Framing the issue:
- Hospitals and health systems around the nation are promoting healthy living by revamping their food offerings to set a better example for the communities they serve.
- Research shows that one-third of patients enter the hospital malnourished and, if left untreated, two-thirds of those will experience further decline.
- Malnourished patients tend to have more complications, readmissions and longer lengths of stay. Mindful of new rules and penalties around readmissions and complications, hospital executives are taking a close look at nutrition as a tool to reduce incidence of adverse events.
- Recognizing that nutrition doesn't stop at the hospital walls, health systems are implementing programs that allow patients to experience better nutrition at home and across the care continuum.
Hospitals are improving the food they serve to patients, visitors and staff as part of their overall strategy to transform care delivery to better meet the needs of the communities they serve.
Hospital executives have become mindful that better nutrition inside their walls not only sets a good example, but also can lower costs through improved patient outcomes. Some hospitals are taking the idea even further by integrating nutrition into discharge planning and education.
Several collaborative efforts have launched in the past year to help health systems achieve and sustain improvement to food served. These projects are elevating the discussion around hospital nutrition in the context of the overall continuum of care and driving rapid change at participating organizations.
"We started on this journey toward better food because our system as a whole has a focus on community health improvement," says Deborah Deatrick, senior vice president of community health at MaineHealth. "We want to make the healthy choice the easy choice for our patients, visitors and employees."
MaineHealth is one of 17 health systems around the country participating in the Hospital Healthy Food Initiative, which debuted in fall 2012. The initiative is part of the Partnership for a Healthier America, founded in 2010 by First Lady Michelle Obama. Other participating health systems include Catholic Health Initiatives, Kaiser Permanente, the Cleveland Clinic and the Henry Ford Health System.
In addition, in June 2013, several health professional member organizations founded the Alliance to Advance Patient Nutrition, an interdisciplinary partnership dedicated to raising awareness about malnutrition among patients and to advocate for early inpatient screening, detection and intervention. The alliance includes leaders from the Academy of Medical-Surgical Nurses, the Academy of Nutrition and Dietetics, the American Society for Parenteral and Enteral Nutrition, the Society of Hospital Medicine and Abbott Nutrition.
"What we are doing at the alliance is educating and advocating for the broad acceptance of nutrition practices that we know make a difference for patients," says Kelly Tappenden of the Alliance to Advance Patient Nutrition.
MaineHealth, an eight-hospital integrated system based in Portland, Maine, took up the challenge by the Hospital Healthy Food Initiative to transform its food service in three short years. To start, all MaineHealth hospitals were required to submit baseline data from 2011 on the fruits and vegetables they serve compared with total dollar food purchases, as well as healthy beverage dollars compared with total beverage dollars spent.
Because MaineHealth has a decentralized food service system, with each hospital employing its own food service director and purchasing department, gathering the data across the system was no easy task, Deatrick says. But after collecting vendor receipts and calculating food expeditures, the system was able to show that it met the baseline requirement of the Hospital Healthy Food Initiative to spend at least 10 percent of total food dollars on fruits and vegetables. As of September 2013, 17 percent of MaineHealth's food dollars are spent on fruits and vegetables.
A core component of the Hospital Healthy Food Initiative is improving nutritious choices in hospital cafeterias. For instance, the initiative requires participating hospitals to offer only healthy foods within five feet of cash register stations in cafeterias to curb impulse buys of candy and soda. Hospitals must also ensure that 40 percent of all entrees and side dishes and general patient service menus meet nutritional and food profiles set by the Partnership for a Healthier America. They also must offer at least one adult and one child "wellness meal" that meets standard nutritional and food requirements. In addition, all advertising and pictures in cafeterias and on patient menus must include only health-promoting food options such as fruits and vegetables, under the terms of the initiative.
While these requirements were challenging, MaineHealth went even further. Deatrick says the changes to the menus and signage have helped to reorient the workforce culture around wellness. MaineHealth is one of the largest employers in the state with a staff of 15,000. Some two-thirds of employees are overweight or obese, with an average age of 45.
"It can be difficult to change behavior," Deatrick says. "Our strategy is to gradually substitute choices in a favorable way. We are educating our employees about healthier foods that taste great and can help them achieve their weight loss or fitness goals."
