Good Meeting “Flavor [email protected] – A Medical Solution to Elder Malnutrition”

flavor-harvest-at-homeLMHS Malnutrition Study

Flavor [email protected] – FAQ


Patients 65 or older are often at risk for malnutrition, and some studies have indicated as many as 1 in 3 patients are at risk for malnutrition upon admission. 45% of LMHS patients are 65 or older, so the financial risk to Lee County and LMHS is significant if the need for nutrition intervention in some form is not identified correctly or initiated early on in the provision of care.  Without treatment approximately 2/3 of these individuals will experience a further decline in their health status.  Malnourished patients are 2 to 3 times more likely to develop surgical site infection or post-operative pneumonia.  Data from the 2010 healthcare Cost and Utilization Project (HCUP), the most current nationally-representative data describing U.S. hospital discharges, found malnourished patients spent an average of 12.6 days in the hospital compared to 4.4 days for other patients, a 3 fold increase in hospital costs ($26,944 versus $9,485).


Financial = Nutrition support at home can prevent readmissions, cost of care and is a low risk, low cost approach to improving patients’ health status. Early identification and subsequent interventions have proven to reduce length of stay (LOS), and readmission rates.

  • One study by Johns Hopkins determined that using a team approach to address malnutrition reduced length of stay by 3.2 days in severely malnourished patients.
  • An additional study by Premier Healthcare Alliance 2000 -2010 representing 20% of all hospital admissions demonstrated a reduction in LOS of 2.3 days when nutrition intervention was provided.
  • Additional studies demonstrating improved nutrition screening, education, intervention, nutritional support, oral nutritional supplements and coordinated discharge planning will result in lower costs incurred by those patients 65 years or older when a nutritional intervention is introduced in an interdisciplinary way.

Demographics – Nationally – Aging America:

  • The percent of people ages 65 and over living in the United States increased 15.3 percent between 2000 and 2010 to 40.4 million people. The population is expected to grow to 55 million people in 2020 – an increase of 36 percent.
  • In the next 20 years, the number of Americans between 45 and 64 years old will increase by 31 percent.
  • One in every eight Americans (13.1 percent) was over 65.
  • In 2010, the median income for people over 65 was $25,704 for men and $15,072 for women. The major sources of income in 2009 were: Social Security (87 percent), income from assets (53 percent), private pensions (28 percent), government-employee pensions (14 percent), and earnings (26 percent)

Demographics – LMHS:

Percent of Patients Over 65 49% 51% 34% 49% 45%
Percent of Patients Readmitted 12.6% 13.2% 10.2% 13.8% 12.2%


The primary intent of this research and program is to improve the health status of the patients at risk for malnutrition.  To that end LMHS Food and Nutrition Department conducted an evaluation of patients at risk for malnutrition from April to October of 2014 following a “proposed” care plan using Intensive nutrition protocols at Cape Coral Hospital and Gulf Coast Medical Center targeting patients with the following medical condition:

  • Cardiopulmonary disease
  • Congestive Heart Failure
  • Pneumonia
  • Acute Myocardial Infarction (AMI)

The intention of this effort was to evaluate a more intensive nutritional intervention program that:

Employed more aggressive nutrition risk screening, assessment processes, evaluation tools, intervention techniques to determine how we can improve our methods for the identification and treatment of malnutrition.  Once identified a multitude of interventions were developed to support the patient’s improvement while an inpatient and post discharge.

From our research the recommendation was to utilize a program incorporating the Alliance for Advanced Patient Nutrition model that employs a broad spectrum in intervention options to include:

  1. Food and/or nutrition meal delivery – using individualized approach to the delivery of nutrient dense foods during and after discharge, plus adding oral nutritional supplements as an element to provide micronutrients to the patient.
  2. Providing nutritional education for clinical providers engaging staff on better risk indicators for the identification of malnourishment via appropriate education, improved screening tools and increased nutritional assessment,
  3. Nutritional counseling with patients to facilitate consumption, improve nutritional status, educate them on the appropriate foods to eat.
  4. Coordination of nutritional care with during and after discharge.



