Nutrition improves outcomes, helps HMOs score big with HCFA, NCQA

Here’s how and why to add nutrition screening to CM plans

Good nutrition is essential to management of every chronic disease, including the big three: congestive heart failure, diabetes, and cancer. Studies show that hospital costs for patients at nutritional risk are four times higher than those for patients who are well-nourished. And health plans and managed care organizations are starting to understand that nutrition screening and intervention can help them demonstrate the type of quality improvement that earns the favorable attention of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL, and the National Committee for Quality Assurance (NCQA) in Washington, DC.

"Addressing nutrition needs improves outcomes, and that’s what JCAHO and NCQA look at," says Elizabeth DiGiaccomo-Geffers, RN, MPH, CNAA, a health care consultant in Trabuco Canyon, CA, who helps managed care organizations with regulatory agency compliance. "Managed care organizations have to address nutrition risk. It’s much easier and less expensive to screen for nutrition risk, intervene, and prevent malnutrition than it is to manage chronic disease."

Oxford Health Plans in White Plains, NY, recently launched a nutrition screening and intervention program for its 170,000 Medicare members. "We used the DETERMINE checklist and found that between 22% and 30% of our seniors are at risk for malnutrition," says Mellany Hanson, MS, Oxford’s senior health promotion coordinator. "There is no doubt that malnutrition increases length of stay. The screening and intervention program gives Oxford an opportunity to be more proactive instead of relying on a Band-Aid approach." (For a copy of the DETERMINE checklist developed by the Nutrition Screening Initiative in Washing-ton, DC, see p. 40.)

The good news for managed care organizations is that most everything you need for a nutrition management program is available for little or no cost. "The tools already exist. They are simple and effective, like the screening tools available from the Nutrition Screening Initiative. And any organization can incorporate them into their member services without a great deal of cost or effort," says Carol M. Capozza, RD, CNSD, diagnostic services department manager for Vencare Health Services in San Jose, CA.

Not only are the screening tools available, but so are many of the nutrition services. "The interventions are available in this country. There are many resources for older adults, but many people don’t know about them or how to access them," Hanson adds.

Volunteers assist the elderly

Oxford mails the DETERMINE checklist to members and scores them as they are returned. High-risk members are contacted by trained outreach counselors who work to identify needs and hook members up with community and government-run services such as Meals-on-Wheels or food stamp programs.

"We’ve compiled binders of resources for our outreach workers. The outreach workers are truly caring people with backgrounds in gerontology or public health," Hanson says. "We’ve had some pretty dramatic experiences. One woman was having a heart attack when the outreach worker called. The worker got the on-call nurse on the line and the two of them stayed on the line with the member until the ambulance arrived. As soon as she came home from the hospital, the outreach worker began working with the member on her nutrition issues."

Members at moderate risk for malnutrition are linked with Oxford’s volunteer Partners in Caring program. Partners in Caring is a health care service banking program in which members earn credits by volunteering they can cash in later when they need services. "Our Partners in Caring volunteers provide grocery shopping, cooking, and provide other small unskilled tasks for moderate-risk members," Hanson says.

In a small pilot of its nutrition management program, Oxford saved $10 for every dollar spent, she notes, and its claims dropped more than 34% per month for high-risk members, from roughly 400 claims nine months before the 1996 pilot to 261 claims seven months after the nutrition management program began.

Case management and nutrition are a per- fect combination, says Gayle S. Hoxter, MPH, RD, director of nutrition services for Ramona Visiting Nurses Association in Hemet, CA. "Case managers can help managed care organizations implement nutrition screening and interventions to improve patient care and demonstrate positive outcomes," she says."There are countless examples of the benefits, and adding nutrition to case management plans is very easy." (For examples of how to blend nutrition into your case management efforts, see flowchart, p. 39, and nutrition checklist, p. 41.)

In addition to improving the general health of your members and clinical outcomes of chronically ill or at-risk members, several of NCQA’s Health Plan and Employer Data and Information Set (HEDIS) 3.0 measures address nutrition issues. Those are:

• cholesterol management of patients hospitalized after coronary artery disease;

• controlling high blood pressure;

• monitoring diabetes patients;

• the health and functional status of seniors.

Even disability and workers’ compensation patients may have nutritional needs. One worker’s comp case manager called Hoxter to help a back pain patient on a weight reduction program. "The woman had surgery and was homebound. She was overweight and had to lose more before her doctor would perform a second surgery," she says. "Dietician involvement can have a great impact on all types of medical outcomes, but because Medicare reimbursement for dietician is limited, an RD may need to be a consultant rather than a one-on-one health care provider."

"More organizations are including nutrition screening in their member services," Capozza says."As the population ages and we face members with co-morbidities, nutrition will become increasingly important to controlling health care costs."

As an added benefit, nutrition screening and intervention programs help HMOs improve their scores on HEDIS 3.0 member satisfaction surveys, Hanson says. "Members and physicians are overwhelmingly enthusiastic about the nutrition program. Members are so happy just to get a phone call from their health plan. They appreciate the fact the someone is going to spend time to help them, even if it is over the telephone."

Suggested reading

Barents Group of Peat Marwick. The Clinical and Cost-effectiveness of Medical Nutrition Therapy: Evidence and Estimates of Potential Medicare Savings from the Use of Selected Nutrition Interventions. Washington, DC; 1993, 1996.

Detsky AS, Baker JP, et al. Perioperative parenteral nutrition: A meta-analysis. Ann Intern Med 1987; 107:195-203.