the high price of undiagnosed malnutrition high price of... · •dietitians need to be trained...
TRANSCRIPT
The High Price of Undiagnosed Malnutrition
Kathy J Irwin MS RD LDN CNSC
Clinical Nutrition Manager Morrison Healthcare
Methodist Medical Center
A member of Covenant Health
Oak Ridge Tennessee
Service Area Map
Methodist Medical Center
bull 301 bed acute care hospital not-for-profit community hospital
bull Fourth largest employer in Oak Ridge
bull Approximately 1000 employees and 275 physicians
bull Average Daily census 140
bull ED Visits 45000+ annually
Malnutrition ndash Patient Care
bull The Skeleton in the Hospital Closet by Charles Butterworth MD 1974
bull The LeRoy Catastrophe by Michael M Meguid MD 2015
bull Definition of malnutrition bull Any nutritional imbalance bull Undernutrition typically with inadequate intake andor increased
requirements impaired absorption altered transport and altered nutrient utilization
bull Undernutrition historically is poorly described bull Difficult to ldquoseerdquo in patients
Consensus Statement of the Academy of Nutrition and DieteticsAmerican Society for Parenteral and Enteral Nutrition Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition) White Jane V et al Journal of the Academy of Nutrition and Dietetics Volume 112 Issue 5 730 - 738
Malnourished patients havehellip
bull 5x the likelihood of death bull Increased comorbidities bull 4x more likely to develop a pressure injury bull Depression of immune system bull Near 3x increase in length of hospital stay bull Near 3x increase in cost of hospital stay
Corkins MR Malnutrition diagnoses in hospitalized patients United States 2010 JPEN J Parenter Enteral Nutr 2014 Feb38(2)186-95 doi 1011770148607113512154 Epub 2013 Nov 18 Weiss AJ Fingar KR Barrett ML et al Characteristics of Hospital Stays Involving Malnutrition 2013 Statistical Brief 210 2016 Sep In Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet] Rockville (MD) Agency for Healthcare Research and Quality (US) 2006 Feb- Available from httpswwwncbinlmnihgovbooksNBK396064
Admission and Discharge Characteristics of Discharged Patients With and
Without a Diagnosis of Malnutrition United States
Mark R Corkins et al JPEN J Parenter Enteral Nutr 201338186-195
44
95
126
269
0
5
10
15
20
25
30
Length of stay (in days) Total Costs (mean $) x1000
Malnutrition Effects
Not malnourished Malnourished
Malnutrition Prevalence
bull Malnutrition is under recognized in the hospital setting in the United States bull 33-54 estimated to be malnourished in the hospital bull Yet only 32 of patients are diagnosed in the hospital
bull Therefore opportunities exist for patient care and financial reimbursement
bull In 2015 physicians at Methodist Medical Center were diagnosing 3-4 of hospital patients with malnutrition
Corkins MR Malnutrition diagnoses in hospitalized patients United States 2010 JPEN J Parenter Enteral Nutr 2014 Feb38(2)186-95 doi 1011770148607113512154 Epub 2013 Nov 18
Malnutrition is costly
bull The annual burden of disease-associated malnutrition across the 8 diseases was $1567 billion in 2014 ($508 per US resident)
bull Why are hospital cost nearly tripled among malnourished patients Infections wounds staff timeattention MD
timeattention specialists increased ICU days increased vent days PTOTST needs length of stay medications readmissionshellip Corkins MR Malnutrition diagnoses in hospitalized patients United States 2010 JPEN J Parenter Enteral Nutr 2014 Feb38(2)186-95 doi 1011770148607113512154 Epub 2013 Nov 18 Economic burden of community-based disease-associated malnutrition in the United States Snider JT JPEN J Parenter Enteral Nutr 2014 Nov38(2 Suppl)77S-85S doi 1011770148607114550000 Epub 2014 Sep 23
Benefits of recognizing and diagnosing
Malnutrition
bull Improved patient care bull Nutritional interventions (earlier) bull Patient specific nutrition plan of care bull Follow-up and support by dietitians
bull Adjusted hospital measures bull Geometric mean length of stay (GMLOS) bull Risk of mortality (ROM) bull Severity of Illness (SOI)
bull Significant Improved reimbursement
Lung ca w lobectomy Lung ca w lobectomy Lung ca w lobectomy
$9000 $12300 ($3300 increase)
$16300 ($7300)
DRG DRG with CC (Moderate PCMMalnutrition)
DRG with MCC (Severe PCMMalnutrition)
GMLOS 30 SOI 1 ROM 1
GMLOS 51 SOI 2 ROM 2
GMLOS 104 SOI 3 ROM 2
DRG ndash Diagnostic Related Groups CC ndash Complication or Comorbidity MCC ndash Major Complication or
Comorbidity
Each DRG also has an assigned expected length of stay (GMLOS) [OE ratio] severity of illness
(SOI) [how sick are our patients] and risk of mortality (ROM) [mortality index]
Example of a Diagnosis Impact
Diagnosing Malnutrition
can be Challenging
bull Old markers are not reliable bull BMI ndash malnutrition can be present in all BMIs bull PAB Albumin ndash influenced by inflammation
