A team-based nutrition care program at Premier Medical AssociatesKirk W. Kerr, PhD | Health Economics & Outcomes Research | Abbott

OPTIMIZING QUALITY CARE FOR OUTPATIENTS

OPTIMIZING QUALITY CARE FOR OUTPATIENTS | 1

1. INTRODUCTIONPoor nutrition has been underdiagnosed and undertreated in the outpatient setting even though research has shown that anywhere between 25-30% of community-living adults are at risk for poor nutrition.1,2 Since poor nutrition is associated with worse patient outcomes and higher medical costs, it is important that healthcare systems develop tools and procedures to diagnose and address poor nutrition and improve the overall health of community-living adults.

As healthcare systems across the United States are focusing on identifying effective population health management strategies, nutrition care is becoming increasingly important in outpatient/ambulatory settings. Extensive research supports the effectiveness of nutrition care in decreasing length of stay, hospital readmissions, and overall costs to help healthcare systems realize substantial cost savings.3,4 Such nutrition care programs emphasize the importance of identifying poor nutrition, nutrition counseling and support, and offering dietary assistance. This report describes the approach taken by Premier Medical Associates, a large group practice in western Pennsylvania, to identify and address malnourished outpatients receiving care after hospital discharge.

2. BACKGROUND ON PREMIER MEDICAL ASSOCIATES

Premier Medical Associates (PMA), an affiliate of Allegheny Health Network, has 100 providers across 24 specialties at 10 locations in the Greater Pittsburgh area. PMA serves over 70,000 primary care patients, of whom 32% are over 65. In 2018, PMA had 377,000 patient visits across all service areas. PMA is an award-winning organization, having won the 2016 AMGA

(American Medical Group Association) Acclaim Award and the 2017 Optum & AMGA Award for Innovation in Population Health.

3. KEY FINDINGS• PMA leadership enacted changes to promote

nutrition care and elevate the role of the dietitian in optimizing patient care.

• Nurses and medical assistants were empowered to make nutrition therapy recommendations through education and distribution of a standardized nutrition care pathway.

• Implementation of a nutrition care program required no additional human or financial resources.

• Practitioners reported patients following nutrition regimens were regaining their appetite, gaining strength, experiencing improvements in lab results, and staying out of the hospital.

4. NUTRITION PROGRAM IMPLEMENTATION

Dr Francis Colangelo, PMA’s Chief Quality Officer, started PMA’s focus on nutrition care when he read two recent publications3,5 showing that nutrition care can have a significant impact in reducing length of stay and 30-day readmissions at in-hospital and home health settings. “After I heard about the results of the Advocate Health studies at the AMGA meetings, I talked to Dr Moukamal during one of the breaks and said, ‘this is something incredible that can improve hospital outcomes,’” said Dr Colangelo. PMA’s Chief Medical Officer, Dr Ezz-Eldin Moukamal, added, “We identified that when the patient is leaving the facility, nutrition has not been addressed as well as it should be, especially because it’s not listed as a therapeutic agent. Whenever the nutritionist was making a recommendation to a patient…that wasn’t materializing into specific discharge instructions for the patient.” Drs Colangelo and Moukamal empowered Holly Kern, PMA’s Director of Quality, to implement a transitions of care program that would address the nutritional needs of patients recently discharged from the hospital. PMA chose to partner with Abbott to provide pathways with examples for how HCPs can incorporate different nutrition therapy into a variety of nutrition plans, as well as to create nutrition education materials for patients. Abbott provided data on the role nutrition can play in improving patient

OPTIMIZING QUALITY CARE FOR OUTPATIENTS | 2

health, as well as the health economic benefits of using nutrition interventions to increase acceptance of the new program.

Implementation began almost immediately as Ms Kern integrated nutrition questions into the nurse navigators’ transitions of care notes. Additional program components have been added over time such that the program now follows the steps diagrammed in Exhibit 1.

