Handout September 21 PDF 2

Malnutrition and Transitions of Care
Between Health Care Settings

Friday, September 22, 2023 • 12:00 – 1:00 PM ET
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How to Claim CE 3–4
Session Slides 5 – 64
ASPEN24 Opportunities 65 – 66
ASPEN Resources 67
Self-Assessment Q&A 68 – 74
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1. Describe methods to identify and address gaps in care for Disclosures and Relevant Financial Relationships for Faculty and
hospitalized malnourished patients. Planning Committee Members
2. Identify valuable strategies and interventions healthcare
professionals can implement across health care settings to The following individuals have no relevant financial relationships with
support individuals with malnutrition. ineligible companies: Rose Ann DiMaria-Ghalili, Nina Rocca, Joy
Heimgartner, Terese Scollard, Monica Agarwal, Jaime Avila, Moriah
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to Pars. ASPEN does not submit data to any other credentialing Ponce, Ajanta Raman, Carol Rollins, Joel Rush, Adeeba Spann,
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NUTRITION CARE
IS A PATIENT RIGHT
nutritioncare.org/Malnutrition | #ASPENMAW23
Malnutrition and Transitions of Care

Between Health Care Settings
September 22, 2023 • 12:00 – 1:00 PM ET
5
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Moderator Faculty
Terese Scollard, MBA, RD, Rose Ann DiMaria-Ghalili, Nina Rocca, DCN, RDN, Joy Heimgartner, MS, RDN,
LD, FAND, PhD, RN, FASPEN, FAAN, LDN, FAND, CPT, CSO, LD,
Owner FGSA, Private Practice Owner, Registered Dietitian
My Surgery Plate, Portland, Professor of Nursing, Senior Prestige RD, LLC; Clinical Nutritionist (APII), Certified
OR Associate Dean for Research, Dietitian Specialist in Oncology, Blood
College of Nursing and Health BayCare Hospitals, and Bone Marrow Transplant,
Professions Clearwater, FL Assistant Professor of
Drexel University, Philadelphia, Nutrition
PA Mayo Clinic College of
Medicine and Science,
Rochester, MN
6
Malnutrition Across the Care
Continuum
R. DiMaria-Ghalili, PhD, RN, FASPEN, FAAN, FGSA
Professor of Nursing, Senior Associate Dean for Research
College of Nursing and Health Professions
Drexel University
Philadelphia, PA
Disclosure
• No commercial relationships to disclose.
7
Learning Objectives
Upon completion of this educational activity, the learner will be able to:
• Describe the relationship between U.S. demographic trends and
malnutrition across the care continuum.
• Discuss barriers and facilitators to promoting optimal nutrition care during
care transitions.
• Identify solutions to addressing malnutrition across the care continuum.
Source: National Population Projections, 2017

www.census.gov/programs-surveys/popproj.html
8
MALNUTRITION RISK FACTORS in OLDER ADULTS
• Physiological
• Chronic Conditions
• Medications
• Psychosocial
• Economic
• Environmental
• Dietary Intake
DiMaria-Ghalili, R. A., & Amella, E. (2005). Nutrition in Older Adults: Intervention and assessment can help curb the growing threat of malnutrition. AJN The American Journal of Nursing, 105(3),
40-50.
Nutrition and Functional Outcomes
Functional
Decline
• Risk Factors in older • Negative outcomes

adults • Weight loss
• Loss muscle mass
• Inadequate protein, • Poor recovery
energy, and/or • ↓ strength
micronutrient intake • ↓ power
• ↓ walking speed
• Impaired balance
Poor Nutritional • ↓ activity Disability
Status
FRAILTY
Adapted from: Sharkey, Ann NY Acad Sci, 1136: 210-217, 2008.
9
• Data source: 2010 Health Care Cost and • Data source: 2018 Health Care Cost and
Utilization Project Utilization Project
• Of the 39 million hospital discharges analyzed, • Of the 27.8 million hospital discharges
3.2% (1.2 million) had a clinical diagnosis of analyzed, 8.9% (2.5 million) had a clinical
malnutrition. diagnosis of malnutrition.
• The mean age of those with malnutrition was • The mean age of those with malnutrition was
64.8 years of age. 64.8 years of age.
• Older adults accounted for 58.3% of all • Older adults accounted for 59.5% of all
malnutrition diagnoses. malnutrition diagnoses.
• 41.9% were 65-84 years of age • 42.9% were 65-84 years of age
• 16.4% were 85 and older • 16.1% were 85 and older
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Hospital Malnutrition Facts
Patients coded for malnutrition
Older adults with a malnutrition
tend to be 65 years and older,
diagnosis were more likely to
have higher infection rates, Weight loss increased risk of
be admitted to hospital from
longer lengths of stay, higher 30-day readmission in medical
SNF, and more likely to be
costs, higher rates of death, patients (Allaudeen et al., 2011)
discharged to SNF (DiMaria et
and higher usage of home care
al., 2014 )
(Corkins et al., 2014)
High prevalence of malnutrition

Failure to thrive/malnutrition Malnutrition and Posthospital
on hospital admission and
frequent reason for Syndrome “an acquired,
predischarge (31% and 36%
readmission in surgical patients transient period of vulnerability”
respectively) (van Vliet et al.,
(Kassin et al., 2012) (Krumholz et al., 2013)
2020)
Corkins, M. R., et al. (2014). Malnutrition diagnoses in hospitalized patients United States, 2010. Journal of Parenteral and Enteral Nutrition, 38 (2), 186-195.
DiMaria-Ghalili, R.A., et al. (2014). A comparison of characteristics by age of hospitalized adults with a diagnosis of malnutrition: United States, 2010. The Gerontologist ,54 (Suppl. 2): 692.
Allaudeen N, et al. (2011). Redefining readmission risk factors for general medicine patients. Journal of Hospital Medicine, 6(2):54–60.
Kassin MT, et al. (2012). Risk factors for 30-day hospital readmission among general surgery patients. Journal of the American College of Surgeons; 215(3):322–330.
Krumholz HM. (2013). Post-hospital syndrome—An acquired, transient condition of generalized risk. New England Journal of Medicine, 368(2):100–102.
van Vliet, I. M., Gomes-Neto, A. W., de Jong, M. F., Jager-Wittenaar, H., & Navis, G. J. (2020). High prevalence of malnutrition both on hospital admission and predischarge. Nutrition, 77, 110814.
Nutrition Risk in Community -Dwelling Older Adults

Total Normal At Risk Malnourished
Age n (%)
65-74 16,485,371 (52.4) 11,857,985 (55.3) 3,893,416 (47) 733,970 (42)
75-84 11,097,355 (35.3) 7,468,497 (34.9) 2,948,565 (35.6) 680,293 (39)
85+ 3,881,103 (12.3) 2,099,121 (9.8) 1,450,174 (17.5) 331,808 (19)
*Weighted sample, P <.01
Data Source: NHATS 2017

DiMaria-Ghalili, R. A., Granche, J., Coates, M., Hathaway, Z., & Sefcik, J. (2020). Prevalence of Malnutrition in
a National Sample of Older Adults Residing in Community or Residential Care: NHATS 2017. Innovation in
Aging, 4(Suppl 1), 793. https://doi.org/10.1093/geroni/igaa057.2874
11
Gaps: How prevalent is malnutrition in older
adults across the care continuum? What are
the facilitators and barriers for best treatment
options during care transitions?
• Older adults are at risk for malnutrition across

the continuum of care.
• Great emphasis on malnutrition risk in acute
care settings (hospitals).
• Transitions from hospital to home are high risk
periods.
• Older adults are living longer and may need
different levels of care and supervision over
their lifetime.
• Gaps in understanding the presence of
malnutrition across the care continuum and
best interventions to promote positive health
outcomes and quality of life.
https://www.wthr.com/article/news/local/elderly-man-calls-911-because-hes-hungry-and-dispatcher-brings-him-food/531-9d899f9b-
6640-4bb4-91f5-8d36b2ededbb
Prevalence of Malnutrition at Care Transitions
• Not documented at hospital discharge

• Not reported in current CMS OASIS
(Outcomes and Assessment
Information Set)
• Few prevalence studies in the U.S. at
care transitions
12
Nutrition Screening At Hospital Discharge
Online Survey of Nurses’ Nutritional Care Practices in the United States
across care settings (DiMaria-Ghalili et al., 2017)
• N=174 hospital or long-term acute care RNs

• 86.6% reported conducting a nutrition screen on admission
• 38.4% reported re-evaluating nutrition at discharge
DiMaria-Ghalili, R. A., Miller, E., Chen, C., & Hathaway, Z. (2017). A Survey of Nurses' Nutritional Care Practices. Nursing Research, 66, 2, E89-E89.
Malnutrition and Hospital Discharge Nutrition Care

