Learning Collaborative Sites Address Gaps in Transitions of Care
In late 2018 and in early 2019, the MQii Team fielded a survey to Learning Collaborative participants regarding nutrition-related discharge planning activities and pre-admission nutrition activities. We received responses from over 25 Learning Collaborative sites, highlighting an exciting range of innovative tactics that address malnutrition-related transitions of care processes. Based on responses to the survey, we conducted a subset of interviews with sites who had insightful stories to share. Overall, the two main trends from these interviews included:
- The use of tailored meal delivery for malnourished patients in the home; and
- A program for malnourished patients to help bridge the gap between the care they receive in the hospital and what is experienced once they return home.
For example, New Hanover Regional Medical Center (NHRMC) is implementing an initiative to provide nutrition to malnourished patients who have limited access to food through the use of a clinical outreach dietitian and a discharge nutrition food box. When patients are diagnosed as malnourished by a registered dietitian (RD) at NHRMC, specific nutrition interventions are put into place to meet each patient’s medical nutrition needs. The care plan is designed to help patients improve and teach them how to properly nourish themselves when they are discharged. However, until now, the clinical nutrition services team did not know if patients had access to nutritious food once they left the hospital, or if they were able to follow the care plan that was created specifically to help them rebuild strength. The initiative put in place allows NHRMC to work with a clinical outreach dietitian who visits malnourished patients in their homes to reinforce their nutrition plan of care and ensure they get connected to the resources they need to continue recovering at home. Additionally, patients receive a discharge nutrition food box to support their continued recovery. The NHRMC Nutrition Services team selected items for the food boxes, which include peanut butter, lean protein, granola bars, whole wheat bread, fruit and other staple items.
Similarly, Legacy Health is implementing a grant-funded program where the registered dietitian nutritionist (RDN) identifies malnourished patients when they are discharged to their home and then works with the hospital to provide three nutritionally-tailored meals to the patient for four weeks post-discharge. The discharge meal provision delivery pilot started with 15 patients, and Legacy Health is working to expand it to many more patients in the hospital.
If you were unable to contribute to the survey but have an interesting discharge/transitions of care effort planned or underway to share, please reach out to your MQii Team Point of Contact to share your experience and insights!
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