For instance, two MaineHealth hospitals, Stephens Memorial Hospital and Waldo County General Hospital, both in rural communities, have stopped selling soda pop entirely. Employees still can bring soda from home, they just can't buy it at work. "Anecdotally, I think employees recognize that, as hospitals, our job is not just to treat illness, but promote health. We got rid of cigarette machines a long time ago. Now we are moving into this area. Obesity is a huge issue and we have an obligation to do something about it."
Today, MaineHealth is focused on buying more sustainable and local healthy foods to serve at its facilities. Penobscot Bay Medical Center, on coastal Maine, buys shares of seafood from local fishmongers, for instance. "This is a bit of an experiment because we are trying to make this as cost-neutral as possible," Deatrick says, adding that buying local and organic foods can add 10 to 15 percent of the costs. "But the number and nature of local and organic products is growing each year, which is helping us to maintain current food spending."
6 principles of nutritional care
An estimated one-third of patients admitted to U.S. hospitals are malnourished. Being malnourished means either an individual has an over- or underconsumption imbalance, so someone who is obese can be malnourished. Moreover, many Americans entering the hospital suffer from at least one chronic disease, putting them at higher risk of malnutrition, says Tappenden of the Alliance to Advance Patient Nutrition.
"Malnutrition in hospitals is such an overlooked problem and it is increasingly important, especially in the era of health care transformation," says Tappenden, who is also the editor of the Journal of Parenteral and Enteral Nutrition and a professor in the Department of Food Science and Human Nutrition at the University of Illinois, Urbana-Champaign.
The alliance is urging hospitals to adopt a nutritional care model with six principles [see Executive Corner]. Although the Joint Commission requires that hospitals conduct patient nutritional screenings, it doesn't offer specifics on how to do this, so there is a lack of standardization in the industry, Tappenden says. In response, some hospitals, most notably the University of Kansas Medical Center, have moved to a system in which staff dietitians have privileges to order oral nutritional supplements, such as Ensure, for patients. An October 2013 study in the American Journal of Managed Care indicated that use of oral nutritional supplements reduced 30-day hospital readmissions for Medicare patients with any diagnosis by 8.4 percent.
Many hospitals have moved from set patient mealtimes to a room service type of option to order meals, which Tappenden says better meets the needs of patients. "It's a step up, but we need to make sure that everyone on the care team recognizes that food is part of the care plan," she adds. "Can the patient chew? Is the mealtime environment conducive to eating? Can the patient reach everything on the tray? Is his or her bed elevated correctly to facilitate eating?"
These changes have to come from the C-suite, she stressed — and executives are beginning to push that change with the increased focus on holistic care across the continuum. Nutrition intervention can reduce avoidable readmissions by 28 percent and length of stay by two days, according to several recent studies. Better nutrition also can improve healing, with one study showing a 14 percent decrease in complications, and a reduction in common health care-acquired conditions.
St. John Hospital and Medical Center, a 772-bed hospital in Detroit, integrated nutritional services into care plans of patients at-risk of hospital-acquired pressure ulcers, or HAPUs, in 2005 with excellent results. St. John, which is part of Ascension Health, adopted a model created internally and dubbed the SKIN bundle (which stands for Surfaces, Keep patients turning, Incontinence management, and Nutrition and hydration).
Malnourished patients are more than twice as likely to develop a HAPU as properly nourished patients are. Changes to patient care at St. John included reducing the lag time between when nurses and physicians order a nutritional consultation and dietitians perform the assessment and start nutritional care plans. St. John came up with a screening system for nurses to begin patients on oral nutritional supplements prior to consulting with a dietitian if patients meet certain criteria. The hospital also leveraged its electronic health record to build in a nutritional screening tool, order sets, requests and documentation.
If a patient is older than 65, oral nutritional supplements upon admission are the norm at St. John. With a focus on nutrition, St. John's HAPU rate fell from 0.74 to 0.59 from 2011 to 2012.
In the past year, St. John made its EHR oral nutritional supplement screening tool mandatory for all admissions, so it is capturing 100 percent of patients. Previously, adherence to the screening tool reached about 78 percent, says Vicki Boyce, clinical nurse specialist at St. John.