Instructions
Brooks et al (2019) reviewed EMR discharge nutrition care instructions
provided to adult patients (N=76) identified as malnourished by RD in
US over a 4-month period
• 6.6% received discharge instructions to consume ONS
• 47.4% received general diet instructions that did not address malnutrition
• 44.8% received inappropriate instructions to limit caloric intake
• Need for clinician education and redesign of nutrition care options in EMR
Brooks, M., Vest, M. T., Shapero, M., & Papas, M. (2019). Malnourished adults’ receipt of hospital discharge nutrition care instructions: a pilot study. Journal of Human Nutrition
and Dietetics, 32(5), 659-666
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Malnutrition Patient and Caregiver Study (August 2015)
About the Data
The Gerontological Society of America’s National Academy on an Aging Society commissioned a
national study about older adult malnutrition among individuals who were self-identified as adults or
nonpaid family caregivers of an older adult, age 65 years or older. The electronic survey was e-mailed
to a sample of 75,000 potential respondents from July 23 to August 3, 2015. The sample consisted of
adults age 18 years or older in the United States. Participants in this study were provided through the
Harris Panel, including members of its third-party panel providers. The survey yielded a total of 1,035
responses, which included 529 responses among adults and 506 responses among family caregivers.
The data were weighted to be representative nationwide by age, sex, region, education, income, and
race.
Read more at https://www.geron.org/programs-services/alliances-and-multi-stakeholder-

collaborations/malnutrition
©The Gerontological Society of America National Academy on an Aging Society Malnutrition Study
The Gerontological Society of America; National Academy on an Aging Society. Profiles of an Aging Society: What We Know and Can Do About Malnutrition. Washington, DC: The Gerontological
Society of America; Fall 2015.
Patient “Transition” Perspectives Total

Response
Yes
Inpatient hospital stay in the last 12 months 1035 12%

Asked any questions about your appetite, diet, weight, or nutrition on admission 126 65%
or other times during hospital stay
Received info about appetite, diet, weight, or nutrition at DC 126 33%
Referred to a dietitian/nutritionist /diabetes educator when DC 126 17%
Referred/enrolled to home meal delivery program upon DC 126 15%
Referred/enrolled to meals at community or senior center upon DC 126 12%

Referred/enrolled in SNAP upon DC 126 24%
Received educational materials on diet/nutrition info upon DC 126 33%
Recommended an oral nutrition supplement upon DC 126 18%

DC: discharge. SNAP: Supplemental Nutrition Assistance Program, formerly known as food
stamps.
14
Caregiver “Transition” Perspectives Total
Response
Yes
Was older adult (65 and older) you care for hospitalized in last 5 years? 119 72%
Was the older adult asked any questions about their appetite, diet, weight, or 86 62%
nutrition on admission or other times during hospital stay?
Were you or other family members given any information about the appetite, diet, 86 55%
weight, or nutrition of the older adult for whom you care when he/she was DC ?
Referred to a dietitian/nutritionist /diabetes educator when DC 126 17%
The Gerontological Society of America; National Academy on an Aging Society. Profiles of an Aging Society: What We Know and Can Do About Malnutrition. Washington, DC: The Gerontological Society of America;
Fall 2015.
Caregiver “Transition” Perspectives (n=119)

What specific nutrition actions would be the most helpful for you and the older adult in your care?
(top 3 responses)
• Educational resources-44%
• Coverage reimbursement of oral nutritional supplements-40%
• Referral to community nutrition resources-33%
Which community nutrition resources does the older adult you care for currently use?
• None of the above-56%
• Home delivered meals-21%
• Meals at a community or senior center-20%
• SNAP-19%
• Food assistance programs (food banks, food pantries, Senior Farmer’s Market)-16%
• Local transportation services to and from nutrition programs-15%
Which community nutrition resources would you like the older adult to use?
• None of the above-40%
• Home delivered meals-30%
• Meals at a community or senior center-23%
• SNAP-28%
• Food assistance programs (food banks, food pantries, Senior Farmer’s Market)-23%
• Local transportation services to and from nutrition programs-24%
15
Malnutrition Patient and Caregiver Study: Take Away
Points
Strengths:
• Weighted representative nationwide sampling plan (age,
gender, region, education, income, race)
• Unique “end-user” patient and caregiver perspective of
nutrition during and after hospitalization
Weaknesses:
• Not known what percentage of patients were
malnourished.
Global Perspectives
Nutrition and Care Transitions
16
Scandinavian Discharge Survey
Survey of nutrition routines at discharge (MD and RN)
• Weight at discharge <25%
• Evaluation of nutrition status at discharge <20%
• Nutrition regimens started in hospital included in discharge summaries <63%
Pohju, A., Beck, A. M., Belqaid, K., & Rasmussen, H. H. (2018). Changes in nutritional routines at discharge in Scandinavia during a 10-year period: A follow-up survey. Clinical
nutrition ESPEN, 28, 148-152.
Norway: Patient and Family Caregivers’ Perspectives

Hestevik et al (2020) qualitative study with 15 older patients with
documented risk of malnutrition or malnourishment and family
caregivers’ post-discharge in Norway.
Themes:
• Comprehensive approach to nutritional care
• Non-individualized nutritional care at home (viewed as problematic)
• Lack of mutual comprehension and shared decision making
• Role of family caregivers
Hestevik, C. H., Molin, M., Debesay, J., Bergland, A., & Bye, A. (2020). Older patients’ and their family caregivers’ perceptions of food, meals and nutritional care in the transition
between hospital and home care: a qualitative study. BMC nutrition, 6, 1-13.
17
Israel: Adherence to Dietary Regimen Post-Discharge
• Ginzburg et al. (2018) prospective study in Israel
≫Older adults treated with oral nutrition supplement (ONS) and discharged with dietary
recommendations
≫Followed up for adherence 3 months
• Barriers to adherence:
≫GI symptoms
≫Lack of knowledge of purpose of ONS
≫No prescription for ONS.
Ginzburg, Y., Shmilovitz, I., Monastyrsky, N., Endevelt, R., & Shahar, D. R. (2018). Barriers for nutritional care in the transition from hospital to the among older patients. Clinical
nutrition ESPEN, 25, 56-62.
Belgium & Denmark: Care Transition Barriers

Education: individual knowledge and attitude, lack of training and
experts
Organization: lack of communication from hospital on reason for

nutritional therapy, goals and follow-up; lack of common guidelines and
instructions
Economic: Short hospital stay; therapy not started at discharge
Geurden, B., et al. (2015). Prevalence of ‘being at risk of malnutrition and associated factors in adult patients receiving nursing care at home in Belgium. International Journal of
Nursing Practice, 21(5), 635-644.
Holst, M., & Rasmussen, H. H. (2013). Nutrition therapy in the transition between hospital and home: an investigation of barriers. Journal of Nutrition and Metabolism, , Article ID
463751, http://dx.doi.org/10.1155/2013/463751
18
Canada: Consensus-based nutrition care pathways for hospital-
to-community transitions and older adult sin primary and
community care (Keller et al., 2022)
Reviewed best-practices for nutrition care and clinical guidelines; draft care
pathways developed by the Primary Care Working Group of the Canadian
Malnutrition Task Force, stakeholders (N=21) reviewed and revised.
Barriers and facilitators to primary care and community nutrition care

practices:
• Nutrition care plan at hospital discharge
• Nutrition risk screening
• Weight monitoring
• Appetite monitoring
• Dietitian referral
• Educational resources
• Community services
Keller, H., Donnelly, R., Laur, C., Goharian, L., & Nasser, R. (2022). Consensus‐based nutrition care pathways for hospital‐to‐community transitions and older adults in primary
and community care. Journal of Parenteral and Enteral Nutrition, 46(1), 141-152.
Moving Forward
19
INTERVENTIONS
• Education
• Increase Intake
≫TPN, tube feeding
≫Therapeutic Diet
≫Oral Nutritional Supplements
≫Home Delivered Meals
≫Congregant Meals
• Social Services
≫Homemaker support: feeding, shopping, cooking
≫Transportation Services
≫SNAP
Models of Care
• Integrate nutritional risk assessment into predictive models to
determine levels of intensity of nutritional care post-discharge
≫High-risk: intervention delivered by dietitian
≫Medium-risk: intervention delivered by nurses
≫Low-risk: intervention delivered by social worker or lay-health
worker
• Identify and review programs instituted by hospitals to address
nutrition needs post-discharge
≫Common elements
≫Program costs
≫Cost savings
≫Sustainability
≫Patient outcomes
DiMaria-Ghalili, R.A. in National Academies of Sciences, Engineering, and Medicine. 2016. Meeting the Dietary Needs of Older Adults: Exploring the Impact of the Physical, Social, and Cultural Environment: Workshop
Summary. Washington, DC: The National Academies Press. https://doi.org/10.17226/23496.
20
Summary (PIER)
Policy: Advocate for practice change--malnutrition screening at discharge and
upon admission to home care
Interventions: Implement appropriate transition interventions, recognize the