The primary objective is facilitating the healing process using food as medicine so that our patients recover quicker with an improved long term health status.  Patients were assessed for improvement in clinical indicators such as weight gain, grip strength, and functional status.

Health System:

Positive health system impacts were assessed for:

  • Reducing Length of Stay
  • Lowering Readmission Rates
  • Improve Reimbursement Opportunities
  • Minimize Operational Costs


Physicians and clinical staff on the nursing units will be continually educated on the purposes of this program plus tools to use to increase awareness of clinical indicators of malnutrition.  All patients on the Cape Coral Hospital clinical units identified were screened online using the approved screening tool by a dietitian for the general indicators of malnutrition. Patients who are either identified through this process or via other clinical triggers had a physical nutrition assessment completed by a dietitian.  Clinical and measurable criteria was used by the RD to identify patients at risk for malnutrition earlier in the care continuum than would normally happen.

Patients will be assessed for:

  1. Insufficient energy intake
  2. Weight loss
  3. Loss of subcutaneous fat
  4. Loss of muscle mass
  5. Localized or generalized fluid accumulation
  6. Diminished functional status

Patients identified as “at risk” by meeting 2 of the 6 criteria above received the appropriate nutritional intervention as defined by the RD and were eligible for the 4 week post discharge nutrient dense meal program provided to them at no charge.


10 / 14 / 14 Preliminary Data – Intensive Nutrition Intervention Study

Total patients screened based on DRG 546  
Study 318 63.7%
Control 228 41.8%
Eligible for meals 169 30.9%
Signed consent for meal program 75 23.6% (study)

13.7% (total)

Did not meet criteria 112 20.5%
At risk for malnutrition, potential for 2nd tier per MD 134/546 24.5%
Confirmed would not have been pu by MST 104 77.6%
Potentially at risk 259 / 546 47.4%
Average Age of Patients 72  

Data Evaluation:

Of the 546 patients studied, 318 or 63.7% constituted study patients.  The average age of the patients in the study was 72.  Of the study patients 169 or 30.9% were eligible for meal support – by clinically meeting 2 of the 6 criteria necessary for clinical diagnosis.  Of that group 75 signed informed consent for eligibility to participate in the study, or 13.7% of the total.  59 of those patients actually received the full 30 allotment of meals.  134 or 24.5% met the criteria for a clinical diagnosis of malnutrition either moderate or severe.  Of those patients, 104 were picked up because of the Intensive Nutrition Intervention protocol.  77.6% of those patients meeting the criteria for medical diagnosis would not have been identified by strictly using the current tools available (MST).    The current screening tools are not sufficient to pick up a large majority of the patients who are at risk for malnutrition.

Most of the patients receiving home meals are economically disadvantaged based on information provided or observations.

The average age of the patients studied in total = 72.


While limited in size, our evaluation identified that roughly 30% of the patients screened in the targeted diagnosis related groups (DRGS) met the clinical criteria for malnutrition, with roughly 14% agreeing to participate in support at home. It was determined that a majority of patients who were at risk for undernourishment would not have been identified if it were not for the new, more aggressive protocols.  Hence, aggressive physical assessments improved the overall identification of patients at risk, and supported post discharge intervention.  Positive gains in length of stay reduction, and reduce readmission rates were also achieved from the participant population.

Anecdotal feedback from clients has been very positive with regard to food provided, as well as, the social interaction provided to the patients was perceived as helpful in their care by the patients.  Those surveyed were impressed with LMHS outreach and concern.

The evaluation outcomes mirrored similar findings of other national studies on this topic.

The average age of the patients studied in total = 72, the majority were female.