Exhibit 1. Premier Medical Associates’ Transitions of Care Process

PMA’s program addresses the nutrition needs of patients when they are discharged from the hospital. Within 48 hours of hospital discharge, patients are contacted by nurse navigators. During these phone calls, the nurse navigators review discharge instructions and medications with the patient, as well as schedule an office visit for follow-up with a physician. As part of these telephone follow-ups, the nurse navigators ask patients about their nutrition and whether they were given or recommended nutrition therapy during their hospital stay. Exhibit 2 is a screenshot of the nutrition questions used by nurse navigators as they appear in PMA’s electronic medical record (EMR) system. If patients are identified as being at nutritional risk, the nurse navigators recommend an appropriate nutrition therapy and mail the patient a packet with nutritional information and coupons for nutrition therapy. Nurse navigators use a standardized pathway to identify the product that will best address the patient’s nutritional

needs. PMA chose to document nutrition supplements in the Medication section of the EMR for patients in their system.

Exhibit 2. Nutrition questions from Premier Medical Associates’ EMR

The second phase of PMA’s nutrition transitions of care program occurs during the patient’s follow-up visit. Here, the medical assistant serves as the point of contact to review compliance with nutritional recommendations listed in the patient’s EMR. Medical assistants can also identify patients with nutritional needs by examining changes in weight and body mass index (BMI), as well as patient-reported changes in appetite and difficulty with daily activities. Medical assistants utilize the same standardized nutrition care pathway as nurse navigators to recommend nutrition therapy to patients with nutritional needs. Since they are meeting with patients in person, medical assistants can provide nutrition therapy samples on the spot and additional coupons to increase adherence to the nutrition recommendation.

PMA’s focus on nutrition also carries over into its hospitalist practice. In the in-patient setting, PMA physicians work directly with dietitians in assessing and addressing patients with nutritional needs. Organizationally, dietitians were given authority to prescribe nutrition therapy for a patient as a verbal order from the physician. This made it easier for nutrition therapy recommendations from the dietitian to be incorporated into patient orders and made their recommendations more prominent. PMA also adjusted their system to allow nutrition recommendations to be included in discharge instructions, making these instructions more noticeable to increase patient awareness and adherence to nutrition therapy recommendations.

DISCHARGED FROM HOSPITAL

CONTACT WITH NURSE NAVIGATOR

NUTRITIONAL RECOMMENDATIONS MADE AS NEEDED

OFFICE FOLLOW-UP VISIT

WITHIN 48 HOURS

WITHIN 7 DAYS

Have you recently lost weight without trying?

Have you been unable to eat the amount of food that you normally eat because of decreased appetite or fatigue?

Have you had di�culty doing your daily life activities (bathing, cooking, dressing, etc)?

While you were in the hospital, were you given an oral nutritional supplement?

* If any questions get a “yes” answer, mail packet for nutrition supplements: Nutrition packet mailed.

Post Discharge Tests Ordered/Pending

Nutrition Needs

Y N

Y N

Y N

Y N

OPTIMIZING QUALITY CARE FOR OUTPATIENTS | 3

PMA’s nutrition program is improving patient health. Practitioners reported that undernourished patients who followed the nutrition program were regaining their appetite and gaining weight. This led to a virtuous cycle as these patients continued to follow the program because of the positive results they were seeing. The program is also helping patients with diabetes. Heather Reagan, a nurse navigator at PMA, reported: “I have one patient who came out of the hospital with multiple issues. He just kind of ate whatever. He got just a little bit of education and he’s hooked. Now his A1c has improved and his heart failure symptoms seem to be better. He’s not been back in the hospital.”

PMA’s practitioners also reported satisfaction with the nutrition program. In a survey of eight practitioners at Premier, nearly 90% of respondents reported they were satisfied with program materials and that the nutrition program met the needs of their patients. These respondents also reported that they would recommend the nutrition care program to other clinics and planned to employ the program with future patients. Nearly 90% of respondents also reported that they were better able to respond to patient nutrition questions after the program had begun. Lastly, survey respondents reported that they had increased their recommendations of oral nutritional supplements from an average of 4.6 patients per week to 9.4 patients per week.

5. KEYS FOR SUCCESSBoth practitioners and leadership identified several keys to the successful implementation of the transitions of

care nutrition program. Leadership from Drs Colangelo and Moukamal was essential to enacting changes in the standard of care. With their buy-in and support, the entire PMA staff recognized that improving patient nutrition care was a priority to PMA, would positively impact patient care, and they were empowered to act.

Practitioners reported that education on how nutrition therapy can be used as part of a nutrition plan was invaluable. The nutrition pathway served as a useful guide as nurse navigators and medical assistants made nutrition therapy recommendations to patients. Additionally, having tasted a

variety of the nutrition therapy, made possible through the collaboration with Abbott, nurse navigators and medical assistants were able to address patient concerns about palatability of nutrition therapy, a common patient concern and barrier to use.