importance of continued monitoring. Align with Food is Medicine opportunities.
Educate: Health care professionals about the importance of nutrition screening

during care transitions
Research: Most effective interventions to promote positive outcomes and

improved recovery in older adults
Nutrition Curing Care Transitions
IMPOSSIBLE
21
Nutrition Curing Care Transitions
IMPOSSIBLE
Learning Assessment Question 1
Malnutrition assessment at hospital discharge is a

standard aspect of care in the United States?
A. True
B. False
22
Learning Assessment Answer 1
Malnutrition assessment at hospital discharge is a

standard aspect of care in the United States?
A. True
B. False
Older adults are at risk for malnutrition across the care

continuum?
A. True
B. False
23
Older adults are at risk for malnutrition across the care

continuum?
A. True
B. False
References List
1. Allaudeen N, et al. (2011). Redefining readmission risk factors for general medicine patients.
Journal of Hospital Medicine, 6(2):54–60.
2. Brooks, M., Vest, M. T., Shapero, M., & Papas, M. (2019). Malnourished adults’ receipt of hospital
discharge nutrition care instructions: a pilot study. Journal of Human Nutrition and Dietetics, 32(5),
659-666 .
3. Corkins, M. R., et al. (2014). Malnutrition diagnoses in hospitalized patients United States, 2010.
Journal of Parenteral and Enteral Nutrition, 38 (2), 186-195.
4. DiMaria-Ghalili, R.A., et al. (2014). A comparison of characteristics by age of hospitalized adults
with a diagnosis of malnutrition: United States, 2010. The Gerontologist ,54 (Suppl. 2): 692.
5. DiMaria-Ghalili (2016). Nutrition During Care Transitions in: Meeting The Dietary Needs of Older
Adults: Exploring the Impact of Physical, Social, and Cultural Environment. Workshop Summary.
Washington, DC: National Academies of Sciences, Engineering, Medicine.
6. DiMaria‐Ghalili, R. A. (2014). Integrating nutrition in the comprehensive geriatric
assessment. Nutrition in Clinical Practice, 29(4), 420-427
7. DiMaria-Ghalili, R. A., Miller, E., Chen, C., & Hathaway, Z. (2017). A Survey of Nurses' Nutritional
Care Practices. Nursing Research, 66, 2, E89-E89.
8. DiMaria-Ghalili, R. A., Granche, J., Coates, M., Hathaway, Z., & Sefcik, J. (2020). Prevalence of
Malnutrition in a National Sample of Older Adults Residing in Community or Residential Care:
NHATS 2017. Innovation in Aging, 4(Suppl 1), 793.
24
References List Cont.
9. Geurden, B., et al. (2015). Prevalence of ‘being at risk of malnutrition and associated factors in
adult patients receiving nursing care at home in Belgium. International Journal of Nursing
Practice, 21(5), 635-644.
10. Ginzburg, Y., Shmilovitz, I., Monastyrsky, N., Endevelt, R., & Shahar, D. R. (2018). Barriers for
nutritional care in the transition from hospital to the among older patients. Clinical nutrition, 25, 56-
62.
11. Guenter P, Abdelhadi R, Anthony P, et al. (2021). Malnutrition diagnoses and associated
outcomes in hospitalized patients: United States, 2018. Nutrition in Clinical Practice, 36(5):957-
969.
12. Hestevik, C. H., Molin, M., Debesay, J., Bergland, A., & Bye, A. (2020). Older patients’ and their
family caregivers’ perceptions of food, meals and nutritional care in the transition between hospital
and home care: a qualitative study. BMC Nutrition, 6, 1-13.
13. Holst, M., & Rasmussen, H. H. (2013). Nutrition therapy in the transition between hospital and
home: an investigation of barriers. Journal of Nutrition and Metabolism,
http://dx.doi.org/10.1155/2013/463751
14. Kassin MT, et al. (2012). Risk factors for 30-day hospital readmission among general
15. surgery patients. Journal of the American College of Surgeons; 215(3):322–330.
16. Keller, H., Donnelly, R., Laur, C., Goharian, L., & Nasser, R. (2022). Consensus‐based nutrition
care pathways for hospital‐to‐community transitions and older adults in primary and community
care. Journal of Parenteral and Enteral Nutrition, 46(1), 141-152.
References List Cont.

17. Krumholz HM. (2013). Post-hospital syndrome—An acquired, transient condition of generalized risk. New
England Journal of Medicine, 368(2):100–102.
18. Pohju, A., Beck, A. M., Belqaid, K., & Rasmussen, H. H. (2018). Changes in nutritional routines at discharge in
Scandinavia during a 10-year period: A follow-up survey. Clinical nutrition ESPEN, 28, 148-152.
19. Sattler, E.L.P., et al. (2015). Factors associated with inpatient hospital (re)admissions in medicare beneficiaries
in need of food assistance. Journal of Nutrition in Gerontology and Geriatrics, 34, 228-244.
20. Sharkey JR. (2008). Diet and health outcomes in vulnerable populations. Ann NY Acad Sci., 1136: 210-217.
21. The Gerontological Society of America; National Academy on an Aging Society. Profiles of an Aging Society:
What We Know and Can Do About Malnutrition. Washington, DC: The Gerontological Society of America; Fall
2015.
22. van Vliet, I. M., Gomes-Neto, A. W., de Jong, M. F., Jager-Wittenaar, H., & Navis, G. J. (2020). High prevalence
of malnutrition both on hospital admission and predischarge. Nutrition, 77, 110814.
25
Implementation of a Transitions of Care
Nutrition Intervention
for Malnourished Patients
Nina Rocca, DCN, MS, RD, LDN, FAND

Clinical Dietitian
Food and Nutrition
BayCare Hospitals
Clearwater, Florida
Research completed at Lawrence General Hospital, Massachusetts
Disclosure
26
Learning Objectives
• Understand the burden of malnutrition in relation to hospital readmission and
nutrition status
• Understand existing gaps in transitions of care systems for malnourished
patients
• Identify valuable strategies and interventions RDNs and other health
professionals can implement across health care settings to support patients with
malnutrition.
Burden of Malnutrition on Health Outcomes
Prevalent in 20-50% of hospitalized and community dwelling patients

Tied to poor health outcomes, 1.9 times longer hospital stays, frequent hospital readmission
30-day all cause readmission was nearly 50% higher among patients with malnutrition
Billions of dollars in estimated annual costs for older adults with malnutrition
AND Supports the Medical Nutrition Therapy (MNT) Act to include malnutrition coverage
Currently, Medicare does not provide MNT reimbursement for malnutrition
Valladares 2018, ASPEN, AHRQ, Mogensen 2015, Heersink 2010, White 2012, Alberda 2006, AND MNT Act, CMS Final Rule.
27
ASPEN Malnutrition Solution Center Infographic
ASPEN Malnutrition Solution Center Infographic
28
Transitions of Care
Safe transitions across levels of care and different care settings
Reduces hospital readmissions, Improve health outcomes
JCAHO* & CMS* requires nutrition screening, not discharge planning
Nutrition is often missing from documentation across settings
Missing Information, inconsistent care, poor health outcomes
*Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

*Centers for Medicare & Medicare Services
CMS 2020, JCAHO 2012, Valladares 2020, Baker 2005, Mogensen 2015, Heersink 2010.
Literature Review Summary
29 studies included in the literature review
< 18 utilized dietitians as part of transitions of care

interventions
Outcomes of Interest:
• Hospital readmissions (< 30 days from discharge)

• Nutrition status (weight, and nutrient intake)
Population of interest:
• Adults (primarily older-adults > 65-years old)