What happens after discharge?
But there is still much more work to be done. "There is huge opportunity to bridge the continuum of care," Boyce says. "It's not just about our HAPU rates in the hospital, but what our patients do when they leave the hospitals. Here in Detroit, our patients have enormous challenges in accessing nutritious foods in the community. Meals on Wheels has a long wait list. A patient leaves here and goes home and opens a can of soup loaded with sodium, and pretty soon he or she is back to congestive heart failure."
Kaiser Permanente, the Oakland, Calif.-based integrated health system, was a pioneer in the fresh and local foods movement, bringing farmers markets to its hospitals in 2003. Today, officials at Kaiser Permanente are thinking hard about patients' nutritional realities when they get home from the hospital. In March 2013, the system began a pilot affordable meal delivery service for high-risk discharged patients in Oakland and Richmond, Calif. The service is now available to patients in five Northern California service areas through a partnership with PurFoods LLC. Each delivered meal costs $5.98, including tax and shipping, and is under the brand "Mom's Meals."
Preston Maring, M.D., associate physician-in-chief at Kaiser Permanente Oakland Medical Center, says patient nutrition in care transitions is critically important, especially because there are limits on what hospitals can do for many patients while they are in their beds. "What we can do is provide good healthy food that is tasty and, when possible, sustainably produced, when people are in the hospital," Maring says. "But a lot of the issues around malnutrition have to do with the reality of people in the hospital. They are in the hospital because they aren't feeling well. It takes time for them to recover. Maybe only one forkful will get eaten."
Maring advocates that meal planning be part of discharge planning. "We should ask every patient, 'Are you going to be able to get healthy food at home?' " he says. "There are lots of reasons why people say, 'No.' Some people don't know what is healthy. So let's talk about what is your bridge to a healthy diet."
Morrison Healthcare, an Atlanta-based provider of inpatient and cafeteria foods to 600 hospitals nationwide, is building that bridge to post-discharge patient nutrition. The company is a participant in the Hospital Healthy Food Initiative.
In 2012, Morrison Healthcare rolled out its Great Living menu. The menu, now in 200 hospitals nationwide, eliminates specific heart healthy or diabetic choices, instead making every meal choice low in fat and low in sodium. The Great Living menu has 28 percent fewer calories than the previous standard menu, 50 percent less sodium and 25 percent more dietary fiber. And 85 percent of grains served are now whole grains.
In addition to requiring every meal to meet these nutritional criteria, Morrison asked its chefs to make sure every item they serve hospital patients can be replicated easily at home. The change was cost-neutral to participating hospitals.
"It's not enough to be 100 percent on task in the hospital," says Lisa Robertson, corporate director of wellness at Morrison Healthcare. "We wanted to take it a step further as a company and make this transferable to the home, and also make changes in the communities hospitals serve."
So, Morrison Healthcare added an educational component to its inpatient meal service. The company trains workers who deliver meals to the bedside how to communicate with patients about portion sizes and culinary techniques, like blending ground turkey into a meatloaf to cut saturated fat. Then, as part of their discharge packet, patients receive a DVD with a five-to-seven-minute segment on transforming food buying habits and a two-minute cooking demonstration. "We want to change the way our communities eat," Robertson says. "It's about getting people less reliant on fast food."
— Rebecca Vesely is a freelance writer in San Francisco.
Addressing malnutrition among patients is a low-cost, high-impact way to improve outcomes, according to the Alliance to Advance Patient Nutrition. Hospital executives can institute policies and procedures to address malnutrition within their own walls. A collaborative and interdisciplinary approach can help to identify and treat at-risk patients. In a recent study by John Hopkins, about half of malnourished patients were not identified as such in the hospital. Another study found that hospital dietitian recommendations were not implemented in 58 percent of cases. The alliance developed a nutritional care model to drive improvement, emphasizing the following six principles:
1. Create an institutional culture in which all stakeholders value nutrition.
2. Redefine clinician roles to include nutritional care.
3. Recognize and diagnose all malnourished patients and those at risk.
4. Rapidly implement comprehensive nutrition interventions and continued monitoring.
5. Communicate nutrition care plans.
6. Develop a comprehensive discharge nutritional care and educational plan.