Go Forward Strategy:

The program is currently being tested in full capacity for all patients at Cape Coral Hospital, and in a controlled status at Gulf Coast Medical Center with expansion plans to the full facility at GCMC in October.  This is intended to validate the economic, clinical outcomes originally derived in the evaluation.  Expansion of the plan is pending clinical outcomes at the end of fiscal 2015 to determine to what extent the full program of intervention and meal support should be applied to other hospital populations.  In addition, relationships with various community outreach programs providing meal support to the home bound are being developed so that the full program can be expanded beyond the 4 week medical discharge component.

Flavor [email protected]:

Flavor [email protected] is a medical nutrition therapy program designed for patients of the Lee Memorial Health System with a potential to become malnourished or undernourished as a result of their medical condition.  Flavor [email protected] is a product line of Culinary Solutions by LeeSar developed in conjunction with LMHS Food and Nutrition.  The program is supervised by LMHS Registered Dietitians trained in the treatment of malnourishment/undernourishment.  Flavor [email protected] provides an array of freshly prepared, frozen and shelf stable meals to home bound customers requiring treatment or having been treated through the Lee Memorial Health System.  A full array of therapeutic meals covering all meal periods, and snacks are available to eligible patients.  Meals are individually packed, microwaveable and ready to eat either hot or cold.

Flavor [email protected] – Future Planning and Expansion:

While presently focused on the nutritional needs of patients with medical necessities post discharge, the [email protected] program could be expanded into other medical nutrition therapy segments, such as:

Pre-operative:  Those with selected chronic disease states or surgical conditions screened for malnourishment/undernourishment screened via medical staff, nutrition professionals, and home-bound caregivers may be potential clients of [email protected]

Self-directed:             Staff, visitors and patients seeking specific therapeutic meals could be able to purchase an array of these products made available through the health systems retail outlets.

Chronic Obesity:       Patients identified as medically obese could have the ability to access a nutritionally balanced meal replacement program designed to assist them with weight reduction and disease management.

Flavor [email protected] Meal Program:

At home meal support provided by Culinary Solutions by LeeSar will include:

  • Fully cooked therapeutic meals with  ONS (Oral Nutritional Supplements)
  • 7 day pattern approved by a dietitian as defined by their medical condition
  • A mix of ready to eat meals:
    • Breakfast – assortment of nonperishable, shelf stable products
    • Lunch – an array of fresh salads, sandwiches, frozen meals
    • Dinner – assortment of frozen meals
  • Program instruction sheet with cooking guideline
  • Support from a Registered Dietitian on meal planning, guidance