• At risk for malnutrition or diagnosed with malnutrition
29
Previous Research Findings
Study Type Intervention Findings References
Dietitians establish individualized care (4) Found significant nutrition improvements Endvelt 2011, Beck 2012, Beck
(4) RCTs plans and be involved in post- Hospital readmission did not differ 2015, Terp 2018
discharge follow up.
Dietitians or staff to provide (4) Found significant nutrition improvements (Feldblum 2011, Mudge 2012,
(15) Mixed- personalized recommendations; ONS, These studies did not look at hospital Hamirudin 2017, Vearing 2019)
Methods meal delivery programs, and nutrition readmissions TenCate 2020, Young 2018
education during hospital D/C planning (3 of 5) Found significant nutrition (Buys 2017, Beck 2012,
and followed at home improvements Reinders 2019)
Allmark 2020, Chareh 2021
(3 of 6) Found less hospital readmissions (Siriam 2017, Mullin 2019, Sulo
2020)
Buys 2017, Beck 2012, Siegel
2018
Nursing staff to provide nutrition (8 of 10) Found readmissions to be (Verhaegh 2014, Kim 2015, Low
(10) Other information post discharge, via phone significantly less 2015, Kansagara 2016, Finlayson
Studies calls and home visits to address These studies did not look at nutrition status 2018, Conroy 2020, Facchinetti
medical and nutrition concerns 2020)
Englander 2014, Aboumatar 2019,
Ohuabunwa 2021
Summary of Gaps Across Healthcare Setting
Screening for malnutrition has become common practice in the hospital
Many facilities lack a malnutrition policy to identify and treat malnutrition
Malnutrition and nutrition documentation missing from discharge planning
Lack of communication among staff from one setting to another
30
Development and Implementation
of the Research Study
Purpose
• Utilize a process evaluation to investigate if a case management / nursing
TOC frameworks can be adapted to develop and implement a successful
TOC nutrition intervention.
• Utilize an outcomes evaluation to determine if the TOC nutrition
intervention, adapted from a case management / nursing TOC framework,
was successful.
31
Methods: Study Design
Study Design Two part; Process Evaluation & Outcomes Evaluation, Quasi-experimental
Length of the Study 6 months from August 2021 – January 2022
5-week Transitions of Care Nutrition Intervention led by an RD including (1)

Intervention inpatient visit prior to discharge, (4) follow-up phone calls to address nutrition
and medical concerns
Monitor the implementation process (CDC Process Evaluation)
Data Collection (Part 1) Tools: Qualitative Tools: Checklists, Interaction Log, Process Evaluation
Questionnaires to track each patient interaction, Staff Interviews
Evaluate the implementation process (CDC Evaluation process)
Data Collection (Part 2) Outcomes Measured: *Unplanned hospital readmissions < 30 days
*Nutrition Status and *Weight using the PG-SGA standardized tool, & body scale
Analyze outcomes: hospital readmissions number, nutrition status; food intake

Analyze
and body weight
CDC Web site; Types of Evaluations

https://www.cdc.gov/std/Program/pupestd/Types of Evaluation.pdf
Methods: Setting & Participants

Setting Lawrence General Hospital (LGH)
Population of interest Hospitalized adult patients identified with Malnutrition
Comparison Group: Chart review May 2019 – November 2019 (n=137)

Comparison Group
*to establish a readmission number
Intervention Group Recruitment: Convenient Sampling from July 2021-

January 2022 Clinical RDs and MDs identify patients with malnutrition
Recruitment
Clinical RDs and MDs identify patients with malnutrition
The TOC RD visited patients, who met inclusion criteria, to enroll them
Sample Size (Estimate 120 participants to meet 80% Power) *Only 21 were enrolled*
LGH Web site: https://www.lawrencegeneral.org/
32
9/22/2023
Data Analysis Summary

• Patient data remained secure
• Mixed-methods were utilized
• Nonparametric t-test used for scale/ratio data
• Pearson’s chi-square test for nominal data
• No missing data – small samples size
• All p-values < .05 are taken as statistically significant
• Statistical Software: IBM SPSS version 26.0 (IBM Corp., Armonk, NY)
Transitions of Care Nutrition Intervention

• Length of the intervention: A 5-week intervention for each patient
• Including 4 interactions
1. In-person interview & individualized nutrition plan “pre”
2. Phone call during week 1 from hospital discharge
3. Phone call during week 3 post-discharge
4. Phone call during week 5 post-discharge “post”
33
Patient-Generated Subjective Global Assessment (PG-SGA)
PG-SGA. Pt-Global Web site. 2014. http://pt-global.org/?page_id=13
Results and Discussion
34
Demographics (n=21)
• Age: Average 67 years old

• Gender: 50% Male/ 50% Female
• Language: English & Spanish (4%)
• Race/Ethnicity: Primarily American and Dominican
• Malnutrition Severity & Etiology: Equally Distributed
• Medical Diagnoses
Outcome: Number of Readmissions

Unplanned hospital readmissions < 30 days from discharge
Readmission Status
Group 1: Groups 3 and 4:
Comparison All patients
Group enrolled in the
study
(n=) (n=137) (n=21) p-value
Readmitted < 30 48 (35%) 6 (28.5%) .561
days (Yes) No difference between groups!
Not readmitted 89 (65%) 15 (71.5%)
*p-value based on Pearson’s Chi-Square
35
Outcome: Nutrition Status
Outcomes: Weight on a scale, PG-SGA weight & nutrition scores (Page 1)
Variable Pre- Post- Statistical Effect

Intervention Intervention Output Two- size
Median (IQR) Median (IQR) sided p
(n=13) (n=13) value*
Weight (pounds) 142.1 (50.80) 141.4 (60.75) .552 -.17

Food Intake 2 (7) 0 (1.50) .012 -.70
Score Range 0 – 14 Food Intake & Total Scores Significantly Improved!
Total PGSGA 14 (14.50) 5 (6) .010 -.72
Score Range 0 - 33
*p value based on Wilcoxon Signed Ranks Test, positive ranks (nonparametric)
Additional Findings
Food Insecurity
Do they have trouble shopping, cooking, or preparing meals?
Yes - 8 out of 21 (38%) report trouble with at least one
Did patients need additional services?

Yes - Elder services, food banks, meal delivery programs (Meals
on Wheels, Community Servings), oral nutrition supplements
Compliance
• Participants (n=21) were most compliance during week 1 (76%)
Were participants satisfied?

• Overall feedback was satisfied with the intervention
36
Hospital Staff Focus Group (Barriers to success)
(1) Lack of communication and understanding among all staff regarding the study
(2) Staff needed more flyers, emails and conversations
(3) Clear communication and documentation is needed in the EMR
(4) Lack of time, rushed to complete nursing interventions often putting nutrition aside
(5) Shorten the time spent during the initiation interview
(6) The pandemic created many barriers; Restrictions on discharge planning meetings
(7) Staff identified that nutrition is important, but whose role it is to address it, is unclear
Strengths & Limitations
Strengths: Challenges/ Limitations:

• Broad data collection • Subjective data collection by the
• Less expensive researcher, at risk for bias
• Evaluates “real world” effectiveness • TOC RD is the primary researcher
• Generalizable to a population • Non-randomized sample
• Previous implementation research • Bias may weaken internal validity
• Hospital in agreement • Limited ability to conclude an
• Expand Research in TOC association or “cause and effect”
• CDC Framework • Pandemic
• Small Sample Size
Schweizer 2016, Zoellner 2017, Miller 2020.
37
Results Summary
Readmissions
Hospital Readmissions were not significantly lower in the intervention
group (n=21) compared to the comparison group (n=137), p = .516
Weight Change
Weight did not improve among participants (n=13) from before to after the
TOC nutrition intervention (p = .552)
Nutrition Status
Participants (n=13) PG-SGA Food Intake scores (p = .012) and Total PG-
SGA score (p = .010) representing malnutrition risk significantly improved
by the end of the TOC Nutrition Intervention
38
Was the study a success?
Challenging to say the implementation was successful due to barriers
• Multiple barriers and potential patients were not included
• The Sample Size was not met
• Intervention – success on an individual level – improving food intake
• Mixed outcomes; readmissions rates were not better; food intake was better
Practice Implications and Forward Thinking

