Bill is a 72-year-old man with diabetes and hypertension. He recently lost his wife to cancer and hasn’t been eating well. He is relying on quick meals such as tea and toast and processed foods, which has led to a 30 pound unintentional weight loss. Unfortunately, no one has noticed or worried about his weight loss since he has always been “on the heavy side”. Bill has fallen several times at home and finally ends up in the hospital after falling on the stairs. He eventually gets discharged home.
In Canada, one out of three seniors is at nutritional risk and one out of two adults is malnourished upon hospital admission.
Health Quality Ontario had a chance to talk with Michele MacDonald Werstuck, RD, MSc, CDE, Acting Nutrition Program Coordinator at the Hamilton Family Health Team (FHT) to learn how she and her team are embedding nutrition screening into clinical practice to help prevent and address malnutrition in seniors, like Bill.
Can you tell us why you began this quality improvement project?
Malnutrition in seniors is happening in our communities but often going un-noticed, as described by Bill’s story. Poor quality of life, increased risk of falls and hospitalizations, longer hospital stays, and frequent re-admissions are just a few of the negative consequences associated with malnutrition.
Despite evidence of the benefit of nutrition counselling and team support to improve health outcomes and reduce hospital admissions, an environmental scan of the 184 FHTs in Ontario identified no active nutrition screening programs, and dietitians in the 184 FHTs reported extremely low referrals for malnutrition nutrition counselling.
The strength of the evidence and gap analysis led to the creation of our QI project. Our goal in our FHT was to raise awareness about the prevalence of senior malnutrition, and to advocate for the use of validated nutrition screening tools and collaborative care pathways to enhance earlier detection and intervention, two themes which align with Hamilton FHT’s Strategic Plan and the Ministry’s focus on Senior Health in Ontario.
How did you start out?
This project started with dietitians raising awareness of malnutrition with their teams and quickly grew into a cross discipline collaboration. Resources were approved by our Health Planning Committee to create a Malnutrition QI Initiative Working Group including dietitians, nurses, quality improvement specialists and program facilitators with dedicated time to work together.
The work included launching an awareness campaign, providing support and leadership, facilitating screening uptake, training teams on screening tools and processes, problem-solving barriers to screening, and tracking outcomes.
Dietitians in our FHT also advocated to be part of a multi-site quality improvement project to embed nutrition screening for seniors across four FHTs in Ontario (Hamilton, Sudbury, Upper Grand and Niagara). Dietitians in these FHTs work together on a committee and have created electronic medical record (EMR) tools to facilitate nutrition screening.
Which senior populations are you targeting?
When we started this initiative in 2016, we wanted to start small and focus on the most vulnerable seniors where the literature supports the benefit of team-based care including:
- Recently discharged seniors from hospital and
- Seniors with cognitive issues
Other FHTs also chose to target the same population groups due to Ministry interest in the post discharge population and to align with the addition of 100 interprofessional memory clinics in FHTs across Ontario.
How did you embed nutrition screening tools into clinical practice?
First, we reviewed the literature to identify appropriate screening tools and determined the feasibility of screening within family practice. We then created tools to support and standardize nutrition screening and facilitate outcome retrieval. For example, we created encounter assistant forms in the Practice Solutions EMR with a choice of three nutrition screening tools embedded into assessment forms.
Training sessions were provided for dietitians and other team members to become familiar with the screening tools and the inter-professional clinical care pathways outlining the screening process.
The following process, which uses the acronym SCREEN, was used to guide nutrition screening in family practice.
- Screen seniors for nutritional risk with validated screening tools
- Chart risk factors (with EMR custom forms)
- Refer to appropriate providers (using clinical care pathways)
- Educate patients/families to correct/prevent malnutrition
- Evaluate outcomes (with EMR custom forms)
- Networks of supports within family practice and with community partners
What are you measuring to determine success?
We are looking at various measures to determine the success of this initiative both within our Hamilton FHT and across the four FHTs involved in the project. These include:
Process measures:
- How many teams are starting to screen?
- Which population of seniors are being screened?
- What screening tools are being used?
- How many referrals to dietitians/other health care providers are being made for malnutrition management?
Outcome measures:
- Percent of seniors identified at nutritional risk
- Percent of seniors identified as malnourished
- Percent of seniors with improvements in scores post intervention
Have you achieved your goals with this project?
We are still in the early days of clinical changes, but awareness around malnutrition is spreading across the more than 90 sites of the Hamilton FHT with approximately 10-15 teams starting to screen different populations of seniors in different ways.
Some teams are doing opportunistic screening, such as screening seniors over 75 years of age coming in for a nutrition visit with the dietitian, while other teams are linking screening with existing clinics such as INR, diabetes or flu clinics.
Several teams are targeting the post discharge population and have added two screening questions about unintentional weight loss and low appetite to their post discharge follow-up phone calls.Nine teams in Hamilton FHT are starting to screen in the waiting room with OCEAN tablets that link screening results to the patient EMR.Another Hamilton FHT team has started healthy aging senior group medical visits every 3-6 months.
Overall, the Hamilton FHT Malnutrition QI project has led to clinical changes with teams more frequently asking about nutrition, adopting best practices such as weighing seniors at least once a year and recording it in the patient EMR, and finding creative ways to deliver care to older adults.
On a provincial note, the four FHTs (Hamilton, Niagara, Sudbury, Upper Grand) are actively screening seniors as part of the Malnutrition QI project and collecting outcomes using custom EMR tools with embedded screening tools and standardized clinical care pathways.
To date, more than 250 dietitians and other health professionals in FHTs and CHCs across Ontario have been trained on the malnutrition screening tools and processes.
What are your next steps?
Next steps will be to:
- Spread the nutrition screening initiative in the Hamilton FHT
- Promote data collection and adoption of best practices
- Look closer at segments of the population of Hamilton with high positive screening rates
- Create a Senior Nutrition Network in Hamilton including dietitians and other interdisciplinary health professionals from primary care (FHTs, CHCs, LTC, home care, public health, private practice) and hospital care to identify strategies to reduce nutrition risk in seniors in the Hamilton community, and facilitate coordination of care from hospital to home
Through this work, we hope to continue to improve earlier malnutrition detection and intervention, and help seniors like Bill maintain his quality of life.
Do you have experiences to share related to malnutrition management and nutrition screening? Add your thoughts to this discussion by clicking on "Add a Comment" below or connect with Michele, on Quorum.