Chapter 20 Preventing Rehospitalization

episodes for any inpatient diagnosis (age 18 and older), statistical analyses were performed to quantify the effect of ONS use on length of stay, episode cost, and probability of 30-day readmission. The results revealed that those receiving ONS had a 6.7% decrease in prob- ability of 30-day readmission (44).

The next study examined a subset of Medicare recipients (age 65 and over) from the original data- base with diagnoses of AMI, CHF, or PNA. This study showed that ONS use was associated with a statistically significant (P < .01) reduction in the probability of 30-day readmission of 12% for AMI episodes and 10.1% for CHF episodes. The research- ers quantified an overall decrease in 30-day readmis- sion probability for all three diagnoses of 8.4% (P < .05) (45). Lastly, a 2014 analysis of Medicare recipi- ents (age 65 and over) with a diagnosis of COPD showed positive results regarding ONS and readmis- sions. The results demonstrated that ONS use lowered the probability of 30-day readmission by 13.1% (P < .01) (46). These health economic studies add to the body of clinical trials and showcase the economic outcomes of nutrition intervention with ONS. A few studies have reported mixed results on the impact of nutrition intervention and ONS in LTC settings. A 2010 Danish retrospective study evalu- ated the impact of a geriatric intervention including nutrition intervention versus standard of care in 211 nursing home residents admitted to the hospital for hip fracture surgery. They found that intervention reduced nonelective hospital readmissions (OR 0.20, 95% CI 0.04, 0.91) (47). Conversely, Johnson et al reported no impact of two ONS per day in 109 LTC residents compared to a random control sample of control residents who did not receive ONS (48). Lastly, research has also shown the benefit of enteral tube feeding and a dedicated nutrition support care team on reducing readmissions in high-risk popu- lations. Kurien et al examined the impact of interven- tion from a dedicated dietetic home enteral feeding team on 313 hospital patients receiving enteral feeding and showed that the intervention significantly reduced gastrostomy-related hospital readmissions, from 23% to 2% (P = .0001) (49). Additionally, Hassell et al showed that a nutrition support team in tube-fed hos- pital patients led to a 43% reduction in adjusted read- mission rates (50). See Table 20.1 on pages 294–297 for a summary of various randomized controlled trials, prospective cohort studies, retrospective studies, and health economic outcomes research studies on nutri- tion intervention and readmission risk. There are many strategies that the health care team, including the registered dietitian nutritionist

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(RDN), can implement in older adults across health care settings to help reduce the risk of hospital read- missions. Researchers and clinicians alike have devel- oped interventions, some of which involve nutrition care, designed to help reduce the risk of 30-day read- missions, including education and coordinated care. Many of these strategies fall into three categories: pre- discharge, postdischarge, and bridging hospital and home (62). A retrospective cohort study compared a hospital that had a care transition program with these strategies to a hospital without this program and found that patients at the hospital without the care transition program had nearly twice the odds of 30-day readmis- sion (OR, 1.90; 95% CI, 1.35–2.67) compared with those who received the care transition program (63). Further, research has shown that well-targeted interventions among LTC residents can help reduce hospital readmissions. Interventions to Reduce Acute Care Transfers (INTERACT) and INTERACT II are programs that have been suc- cessful in reducing avoidable hospital readmissions (64). INTERACT/INTERACT II are quality improvement programs designed to improve the early identification, assessment, documentation, and communication about changes in the status of SNF and LTC residents. “The goal of INTERACT is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital. Such transfers can result in numerous complica- tions of hospitalization and billions of dollars in unnecessary health care expenditures.” The original INTERACT program was developed with input from experts and pilot-tested in three LTC facilities with high readmission rates. INTERTACT II refined the program based on findings from a multistate quality improvement project. INTERACT II was evaluated in 25 nursing homes in three states in a six-month quality improvement initiative and showed a 17% reduction in self-reported hospital admissions (64). See Table 20.2 on page 293 for a list of potential strategies RDNs can use to help prevent hospital readmissions.

SUMMARY

Older adults and those with chronic disease(s) are at high risk for hospital readmissions. These readmissions result in high costs to the health care system and to the older adult regarding quality of care and quality of life. Key populations, including those with CHF, AMI, PNA, and COPD, are the focus of current CMS strategies to reduce payment for excessive readmission rates to help contain costs. In addition, nutrition risk factors, including weight loss and inability to self-feed, are associated with higher readmission rates. Fortunately, nutrition intervention,