Transitions of Care needs to include Nutrition Interventions led by RDs
Identified gaps in communication among staff and address them
Opportunity to further educate health professionals about Malnutrition
Discuss hospital staff perspectives on the malnutrition processes
Help find solutions to bridge the gaps in care from hospital to home
Standardization for analyzing readmission rates is needed
Exciting opportunity for nutrition professionals to be involved in
Establish a Malnutrition Quality Improvement Project at your facility
39
Hospital Remission is how much higher when patients have

malnutrition than those without?
A. 4%
B. 20%
C. 50%
D. 75%
Hospital Remission is how much higher when patients have

malnutrition than those without?
A. 4%
B. 20%
C. 50%
D. 75%
40
When reviewing previous research, transitions of care

interventions that involved dietitians found what to improve?
A. Improved blood work
B. Nutrition status
C. Infection Rate
D. Hospital Length of stay
When reviewing previous research, transitions of care

interventions that involved dietitians found what to improve?
B. Nutrition status
C. Infection Rate
41
When it comes to determining national unplanned

readmission rates related to malnutrition, what is missing?
A. A staff member who is responsible for tracking data
B. A standard tool to measure and track readmissions
C. Patients not understanding they should avoid readmission
D. Primary care doctors telling their patients to go to the hospital
When it comes to determining national unplanned

readmission rates related to malnutrition, what is missing?
42
Involving stakeholders like ____________ is important to

support future research and projects in the topic of
malnutrition and transitions of care.
A. The local news station
B. The Marketing Director
C. Hospital Visitors
D. Hospital Administration
Involving stakeholders like ____________ is important to

support future research and projects in the topic of
malnutrition and transitions of care.
A. The local news station
B. The Marketing Director
43
Data collected from implementing a malnutrition policy and

malnutrition quality improvement projects are best used to
______________.
A. create community awareness
B. give to primary Care Physicians
C. support interventions to prevent malnutrition
D. strengthen the hospital team dynamic
Data collected from implementing a malnutrition policy and

malnutrition quality improvement projects are best used to
______________.
44
References List
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2. Malnutrition Solution Center. Infographics: Malnourished Hospitalized Patients Are Associated with Poorer Outcomes, Malnourished
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adults/protocol#:~:text=According%20to%20an%20Agency%20for,patients%20with%20no%20associated%20malnutrition Accessed
August 5th, 2023.
4. Mogensen KM, DiMaria-Ghalili RA. Malnutrition vigilance during care transitions. Today’s Geriatric Medicine. 2015;8(4):12.
5. Heersink JT, Brown CJ, DiMaria-Ghalili RA, Locher JL. Undernutrition in hospitalized old adults: patterns and correlates, outcomes,
and opportunities for intervention with a focus on processed of care. J Nutr Elder. 2010;29(1):4-41.
6. White J, Guenter P, Jensen G. Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and
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7. Alberda C, Graf A, McCargar L. Malnutrition: Etiology, consequences, and assessment of a patient at risk. Best Pract
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8. Medical Nutrition Therapy Act. Academy of Nutrition and Dietetics Web site.
https://www.eatrightpro.org/advocacy/legislation/all-legislation/medical-nutrition-therapy-act Accessed August 6, 2023.
9. Centers for Medicare & Medicaid. Federal Register. Rules and Regulations. Final Rule. Fed Regist.
2019;84(189):51836-51884. https://www.govinfo.gov/content/pkg/FR-2019-09-30/pdf/2019-20732.pdf.
10. The Joint Commission. Transitions of care: the need for a more effective approach to continuing patient care. June
2012. https://www.jointcommission.org/-/media/deprecated-unorganized/imported-assets/tjc/system-folders/topics-
library/hot_topics_transitions_of_carepdf.pdf?db=web&hash=CEFB254D5EC36E4FFE30ABB20A5550E0 Accessed
July 2020.
11. Baker EB, Wellman NS. Nutrition concerns in discharge planning for older adults: A need for multidisciplinary
collaboration. J Am Diet Assoc. 2005;105(4):603-607. doi:10.1016/j.jada.2005.01.006
45
Literature Review
12. Endevelt R, Lemberger J, Bregman J, et al. Intensive dietary intervention by a dietitian as a case manager among
community dwelling older adults: The edit study. J Nutr Heal Aging. 2011;15(8):624-630. doi:10.1007/s12603-011-0074-9
13. Beck A, Andersen UT, Leedo E, et al. Does adding a dietician to the liaison team after discharge of geriatric patients
improve nutritional outcome: A randomized controlled trial. Clin Rehabil. 2015;29(11):1117-1128.
doi:10.1177/0269215514564700
14. Beck AM, Kjær S, Hansen BS, Storm RL, Thal-Jantzen K, Bitz C. Follow-up home visits with registered dietitians have a
positive effect on the functional and nutritional status of geriatric medical patients after discharge: a randomized
controlled trial. Clin Rehabil. 2012;27(6):483-493. doi:10.1177/0269215512469384
15. Beck AM, Holst M, Rasmussen HH. Oral nutritional support of older (65 years+) medical and surgical patients after
discharge from hospital: Systematic review and meta-analysis of randomized controlled trials. Clin Rehabil.
2012;27(1):19-27. doi:10.1177/0269215512445396
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941. doi:10.1177/0269215518765912

Literature Review
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after hospitalization: The nutrition intervention study clinical trial. J Am Geriatr Soc. 2011;59(1):10-17.
doi:10.1111/j.1532-5415.2010.03174.x
18. Mudge A, Young A, Ross L, et al. Hospital to home outreach for malnourished elders (Hhome): A feasibility pilot. J
Aging Res Clin Pract. 2012;1(2):131-134.
19. Hamirudin AH, Walton K, Charlton K, et al. Feasibility of home-based dietetic intervention to improve the nutritional
status of older adults post-hospital discharge. Nutr Diet. 2017;74(3):217-223. doi:10.1111/1747-0080.12305
20. Vearing R, Casey S, Zaremba C, et al. Evaluation of the impact of a post-hospital discharge transitional aged care
service on frailty, malnutrition and functional ability. Nutr Diet. 2019;76(4):472-479. doi:10.1111/1747-0080.12511
21. TenCate D, Ettema RGA, Huisman-de Waal G, et al. Interventions to prevent and treat malnutrition in older adults to
be carried out by nurses: A systematic review. J Clin Nurs. 2020;29(11-12):1883-1902. doi:10.1111/jocn.15153
22. Young AM, Mudge AM, Banks MD, Rogers L, Demedio K, Isenring E. Improving nutritional discharge planning and
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Literature Review
23. Reinders I, Volkert D, de Groot LCPGM, et al. Effectiveness of nutritional interventions in older adults at risk of malnutrition
across different health care settings: Pooled analyses of individual participant data from nine randomized controlled trials. Clin
Nutr. 2019;38(4):1797-1806. doi:10.1016/j.clnu.2018.07.023
24. Buys DR, Campbell AD, Godfryd A, et al. Meals enhancing nutrition after discharge: Findings from a pilot randomized controlled
trial. J Acad Nutr Diet. 2017;117(4):599-608. doi:10.1016/j.jand.2016.11.005
25. Allmark G, Calder PC, Marino L V. Research identified variation in nutrition practice by community prescribing dietitians with
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26. Chareh N, Rappl A, Rimmele M, et al. Does a 12-month transitional care model intervention by geriatric experienced care
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2021;13(9). doi:10.3390/nu13093023
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readmissions and length of stay in hospitalized patients. J Parenter Enter Nutr. 2017;41(3):384-391.
doi:10.1177/0148607116681468
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Psychiatry Res. 2020;283(112452). doi:10.1016/j.psychres.2019.06.027
48
Pre-Admission Patient-Reported Screening
Tool Streamlines Assessment: The PG-SGA©
in an Electronic Health Record
Joy Heimgartner, MS, RDN, CSO, CNSC, LDN
Assistant Professor of Nutrition, Mayo Clinic College of Medicine &
Science
Clinical Dietitian, Advanced Practice II, Blood & Marrow Transplant
Mayo Clinic
Rochester, Minnesota
Disclosure
49
Learning Objectives
• Describe how the electronic PG-SGA© can be used for nutrition screening
and assessment when built into the Epic® electronic health record.
92
Timeline of PG-SGA© Integration into Epic®at Mayo Clinic

2015 2016 2017 2018 2019 2020 2021 2022
2014: PG- Mayo Dietetic Medical Proposal for April: Epic Pilot PG-SGA
SGA digital dietitians intern- Oncology PG-SGA build ticket as outpatient
COVID approved.
app & design a involved requests a approved & screening tool
webtool research research validated promoted by All new Epic October: PG- in limited
available for study to use study using nutrition Clinical build halted SGA flowsheet populations.
purchase PG-SGA in PG-SGA in screening tool Nutrition build,
(one time fee) hematology/B newly for outpatient. Specialty validations,
MT patients diagnosed Council. testing Share build
Formal completed. with Epic
AML patients: evaluation of
Dr. Faith Compared Epic build December: users
Ottery, MD, Dept of validated ticket October: Re- worldwide.
existing tool, tools by submitted Questionnaire
PhD, FACN is Medicine MST and PG- submitted: & other Epic
guest speaker Innovation oncology denied due to ticket request components
SGA specialist to build PG-
at November Award for questionnaire built.
Joint Staff tablets & RDs. request. SGA into Epic
Epic arrival: with more Dec 16,
meeting software BMT dietitian Dr. Ottery
takes job as gives CoC makes stakeholder 7:01pm:
Epic Core permission to nutrition support & PG-SGA
Credentialed work with screening now a CoC goes live in
Trainer (April) guidelines a regulatory Mayo Epic!
Mayo Clinic to
build PG-SGA requirement, requirement.
into Epic. effective in
2020.
50
93
PG-SGA: Beyond Nutrition Screening
• Tremendously powerful scored tool for nutrition assessment

≫Identify right patient, right time, right setting
≫More useful with challenging patient populations (those with
fluid overload)
• Research possibilities
≫ disease types, interventions, and outcomes
• International leadership
≫Global demand for PG-SGA© to be implemented into the EMR
(Global TeleNutrition Consortium)
≫Translated and validated in 22 languages, more coming online
every year
Microsoft stock image library
94
Clarification: PG-SGA(SF) & PG-SGA

• The PG-SGA© (SF) is the patient-generated portion of the tool
≫The PG-SG(SF) is considered the screening portion.
• Both the PG-SGA© (SF) by itself and the full PG-SGA© are validated tools in a variety
of patient populations.
MST PG-SGA(SF) PG-SGA

(full)
Validated nutrition screening tool? yes yes yes
Provides interventional triage? no yes yes
Provides ease of monitoring ? no yes yes
Nutrition Assessment tool? no no yes
51
95
Why the PG-SGA?

