Essential Connections: How Improved Referrals From Hospital to Community Meal Provision Can Impact Malnutrition Outcomes in Older Adults

We hypothesize that enhanced continuity of nutrition care between acute care hospital settings and community meal provision organizations providing Title III-C Special Need Plan services (C1 and C2) will be sustainable and improve outcomes for patients older than 60 years of age who are diagnosed with malnutrition. Specifically, the enhanced continuity of care will: a) increase referrals and communication between clinical and community nutrition care providers at each study site location; b) increase the percent of patients receiving nutrition care within the community setting; and c) improve food security, quality of life, and reduce determinants of malnutrition.

To test this hypothesis, we propose to conduct a study which will examine a new model of continuity of nutrition care for sustainability and impact. The model has been developed to facilitate cross-referrals and transmission of structured nutrition care documentation from an acute care setting to a meal provision organization and then for the meal provision organization to use the referral data to increase delivery of nutrition care (medical nutrition therapy- MNT) and meals (medically tailored meals - MTM). The primary subjects for this study are adults older than 60 years of age with malnutrition, with particular emphasis on recruiting sites who serve individuals who are Black, Latino, Indigenous and Native Americans and individuals living in rural areas of the country.

The components of the proposed new model of cross-referral, data transfer, and nutrition care across settings has the potential to be scalable throughout the US. However, barriers and facilitators to data transfer and MNT/MTM provision, cost of implementation, and potential impact on outcomes must be evaluated for the model to be replicable. The results of this study will generate new data on the model of care feasibility, rates of malnutrition within older adults at the study sites, impact of MNT with MTM provision on food security, determinants of malnutrition, and quality of life to inform future scalability of the model.

Goals and Objectives The goal of this new model is to improve food security and quality of life in patients 60 years and older from key vulnerable populations with greatest social and economic need by providing continuity of nutrition care for malnutrition treatment across settings. To test the feasibility of this new model, we will use a stepped wedge cluster-randomized trial design at eight sites throughout the US, specifically recruiting sites and individuals who are Black, Latino, Indigenous and Native American, and individuals living in rural areas of the country. The Academy of Nutrition and Dietetics (the Academy), as the research organization, and the Academy of Nutrition and Dietetics Foundation (Academy Foundation) will partner with collaborating organizations in both acute care hospitals and meal provision organizations (Title III-C1 and C2) within the community to test the newly developed model.

Objective 1) To test the feasibility of a patient identification, cross-referral, data reporting, and communication (including data transfer) process from an acute care hospital to a community meal provision organization.