The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population essential part of the government’s overall nutrition services for elders and may not be keeping up with need. It is essential that comprehensive nutrition services are provided through HHAs, outpatient clinics, and other community programs so that people living in their homes or in assisted living facilities can maintain good health and functionality as long as possible. Essential nutrition services should be provided in a way that respects the role of the informal caregiver and the independence and functionality of the patient. REFERENCES ADA (American Dietetic Association) 1998a. ADA responds to nursing home initiative; task force is developing nutrition care recommendations for HCFA. J Am Diet Assoc 98:1106. ADA (American Dietetic Association) 1998b. Position of the American Dietetic Association: Liberalized diets for older adults in long-term care. J Am Diet Assoc 98:201. Abbasi AA, Rudman D. 1993. Observations on the prevalence of protein–calories undernutrition in VA nursing homes. J Am Geriatr Soc 41:117–121. Abbasi AA, Rudman D. 1994. Undernutrition in the nursing home: Prevalence, consequences, causes and prevention. Nutr Rev 52:113–122. Aldrich JK, Massey LK. 1999. A liberalized geriatric diet fits most dietary prescriptions for long-term-care residents. J Am Diet Assoc 99:478–480. Allen JE. 1997. Long Term Care Facility Resident Assessment Instrument User’s Manual. New York: Springer. Allman RM, Laprade CA, Noel LB, Walker JM, Moorer CA, Dear MR, Smith CR. 1986. Pressure sores among hospitalized patients. Ann Intern Med 105:337–342. AoA (Administration on Aging). 1998. Informal Caregiving: Compassion in Action. Washington, D.C.: U.S. Department of Health and Human Services. Arensberg MBF, Schiller MR. 1996. Dietitians in home care: A survey of current practice. J Am Diet Assoc 96:347–353. Barbenel JC, Jordan MM, Nicol SM, Clark MO. 1977. Incidence of pressure-sores in the Greater Glasgow Health Board area. Lancet 8037:548–550. Bastow MD, Rawlings J, Allison SP. 1983. Benefits of supplementary tube feeding after fractured neck of femur: A randomised controlled trial. Br Med J 287:1589–1592. Bergstrom N, Braden B. 1992. A prospective study of pressure sore risk among institutionalized elderly. J Am Geriatr Soc 40:747–758. Berke D. 1998. The Balanced Budget Act of 1997—what it means for home care providers and beneficiaries. J Long Term Home Health Care 17:2–9. Berlowitz DR, Wilking SVB. 1989. Risk factors for pressure sores. A comparison of cross-sectional and cohort-derived data. J Am Geriatr Soc 37:1043–1050. Blaum CS, O’Neill EF, Clements KM, Fries BE, Fiatarone MA. 1997. Validity of the minimum data set for assessing nutritional status in nursing home residents. Am J Clin Nutr 66:787–794. Breslow RA, Hallfrisch J, Goldberg AP. 1991. Malnutrition in tubefed nursing home patients with pressure sores. J Parenter Enteral Nutr 15:663–668. Breslow RA, Hallfrisch J, Guy DG, Crawley B, Goldberg AP. 1993. The importance of dietary protein in healing pressure ulcers. J Am Geriatr Soc 41:357–362. Bryk JA, Soto TK. 1999. Report on the 1997 Membership Database of the American Dietetic Association. J Am Diet Assoc 99:102–107.

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