• Used internationally for 25 years
≫ 22 validated language translations
• 400+ publications
• “The PG-SGA© is the preeminent interdisciplinary patient assessment
(weight, intake, symptoms, functional status, disease state, metabolic
stress and nutritional physical examination) in oncology and other chronic
catabolic conditions.” http://pt-global.org
96
Not just Outpatient

Not just Oncology
PG-SGA© is validated in a wide variety of settings and clinical conditions:
• Hospitalized and ambulatory patients
• Especially helpful in complex medical conditions
≫Cancer
≫Renal disease & dialysis
• Other institutions use PG-SGA© to screen patients before planned surgeries:
≫Complex spine
≫Cardiac & vascular
≫GI/Gyne surgical
• Opportunities for use in
≫Solid organ transplant
52
97
PG-SGA© (SF) leveraged as an Epic ® Questionnaire

• Can be assigned manually or automatically.
≫Tied to designated providers, visit types, etc.
• Can be set of as a one-time assignment or series of assignments over

time.
• Patients can complete questionnaire within their patient portal on their own
device OR on a tablet when they arrive for appointment.
• Responses flow directly into the PG-SGA© flowsheet where the
calculations are completed automatically.
98
PG-SGA© openly available to any Epic® enabled EHR

• PG-SGA© is now available freely to any institution using Epic®
≫No further copyright approvals needed if using the Mayo Clinic/Epic built
Patient Generated Subjective Global Assessment (PG-SGA©)
• The flowsheet build CANNOT BE CHANGED without copyright approval from Dr. Ottery.
≫Language translations in Epic still need to be approved by Dr. Ottery.

• Norwegian language is approved and in use in Norway currently.
≫Not yet in standard Epic build (2024?)

≫Can be requested as a Turbo Package by your Epic technical specialist
≫FREE of charge
53
99
Patient-facing questionnaire on tablet
Photo credit: Joy Heimgartner
100
54
101
102
55
103
Image: Epic® Flowsheet
104
56
105
New in the Mayo Clinic build

(per request of Dr. Ottery)
106
57
107
108
58
109
Snapshot view print group

using information from the PG-
SGA© flowsheet
Image: Epic® schedule & PG-SGA(SF) print group
110
Synopsis viewer of scores

over time using information
from the PG-SGA© flowsheet
Image: Epic® synopsis viewer
59
111
Sample Note using

information from the
PG-SGA© flowsheet
Image: Epic® note
112
A NOTE ABOUT TRIAGE SCORES
Triage recommendations that are built into the

PG-SGA© are based on a full PG-SGA©
score.
PG-SGA©(SF) Short form scores will always

be lower, although most scoring comes from
weight change, intake, and symptoms (SF
components).
No defined triage numbers have been set for

the PG-SGA©(SF) and institutions can decide
how they choose to use those scores in
patient care.
60
Summary
• Electronic screening should meet the needs of both patients and providers.
• Patient-reported information is valuable to discern what problems are most impacting the
patient. PG-SGA© is a tool that has always meant to be patient-reported and was built to
leverage that knowledge.
• The PG-SGA© (SF) incorporates patient-reported weight change information, symptom
information, intake information, and activity information all in one place.
• PG-SGA© is a scored tool with high content validity and answers/scores can be monitored
over time, regardless of setting (hospitalized/ambulatory/home).
• If your institution uses Epic, the Mayo Clinic/Epic built Patient Generated Subjective
Global Assessment (PG-SGA©) is available free of charge or further copyright
approval.
References List
1. Ruan X, Nakyeyune R, Shao Y, Shen Y, Niu C, Zang Z, Miles T, Liu F. Nutritional screening tools for adult cancer patients: A
hierarchical Bayesian latent-class meta-analysis. Clin Nutr. 2021 Apr;40(4):1733-1743.
2. Gomes-Neto AW, van Vliet IMY, Osté MCJ, de Jong MFC, Bakker SJL, Jager-Wittenaar H, Navis GJ. Malnutrition Universal
Screening Tool and Patient-Generated Subjective Global Assessment Short Form and their predictive validity in hospitalized
patients. Clin Nutr ESPEN. 2021 Oct;45:252-261.
3. De Groot LM, Lee G, Ackerie A, van der Meij BS. Malnutrition Screening and Assessment in the Cancer Care Ambulatory
Setting: Mortality Predictability and Validity of the Patient-Generated Subjective Global Assessment Short form (PG-SGA SF)
and the GLIM Criteria. Nutrients. 2020 Jul 30;12(8):2287.
4. Jager-Wittenaar H, Ottery FD. Assessing nutritional status in cancer: role of the Patient-Generated Subjective Global
Assessment. Curr Opin Clin Nutr Metab Care. 2017 Sep;20(5):322-329.
5. Abbott J, Teleni L, McKavanagh D, Watson J, McCarthy AL, Isenring E. Patient-Generated Subjective Global Assessment Short
Form (PG-SGA SF) is a valid screening tool in chemotherapy outpatients. Support Care Cancer. 2016 Sep;24(9):3883-7.
6. Sealy MJ, Nijholt W, Stuiver MM, van der Berg MM, Roodenburg JL, van der Schans CP, Ottery FD, Jager-Wittenaar H.
Content validity across methods of malnutrition assessment in patients with cancer is limited. J Clin Epidemiol. 2016
Aug;76:125-36.
7. Guerra RS, Sousa AS, Fonseca I, Pichel F, Restivo MT, Ferreira S, Amaral TF. Comparative analysis of undernutrition
screening and diagnostic tools as predictors of hospitalisation costs. J Hum Nutr Diet. 2016 Apr;29(2):165-73.
8. Martin L, Watanabe S, Fainsinger R, Lau F, Ghosh S, Quan H, Atkins M, Fassbender K, Downing GM, Baracos V. Prognostic
factors in patients with advanced cancer: use of the patient-generated subjective global assessment in survival prediction. J
Clin Oncol. 2010 Oct 1;28(28):4376-83.
61
Acknowledgement
This educational offering was provided to you by ASPEN, supported by an
educational grant from Nestlé Health Science.
Companion Practice Tool at:

nutritioncare.org/MAW
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MARCH 1 • 8:00 AM–4:00 PM MARCH 2 • 7:00 AM–11:00 AM
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Location: Tampa General Hospital Nutrition Support (NPPC-2024)
Location: Tampa Convention Center
Designed to stimulate physician interest in nutrition
and underscore its impact on patient outcomes. Explore the management and treatment of a
Includes case-based sessions on: variety of issues including acid-base, fluids and
• Nutrition strategies in the setting of specific electrolytes, refeeding syndrome, anemia, and more
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Location: Tampa Convention Center
Take a deep dive into a variety of endocrine
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Registration opens in October!

nutritioncare.org/PreCon
• Schedule to subject to change.
Pediatric Content Included Virtual Session

66
© Copyright 2023 ASPEN | American Society for Parenteral and Enteral Nutrition
STAY CURRENT WITH CLINICAL NUTRITION
ASPEN Resources Help You Provide Patients With the Best Possible Care
ASPEN Adult & ASPEN Enteral Nutrition-Focused The Practitioner’s Guide

