The Role of Nutrition in Maintaining Health in the Nation's Elderly Evaluating Coverage of Nutrition Services for the Medicare Population (2000) / Chapter Skim
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12 Nutrition Services in Post-Acute, Long-Term Care and in Community-Based Programs
12 Nutrition Services in Post-Acute, Long-Term Care and in Community-Based Programs
Pages 225-254
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or hospital-based sub-acute units Home health agencies (HHA) · Long-term care Institutions Programs of All Inclusive Care for the Elderly (PACE)
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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~.
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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)
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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.
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. 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.
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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.
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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; KayserTones et al., 1999~.
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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~.
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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)
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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 (Bestow et al., 1983; Delmi et al., 1990; Whittaker et al., 1990~.
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, 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~.
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Medicare covers solutions and equipment, but not the consultation by a nutrition professional needed for the assessment of energy and nutrient needs, implementation, and monitoring of the effects treatment on nutritional status (Goff, 1998~. Need for Nutrition Services in Home Health Agencies Health statistics show that more than 2.4 million Medicare beneficiaries received home care services in 1996.
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This is most likely related to the omission of the nutrition professional from HCFA regulations. A small proportion of nutrition professionals work in home health settings.
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Even though a substantial number of patients enrolled in home health care were receiving nutrition support, dietitians reported making at most one visit per week to these patients. The above study found that the greatest obstacle to providing or expanding nutrition services in home care was "lack of reimbursement." The following are areas in which dietitians did not provide services but felt capable of doing so: monitoring nutrition support, conducting home visits, providing counseling for nutrition therapy, and assessing nutrition risk.
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Who Should Receive the Services of a Nutrition Professional in the Home Health Setting? Patients seen in the home care setting are often the most frail, undernourished group of elders in the health care system and, because they are homebound, have no ability to use nutrition services that may be available in other ambulatory settings.
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Medicare beneficiaries who remain on nutrition support following hospitalization or begin it in the ambulatory or home care setting are often at high risk and could benefit from the care of a nutrition professional. The nutrition professional is also knowledgeable about how and when to transition patients to other, often less costly forms of nutrition support.
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Another way that HHAs have obtained nutrition services is to request help from dietitians in hospitals or in outpatient clinics, with or without remuneration. Yet staffing in hospitals is limited by the capitated PPS and in the outpatient setting because there is no reimbursement for nutrition services.
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In this setting, elders are able to use nutrition services that may be available from local outpatient clinics, HHAs, or community-based education programs, when available. Congregate Feeding or Home Meals The Elderly Nutrition Program (ENP)
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Most of the participants of Title III-VI programs also use Medicarefunded programs, such as acute care, ambulatory services, and home health agencies. Almost half of the referrals for Title III-VI programs come from hospitals or community-based organizations, indicating that ENPs function as part of a larger network of community systems, addressing the comprehensive long-term care needs of the elderly.
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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.
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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)
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· 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.
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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.
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1997. Validity of the minimum data set for assessing nutritional status in nursing home residents.
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1995. Malnutrition, tube feeding and pressure sores: Data are incomplete.
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1998. Pressure sores and tube feeding in patients with a fracture of the hip: A randomized clinical trial.
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1997. The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment.
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1998. Administrators' perceptions of nutrition services in home health care agencies.
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J Am Geriatr Soc 46:1223-1227. Whittaker IS, Ryan CF, Buckley PA, Road JD.
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Programs that integrate acute and long-term services in an attempt to improve coordination by bridging through common financing, acute care benefits, and home- and community-based long-term-care services. A payment system under which health care providers are paid a predetermined, fixed amount for patient care.
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