Importantly, the nutrition program did not require any additional human or financial resources to implement. Ms Kern was able to mobilize existing resources among the nurses and medical assistants, as well as adapt the EMR, to make process changes that improved patient care.

6. FUTURE PLANSThough pleased with the implementation of the nutrition care program, PMA is working to improve and expand its program. PMA has empowered hospital dietitians to modify diets and add nutrition therapy when indicated. PMA has started utilizing a nutrition care pathway for its patients with chronic conditions. By addressing nutrition care sooner, PMA believes they can preemptively reduce hospital admissions in addition to reducing readmissions through its transitions of care program. Additionally, PMA wants to empirically measure the impact its care program is having on patients and the important benchmark of unplanned hospital readmissions. To make such analysis possible, PMA is making minor adjustments to its EMR to consistently capture the nutrition recommendations patients receive. Once sufficient data is collected, PMA intends to assess the impact of their nutrition program on hospital readmissions and other patient outcomes.

OPTIMIZING QUALITY CARE FOR OUTPATIENTS | 4

METHODOLOGY In September 2019, Kirk Kerr conducted in-person interviews with physicians and nurses at Premier Medical Associates about the health system’s nutrition programs and outcomes seen thus far. Participants were also asked to complete a survey regarding the nutrition initiative. The survey structure was informed by the Client Satisfaction Questionnaire (CSQ-8)6 and augmented to account for the unique aspects of the nutrition initiative. Eligible healthcare providers included anyone that played a key role and was actively involved in the implementation and performance of the nutrition initiative at their clinic.

Abbott thanks the following individuals for their participation:

• Francis Colangelo, MD, MS-HQS, FACP, Chief Quality Officer

• Ezz-Eldin Moukamal, MD, FHM, Chief Medical Officer

• Holly Kern, RN, Director of Quality• Annabelle McCoy, RD, CDE, LDN• Kristen Merryman, RN, Lead Nurse Navigator• Mackenzie Bellotti, LPN, Operations Supervisor• Jessica Shusteric, RN, Nurse Navigator• Heather Reagan, RN, Nurse Navigator• Marissa Bartges, CMA, Medical Assistant• Ashley Wilferd, Research Coordinator

PREMIER MEDICAL ASSOCIATES Premier Medical Associates (PMA), an affiliate of Allegheny Health Network, has 100 providers across 24 specialties at 10 locations in the Greater Pittsburgh area. PMA serves over 70,000 primary care patients, of whom 32% are over 65, and over 100,000 patients in total. In 2018, PMA had 377,000 patient visits across all service areas. PMA is an award-winning organization, having won the 2016 AMGA (American Medical Group Association) Acclaim Award and the 2017 Optum & AMGA Award for Innovation in Population Health.

ABBOTT Abbott is a global healthcare leader that helps people live more fully at all stages of life. Our portfolio of life-changing technologies spans the spectrum of healthcare, with leading businesses and products in diagnostics, medical devices, nutritional products, and branded generic medicines. We understand that proper nutrition is the foundation for living the best life possible. That’s why we develop science-based nutrition products to nourish your body at every stage of life. Our products help babies and children grow, keep bodies strong and active, and support the unique nutrition needs of people with chronic illnesses—to make every stage of life a healthy one. For more information, visit www.abbott.com.

References:

1. Sheean P, et al. [published online November 6, 2018]. Public Health Nutr. 2019;22(5):894-902.

2. Sauer AC, et al. JPEN J Parenter Enteral Nutr. 2019;43(7):918-926.

3. Sriram K, et al. [published online December 6, 2016]. JPEN J Parenter Enteral Nutr. 2017;41(3):384-391.

4. Sulo S, et al. Am Health Drug Benefits. 2017;10(5):262-270.

5. Riley K, et al. JPEN J Parenter Enteral Nutr. 2019. doi:10.1002 /jpen.1606

6. Attkisson CC, Greenfield TK. Client Satisfaction Questionnaire-8 and Service Satisfaction Scale-30. In Maruish ME, ed, The Use of Psychological Testing for Treatment Planning and Outcome Assessment. Hillsdale, NJ: Lawrence Erlbaum Associates; 1994:402-420.

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