Supporting Research

Malnourishment and Interventional Impacts

  1. Researchers from John’s Hopkins concluded that 30 -55% of acutely ill hospitalized patients in the US are malnourished or undernourished and that leads to significant negative outcomes. Somanchi M, Tao X, Mullin GE. JPEN J Parenter Enteral Nutr 201 1; 35: 209 – 216
  2. Research also shows that early nutrition intervention can improve health outcomes, morbidity, and mortality, and reduce length of stay in hospital patients… Somanchi M, Tao X, Mullin GE. JPEN J Parenter Enteral Nutr 201 1; 35: 209 – 216
  3. 1% – 55.8% of patients were found to be malnourished upon admission..Somanchi M, Tao X, Mullin GE. JPEN J Parenter Enteral Nutr 201 1; 35: 209 – 216
  4. Nutrition intervention significantly decreased LOS in malnourished patients. The LOS in the total malnourished group with nutrition intervention decreased significantly by 2.6 days vs. the historical control…..Somanchi M, Tao X, Mullin GE. JPEN J Parenter Enteral Nutr 201 1; 35: 209 – 216
  5. Older adults receiving Medicare home health services who are experiencing under-nutrition as defined by the Mini Nutritional Assessment (MNA) as either Malnourished or At Risk for Malnourishment, are more likely to subsequently use greater amounts of health care resources…J Am Med Dir Assoc 2011 May 12
  6. Prevalence estimates of under-nutrition is high among this group ranging from between 70% to 93% of individuals…J Am Med Dir Assoc 2011 May 12
  7. According to Stratton’s research in the United Kingdom, 58% of patients malnourished have a longer hospital stay and poor outcomes (Stratton RJ. Etal. Malnutrition Universal Screening Tool predicts mortality and length of hospital stay in acutely ill elderly. Brit J of Nutr 2006: 95;325-330)
  8. Severe complications to malnutrition in hospitalized patients:
    1. Impaired wound healing and infections (Rai et al, Orthopedics 2002; Schneider et al, Brit J Nutr 2004)
    2. Increased post-operative complication (Gupta et al, Br J Nutr 2004, Gupta et al, Am J Clin Nutr 2004; Barbosa-Silva and Barros, Clin Nutr 2005; Hassen et al, eur J Vasc Endovasc Surg 2007)
    3. Increased length of hospital stay (Edington et al, Clin Nutr 2000, Correira and Campos Nutrition 2003; Kyel et al JPEN 2004)
    4. Increased mortality in a number of patient groups (Landi et al Arch Int Med 2000; Madill et al J Heart Lung Transplant 2001)
  9. Administration on Aging reports that 80% of older adults (65 and older) in the U.S. live with at least one chronic condition.
  10. Philipson Health Economic Study measured the impact of oral nutritional supplements of hospital outcomes:
    1. 21% decrease in the length of stay
    2. 6% decrease in episode cost – approximately $4,734 in savings
    3. 77% decrease in the probability of a 30-day hospital readmissions
  11. Malnourished individuals with nutrition intervention had a reduced length of stay of approximately 1.93 days; severely malnourished groups reduced 3.2 days (The Facilitated Early Enteral and Dietary Management Effectiveness Trial in Hospitalized Patients with Malnutrition. Journal of Parenteral and Enteral Nutrition)
  12. Nutrition intervention also resulted in cost savings. For patients with severe malnutrition $1,514 in hospital costs was saved ($473/dayx3.2 days) due to the decrease in LOS…Somanchi M, Tao X, Mullin GE. JPEN J Parenter Enteral Nutr 201 1; 35: 209 – 216
  13. The cost of one day in the hospital is roughly the same cost as providing a patient with one year of meals.
  14. Research, as noted below, was conducted by teams at the University of Southern California, Stanford University, The Harris School at The University of Chicago and Precision Health Economics. The study discovered a 16 percent, or 1.65 days, reduction in length of stay among all the studied patients, and 15.8 percent in cost savings per episode, equivalent to $3,079 when malnutrition identification and intervention was initiated early in care.
  15. Supporting Research – Quality and Safety, Reimbursement – November 19, 2013 – Kelsey Brimmer The study, presented in late October at the Society for Medical Decision Making meeting in Baltimore, relied on an 11-year data analysis of hospitalized Medicare patients aged 65 and over with any diagnosis, and those carrying a diagnosis of acute myocardial infarction, congestive heart failure or pneumonia. The matched sample for all Medicare patients aged 65 and over for any primary diagnosis was 667,684 hospital stays. The analysis demonstrated that use of nutritional supplements were associated with an 8.4 percent reduction in 30-day readmissions for patients with any diagnosis, a 10.1 percent reduction among patients with congestive heart failure, and a 12 percent reduction for acute myocardial infarction patients.
  16. National Payment Rate Schedule – Medicare: If there was no other complications/co morbidities (CC) or major complication/co morbidities (MCC) listed for the patient then depending on which type of malnutrition is documented there may be a difference in reimbursement.  Having a CC listed on account does raise the level of DRG to one with a CC and in turn raises the reimbursement.  Having a MCC on an account raises the level of DRG to one with a MCC and pays at the highest reimbursement possible for the DRG section.  In coding malnutrition is split into couple of different codes and some of those are considered a CC, one is a MCC and the others are not either.  Whether malnutrition has an effect on the DRG would depend on the type that the patient has.



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