Chapter 20 Preventing Rehospitalization

TABLE 20.2 Strategies Registered Ditetian Nutritionists Can Use to Help Prevent Hospital Read- missions

Predischarge

Perform nutrition screening with a validated tool on patients/residents upon admission and at regular intervals. Provide appropriate patient/resident diet education.

Provide effective nutrition intervention, including diet education and ONS, to appropriate high-risk patients/ residents. Tailor nutrition care based on the patient’s/resident’s nutrition risk level. Coordinate patient’s/resident’s care across the multidisciplinary team. Ensure care paths include nutrition for high-risk patients. Be involved in the facility readmissions team/committee. Include nutrition care in discharge planning.

Act as a facility champion for optimal nutrition care and the role it can play in readmissions. Provide staff education on the role of nutrition in preventing hospital readmissions.

Postdischarge Provide effective nutrition care and education to promote patient/resident self-management.

Provide nutrition care elements to the multidisciplinary team’s follow-up telephone calls and patient-activated hotlines.

Provide timely communication with ambulatory care providers. Be involved in postdischarge home visits.

Establish connections with nutrition community networks and resources for patient/resident, family, and/or caregivers.

Bridging Hospital and Home

Work with the multidisciplinary team and transition coaches to ensure nutrition care plan is communicated and followed.

Work with the care team, including the physician, to ensure continuity across the inpatient and outpatient setting.

Provide patient-centered discharge instruction that includes specifics on the patient’s/resident’s nutritional care.

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