As Clinical Outreach Dietitian for New Hanover Regional Medical Center in North Carolina, Skip Allen spends his days calling on discharged patients in their homes, seeing how he can help them manage their medical and social needs. A trained dietitian, he works to solve nutrition-related challenges that can jeopardize their recovery and impede their path to wellness.
“The goal is to help malnourished patients bridge the gap between the nutrition they receive in the hospital and what they experience once they return home,” Allen says. “Malnutrition can lead to dangerous health complications, prolonged hospital stays and readmissions. We want to make sure patients who leave our facility have what’s necessary to thrive.”
Launched with a grant from The Duke Endowment, New Hanover Regional Medical Center’s community dietitian initiative began in 2019. It’s modeled on the medical center’s successful community paramedicine program – and hospital leaders believe there’s nothing quite like it in the country.
‘Connected to Everything’
Malnutrition – the inadequate intake of nutrients over time – includes undernutrition (underweight) and overnutrition (overweight and obesity). Some researchers say it affects about half of the patients admitted to an acute hospital setting. Most at risk are people from lower socioeconomic backgrounds, seniors and patients with chronic illnesses.
Malnutrition isn’t a new problem, but it has often been poorly diagnosed, says Angela Lago, New Hanover’s Manager of Clinical Nutrition.
“Dietitians are leading the way in identifying it, treating it and showing how it negatively affects a patient’s ability to heal and recover,” she says. “Nutrition is connected to everything. We can’t expect our patients to bounce back from a stroke, fall, surgery or any other medical condition if their nutrition is inadequate.”
At New Hanover Regional Medical Center, an 800-bed facility in Wilmington, registered dietitians screen patients for malnutrition and begin a nutrition intervention based on the diagnosis. Discharge instructions include how to properly nourish to maintain or rebuild strength and lean muscle mass.
But before the community dietitian initiative began, patients often had setbacks after returning home – especially since malnourishment can often overlap with “food insecurity,” which the USDA defines as lacking consistent access to adequate food.
“We didn’t know if they had access to nutritious food, if family members were able to help them obtain or prepare meals, if they were able to retain and implement the nutrition education they received, or if they were following the nutrition care plan that was created specifically to help them heal,” Lago says. “We wanted to begin addressing the underlying causes of illness – one of which is a patient’s access and relationship with food.”
The medical center began what Lago calls its “malnutrition journey” in 2016 by building awareness across the organization, gathering data and joining a national learning collaborative called the Malnutrition Quality Improvement Initiative. Efforts focused on several areas, including enhancing post-discharge nutrition care through the community dietitian initiative.
New Hanover designed Allen’s position using its community paramedicine model. In that program, paramedics with the hospital’s emergency medical services work with patients in their homes to help them find ways to better manage their conditions, avoiding recurring trips to the hospital. Community paramedics have specialized training to answer questions, assess patient needs and help them navigate community resources. In some cases, they provide treatments or diagnostic testing in the patient’s home.
The components of Allen’s job are similar: Engage patients in their homes, provide diagnostics and assessment services, identify patients at risk, and offer follow-up care.
Improving Health Outcomes
As the medical center’s first Clinical Outreach Dietitian, Allen was visiting as many as 25 patients in their homes weekly before COVID-19 restrictions took effect. Each had been recently discharged from the hospital, and each had been diagnosed with malnutrition during their stay. During the pandemic, he saw patients virtually; he’s gradually returning to in-person visits.
Allen receives referrals from Lago’s team, then schedules home visits to reinforce nutrition plans and connect patients to the resources they need to continue recovering at home. He asks about their appetite, what they’ve recently eaten and when. Through a nutrition-focused physical exam, he looks for signs of nutrient deficiencies. He gathers relevant socioeconomic metrics such as income and whether community resources are being used.
He also talks to patients about their ability to access food, focusing on transportation and affordability. The New Hanover initiative includes a box of groceries to help food insecure patients continue their recovery after discharge. Stocked with peanut butter, granola bars, fruit and pantry staples, the box provides nutrition to last several days until follow-up from a registered dietitian.
His goal is to prevent obstacles from harming their nutritional status. “I want to leave the patient with an actionable plan that improves their care, health outcomes and life,” he says.
Results have been promising. During the pilot – January through December 2019 – the malnutrition diagnosis rate increased 50 percent. Hospital readmissions for malnourished patients decreased by 19 percent.
More recently, the medical center divided patients into control and intervention groups to study the initiative’s effect on emergency room visits and inpatient admissions. Patients in both groups had an inpatient diagnosis of malnutrition and were seen by a Registered Dietitian – but the intervention group had at least one home visit from Allen and the control group had no visit.
Comparing emergency department visits and costs, and inpatient visits and costs, the intervention group had better results across the board.
Lago and Allen have been sharing their story through local media, national journals and at professional conferences. Part of their message shows how the work aligns with the institutional mission to improve health equity by spanning the continuum of care: Malnutrition among hospitalized patients, food insecurity in the community, and eating for optimal health and healing.
“We are meeting our patients wherever they are on that continuum,” Allen says, “and addressing their needs appropriately.”
Linwood B. Hollowell III
Director of Health Care