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Comprehensive references Second Edition for Adults: An Physical Exam of
covering a full range of Updated and expanded Illustrated Handbook, Infants, Children, and
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to get these must-have resources! 67
Presentation Title: Malnutrition Across the Care Continuum
Name: Rose Ann DiMaria-Ghalili, PhD, RN, FASPEN, FAAN, FGSA
Title, Affiliation: Professor of Nursing and Senior Associate Dean for Research, College of Nursing
and Health Professions, Drexel University
Disclosures: I have no financial relationships with ineligible companies to disclose.
Presentation Overview/Summary:
Older adults are at risk for malnutrition across the care continuum. Nutrition screening is performed on
admission to the hospital; however, nutrition problems may go unnoticed as older adults transition from
hospital to home. This presentation will highlight several barriers for facilitating nutrition during care
transitions and highlight opportunities for change.
Learning Objectives:
At the conclusion of the presentation, the learner will be able to:
1. Describe the relationship between U.S. demographic trends and malnutrition across the care
continuum.
2. Discuss barriers and facilitators to promoting optimal nutrition during care transitions.
3. Identify solutions to addressing malnutrition across the care continuum.
Learning Assessment Questions:

1. Malnutrition assessment at hospital discharge is a standard aspect of care in the United States?
True or False.
A. True
B. False
2. Older adults are at risk for malnutrition across the care continuum? True or False.
A. True
B. False
Learning Assessment Answers:

1. Answer = B; Nutrition assessment is a standard aspect of care upon admission to the hospital
and not at discharge.
2. Answer = A; As individuals age they experience several bio-psycho-social risk factors that can
increase the risk for malnutrition across the care continuum.
68
References:
1. Brooks, M., Vest, M. T., Shapero, M., & Papas, M. (2019). Malnourished adults’ receipt of
hospital discharge nutrition care instructions: a pilot study. Journal of Human Nutrition and
Dietetics, 32(5), 659-666.
2. Corkins, M. R., et al. (2014). Malnutrition diagnoses in hospitalized patients United States, 2010.
Journal of Parenteral and Enteral Nutrition, 38 (2), 186-195.
3. DiMaria‐Ghalili, R. A. (2014). Integrating nutrition in the comprehensive geriatric
assessment. Nutrition in Clinical Practice, 29(4), 420-427.
4. Guenter P, Abdelhadi R, Anthony P, et al. (2021). Malnutrition diagnoses and associated
outcomes in hospitalized patients: United States, 2018. Nutrition in Clinical Practice, 36(5):957-
969.
5. Hestevik, C. H., Molin, M., Debesay, J., Bergland, A., & Bye, A. (2020). Older patients’ and their
family caregivers’ perceptions of food, meals and nutritional care in the transition between
hospital and home care: a qualitative study. BMC Nutrition, 6, 1-13.
6. Keller, H., Donnelly, R., Laur, C., Goharian, L., & Nasser, R. (2022). Consensus‐based nutrition
care pathways for hospital‐to‐community transitions and older adults in primary and community
care. Journal of Parenteral and Enteral Nutrition, 46(1), 141-152.
69
Presentation Title: Implementation of a Transitions of Care Nutrition Intervention for Malnourished
Patients
Name: Nina G. Rocca DCN, MS, RDN, LDN, FAND
Title, Affiliation Clinical Dietitian at BayCare Hospitals, Florida.
Previous Clinical Dietitian at Lawrence General Hospital, Massachusetts (where research was
conducted), Owner of Prestige RD, LLC
Objective: To determine if a transitions of care nutrition intervention can lessen hospital readmissions
and improve nutrition status among hospitalized malnourished patients.
Purpose: Transitions of Care (TOC) research is popular among nursing and physicians, and more
recently nutrition professionals. Registered Dietitians (RDs) can play an important role in TOC by
communicating patients’ nutrition information across health care settings. The primary aim of the study
was to use a CDC process evaluation to evaluate if a case management, care transitions frameworks,
adapted for a TOC nutrition intervention, can result in a successful intervention. The secondary aim
was to use a CDC outcomes evaluation, to evaluate unplanned hospital readmissions and nutrition
status outcome measures of participants enrolled in the 5-week intervention. Methods: The primary
investigator (PI) compiled retrospect Lawrence General Hospital (LGH) patient data from November
2019 through June 2019 to create a comparison group and establish readmissions data. A mixed-
methods study design included qualitative, quantitative, and quasi-experimental pre/post intervention
methods. Patients with malnutrition admitted to LGH during a 6-month period starting August 2021,
through January 2022, who agreed to participate, were enrolled in a 5-week TOC nutrition intervention.
Results: Due to the small sample size (n=21), data was analyzed with caution. There was no
difference in hospital readmissions between the groups. Nutrition status did improve among participants
in the intervention group (n=13). Conclusion: The outcomes support the need to integrate a RD as
part of TOC multidisciplinary team, especially for patients with malnutrition to improve health outcomes
and nutrition status. Future research should focus on developing and evaluating TOC nutrition
interventions to improve hospital readmission rates and nutrition status.
Learning Objectives:
1. Understand the burden of malnutrition in relation to hospital readmission and nutrition status.
2. Understand existing gaps in transitions of care systems for malnourished patients.
3. Identify valuable strategies and interventions RDNs and other health professionals can
implement across health care settings to support patients with malnutrition.
Key Takeaways/Fast Facts:

Transitions of care intervention should be led by dietitians to help improve nutrition status and improve
health outcomes like lessen unplanned hospital readmission. Heath professionals need to be educated
on malnutrition and the process to identify and treat this condition at their facility. Ongoing training to
promote awareness is warranted. As a collective establishing a solution to bridging the gaps in care
between hospital and home need continued research and support.
70
Learning Assessment Questions:
1. Hospital Remission is how much higher when patients have malnutrition than those without?
A. 4%
B. 20%
C. 50%
D. 75%
2. When reviewing previous research, transitions of care interventions that involved dietitians
found what to improve?
B. Nutrition status
C. Infection Rate
3. When it comes to determining national unplanned readmission rates related to malnutrition,

what is missing?
4. Involving stakeholders like ____________ is important to support future research and projects
in the topic of malnutrition and transitions of care.
A. the local news station
B. the Marketing Director
5. Data collected from implementing a malnutrition policy and malnutrition quality improvement
projects are best used to ______________.
71
Learning Assessment Answers:
1. Answer = C; Rationale: Brining awareness to malnutrition and the impact it has on hospital
readmission, when combined with other illnesses and conditions is needed. Stakeholders
become interested and more likely to support interventions that can help reduce the risk of
unplanned hospital readmissions. Knowing the data that hospital readmission is 50% higher in
patients with malnutrition than those without is a strong talking point.
2. Answer = B; Rationale: Previous research found that including dietitians as part of transition of
care interventions improve nutrition status. An important point that dietitians should be valued
and included as part of the discharge planning and transitions of care processes. Sure, other
health care workers may be capable of completing similar tasks like encouraging healthy food
choices and intake. Why not provide more paid roles for dietitians to have the nutrition expert be
a part of providing this information and support to patients during transitions of care.
3. Answer = B; Rationale: A lack of readmission data connected to those patients with
malnutrition is limited. When reviewing the literature, inconsistent methods were used to
measure and track unplanned hospital readmissions in those patients with malnutrition. Poor
methods could lead to misleading results. The reason is unclear. A standard method for
measuring and tracking readmission data needs to be established.
4. Answer = D; Rationale: Involving stakeholders is one of the first essential steps when
developing an intervention program at any facility. According to the CDC guidelines for process
and outcomes evaluations. Stakeholders like hospital administration leaders’ interest and
support is needed for programs related to nutrition and malnutrition treatment and prevention to
be successful. Otherwise, projects may go unrecognized or not have the support needed to
implement and complete the program as planned. Completing a program as intended is
especially important when the data you need from the completion of the program will be used to
show the impact and need for the said program to continue. Stakeholders need to be invested
and see the value and worth of these programs for them to continue financially supporting them.
5. Answer = C; Rationale: Start by assessing the needs of your community to establish the best
malnutrition protocol and malnutrition quality improvement program that should be implemented
at your facility. There are many tools out there to start these initiatives wherever you may work.
Acute care hospital, long term care, or hospital to home. Data collection is needed to show how
malnutrition quality improvement projects and interventions are needed help to improve
malnutrition and associated health outcomes.
72
References:
1. Valladares A, Jones K, Mitchell K, et al. Dialogue Proceedings / Advancing Patient-Centered
Malnutrition Care Transitions. Avalere Health LLC. Defeat Malnutrition Today.
https://avalere.com/insights/dialogue-proceedings-advancing-patient-centered-malnutrition-care-
transitions. Published 2018. Accessed May-June 23, 2020.
2. Malnutrition Solution Center. Infographics: Malnourished Hospitalized Patients Are Associated
with Poorer Outcomes, Malnourished Hospitalized Patients Continue to Rise. 2021. ASPEN
Web site.
https://www.nutritioncare.org/guidelines_and_clinical_resources/Malnutrition_Solution_Center/
Accessed August 5th 2023.
3. Malnutrition in Hospitalized Adults. Research Protocol October 30, 2020. Agency for Healthcare
Research Quality Web site. https://effectivehealthcare.ahrq.gov/products/malnutrition-
hospitalized-
adults/protocol#:~:text=According%20to%20an%20Agency%20for,patients%20with%20no%20a
ssociated%20malnutrition Accessed August 5th, 2023.
4. Centers for Medicare & Medicaid. Federal Register. Rules and Regulations. Final Rule. Fed
Regist. 2019;84(189):51836-51884. https://www.govinfo.gov/content/pkg/FR-2019-09-
30/pdf/2019-20732.pdf.
5. The Joint Commission. Transitions of care: the need for a more effective approach to continuing
patient care. June 2012. https://www.jointcommission.org/-/media/deprecated-
unorganized/imported-assets/tjc/system-folders/topics-
library/hot_topics_transitions_of_carepdf.pdf?db=web&hash=CEFB254D5EC36E4FFE30ABB2
0A5550E0 Accessed July 2020.
6. White J, Guenter P, Jensen G. Consensus Statement of the Academy of Nutrition and
Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics Recommended
for the Identification and Documentation of Adult Malnutrition (Undernutrition). J Acad Nutr Diet.
2012;112(5):730-738. doi:10.1016/j.jand.2012.03.012
7. Beck A, Andersen UT, Leedo E, et al. Does adding a dietician to the liaison team after
discharge of geriatric patients improve nutritional outcome: A randomized controlled trial. Clin
Rehabil. 2015;29(11):1117-1128. doi:10.1177/0269215514564700
8. Endevelt R, Lemberger J, Bregman J, et al. Intensive dietary intervention by a dietitian as a
case manager among community dwelling older adults: The edit study. J Nutr Heal Aging.
2011;15(8):624-630. doi:10.1007/s12603-011-0074-9
73
Presentation: Title: Pre-Admission Patient-Reported Screening Tool Streamlines Assessment: The
PG-SGA© in an Electronic Health Record.
Name: Joy Heimgartner, MS, RDN, CSO, CNSC, LD
Title, Affiliation: Registered Dietitian Nutritionist (APII), Blood and Marrow Transplant, Assistant
Professor of Nutrition, Mayo Clinic College of Medicine and Science, Rochester, MN
The integration of the Patient-Generated Subjective Global Assessment© tool into the electronic health
record allows for consistent gathering of patient-reported information across the care continuum. This
presentation will demonstrate how this questionnaire is assigned to and completed by patients, either
remotely or in person. Electronic health record reporting and charting tools generated from patient
responses will also be shown.
Learning Objectives
1. Describe how the electronic PG-SGA© can be used for nutrition screening and assessment
when built into the Epic® electronic health record.
Key Takeaways/Fast Facts:

To demonstrate an example of how one scored screening and assessment tool can be used across the
care continuum.
References:
1. Ruan X, Nakyeyune R, Shao Y, Shen Y, Niu C, Zang Z, Miles T, Liu F. Nutritional screening
tools for adult cancer patients: A hierarchical Bayesian latent-class meta-analysis. Clin Nutr.
2021 Apr;40(4):1733-1743.
2. Gomes-Neto AW, van Vliet IMY, Osté MCJ, de Jong MFC, Bakker SJL, Jager-Wittenaar H,
Navis GJ. Malnutrition Universal Screening Tool and Patient-Generated Subjective Global
Assessment Short Form and their predictive validity in hospitalized patients. Clin Nutr ESPEN.
2021 Oct;45:252-261.
3. De Groot LM, Lee G, Ackerie A, van der Meij BS. Malnutrition Screening and Assessment in the
Cancer Care Ambulatory Setting: Mortality Predictability and Validity of the Patient-Generated
Subjective Global Assessment Short form (PG-SGA SF) and the GLIM Criteria. Nutrients. 2020
Jul 30;12(8):2287.
4. Jager-Wittenaar H, Ottery FD. Assessing nutritional status in cancer: role of the Patient-
Generated Subjective Global Assessment. Curr Opin Clin Nutr Metab Care. 2017
Sep;20(5):322-329.
5. Abbott J, Teleni L, McKavanagh D, Watson J, McCarthy AL, Isenring E. Patient-Generated
Subjective Global Assessment Short Form (PG-SGA SF) is a valid screening tool in
chemotherapy outpatients. Support Care Cancer. 2016 Sep;24(9):3883-7.
6. Sealy MJ, Nijholt W, Stuiver MM, van der Berg MM, Roodenburg JL, van der Schans CP, Ottery
FD, Jager-Wittenaar H. Content validity across methods of malnutrition assessment in patients
with cancer is limited. J Clin Epidemiol. 2016 Aug;76:125-36.
7. Guerra RS, Sousa AS, Fonseca I, Pichel F, Restivo MT, Ferreira S, Amaral TF. Comparative
analysis of undernutrition screening and diagnostic tools as predictors of hospitalisation costs. J
Hum Nutr Diet. 2016 Apr;29(2):165-73.
8. Martin L, Watanabe S, Fainsinger R, Lau F, Ghosh S, Quan H, Atkins M, Fassbender K,
Downing GM, Baracos V. Prognostic factors in patients with advanced cancer: use of the
patient-generated subjective global assessment in survival prediction. J Clin Oncol. 2010 Oct
1;28(28):4376-83.
74

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Malnutrition and Transitions of Care

Between Health Care Settings

WEBINAR ATTENDEE PACKET

How to Claim CE 3–4

Accreditation Statement Claudia Maza: Abbott, speaker.

Dietitians: ASPEN designates this activity for 1.0 CPEUs.

This activity was planned by and for the healthcare

Deadline for claiming CE Credits: October 18, 2023

Step 1: Log into the ASPEN eLearning Center at https://nutritioncare.org/elearning.

*IMPORTANT NOTE: DO NOT LOG IN TO YOUR ACCOUNT FROM THE MAIN

Access Your Evaluation

* Your CE transcript will be saved in your eLearning Center account.

Step 1: Log into the ASPEN eLearning Center at https://nutritioncare.org/elearning.

*IMPORTANT NOTE: DO NOT LOG IN TO YOUR ACCOUNT FROM THE MAIN

Access Handout and Webinar Recording

Malnutrition and Transitions of Care

Source: National Population Projections, 2017

Nutrition and Functional Outcomes

• Risk Factors in older • Negative outcomes

High prevalence of malnutrition

Nutrition Risk in Community -Dwelling Older Adults

*Weighted sample, P <.01

Data Source: NHATS 2017

• Older adults are at risk for malnutrition across

Prevalence of Malnutrition at Care Transitions

• Not documented at hospital discharge

• N=174 hospital or long-term acute care RNs

Malnutrition and Hospital Discharge Nutrition Care

Read more at https://www.geron.org/programs-services/alliances-and-multi-stakeholder-

Patient “Transition” Perspectives Total

Inpatient hospital stay in the last 12 months 1035 12%

Referred/enrolled to meals at community or senior center upon DC 126 12%

Received educational materials on diet/nutrition info upon DC 126 33%

Recommended an oral nutrition supplement upon DC 126 18%

Caregiver “Transition” Perspectives (n=119)

Norway: Patient and Family Caregivers’ Perspectives

Belgium & Denmark: Care Transition Barriers

Organization: lack of communication from hospital on reason for

Economic: Short hospital stay; therapy not started at discharge

Barriers and facilitators to primary care and community nutrition care

Interventions: Implement appropriate transition interventions, recognize the

Educate: Health care professionals about the importance of nutrition screening

Research: Most effective interventions to promote positive outcomes and

Nutrition Curing Care Transitions

Learning Assessment Question 1

Malnutrition assessment at hospital discharge is a

Malnutrition assessment at hospital discharge is a

Learning Assessment Question 2

Older adults are at risk for malnutrition across the care

Older adults are at risk for malnutrition across the care

References List Cont.

Nina Rocca, DCN, MS, RD, LDN, FAND

Burden of Malnutrition on Health Outcomes

Prevalent in 20-50% of hospitalized and community dwelling patients

Currently, Medicare does not provide MNT reimbursement for malnutrition

ASPEN Malnutrition Solution Center Infographic

Safe transitions across levels of care and different care settings

Reduces hospital readmissions, Improve health outcomes

JCAHO* & CMS* requires nutrition screening, not discharge planning

Nutrition is often missing from documentation across settings

Missing Information, inconsistent care, poor health outcomes

*Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

Literature Review Summary

29 studies included in the literature review