and hydration bull Malnutrition criteria Re-defined in 2012
bull 2 of these 6 must be present for a diagnosis bull Weight loss bull Inadequate Energy Intake bull Loss of Muscle Mass bull Loss of Subcutaneous Fat bull Loss of Fluid Accumulation bull Diminished Functional Capacity
bull 4 of the above criteria requires a physical exam Consensus Statement of the Academy of Nutrition and DieteticsAmerican Society for Parenteral and Enteral Nutrition Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition) White Jane V et al Journal of the Academy of Nutrition and Dietetics Volume 112 Issue 5 730 - 738
Registered Dietitians
The Hospitalrsquos Nutrition Experts
bull Trained to feed support and recognize nutrition problems bull Nutrition undergraduate science degree many have
graduate degrees bull 1200-hour internship with 42 competencies bull Licensed by the state bull Many RDs have advanced certifications bull Nutrition Experts but are they Malnutrition experts
(They can behellip)
Methodist Medical Center
Malnutrition Initiative
bull Dietitians developed an Expertise on Malnutrition bull Nutrition-focused physical Exam (NFPE) essential to
comprehensive assess for Malnutrition bull Dietitian ldquobuy-inrdquo can be challenging
(We werenrsquot trained to ldquotouchrdquo patients) bull NFPE training available from the Academy of Nutrition and
Dietetics bull NFPE is new dietetic internship competency 2017
bull Only a physician can give a medical diagnosis bull Tool was developed to communicated the dietitianrsquos findings to the
physician physician makes an independent decision on diagnosis bull ldquoOut-side the boxrdquo screening (initiated Oct 2017)
bull RD-led comprehensive nutrition screening trial bull Required an additional FTE
bull Team approach bull nurses therapists case managers physicians administrators
bull Awareness effort
Methodist Medical Center
Malnutrition Initiative
Methodist Medical Center Malnutrition Initiative Results
300
700
1100
1500
1900
pe
rce
nta
ge o
f p
atie
nts
Methodist Medical Center
Percentage of In-patients Diagnosed with Malnutrition
Benchmark 19
Above includes only Medicare (excludes all per diem commercial payers managed care TennCare and self pay) only includes severe malnutrition (excludes non-severe mild) only includes severe Malnutrition as the only MCC (excludes patient with multiple MCCs) 2015 data yearly total extrapolated from Oct-Dec 2015 ndash since ICD10 codes Oct 2016 data Actual data 2017 data yearly total estimated from Jan-Aug 2017 data
Methodist Medical Center Malnutrition Initiative Results
$27589600
$65843900
$107414400
$0
$200000
$400000
$600000
$800000
$1000000
$1200000
2015 2016 2017
Incr
eas
e d
ue
to
Mal
nu
trit
ion
Dia
gno
ses
Methodist Medical Center Malnutrition Impact on Medicare Reimbursements
Conclusions
bull Missing Malnutrition is significant to hospitals bull Patient Care bull Financial
bull Dietitians need to be trained bull The NFPE is essential for a comprehensive malnutrition assessment
bull Dietitian duties and staffing is evolving bull A Paradigm Shift is occurring ndash focus changing from Joint Commission
requirements toward improved patient care bull Undertrained and Understaffed units will limit patient care and will
lead to missed reimbursement opportunities
Kathy J Irwin MS RD LDN CNSC
Clinical Nutrition Manager
Contracted by Morrison Healthcare
Phone 865-835-4118
email kathyirwiniammorrisoncom
Questions
Service Area Map
Methodist Medical Center
bull 301 bed acute care hospital not-for-profit community hospital
bull Fourth largest employer in Oak Ridge
bull Approximately 1000 employees and 275 physicians
bull Average Daily census 140
bull ED Visits 45000+ annually
Malnutrition ndash Patient Care
bull The Skeleton in the Hospital Closet by Charles Butterworth MD 1974
bull The LeRoy Catastrophe by Michael M Meguid MD 2015
bull Definition of malnutrition bull Any nutritional imbalance bull Undernutrition typically with inadequate intake andor increased
requirements impaired absorption altered transport and altered nutrient utilization
bull Undernutrition historically is poorly described bull Difficult to ldquoseerdquo in patients
Consensus Statement of the Academy of Nutrition and DieteticsAmerican Society for Parenteral and Enteral Nutrition Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition) White Jane V et al Journal of the Academy of Nutrition and Dietetics Volume 112 Issue 5 730 - 738
Malnourished patients havehellip
bull 5x the likelihood of death bull Increased comorbidities bull 4x more likely to develop a pressure injury bull Depression of immune system bull Near 3x increase in length of hospital stay bull Near 3x increase in cost of hospital stay
Corkins MR Malnutrition diagnoses in hospitalized patients United States 2010 JPEN J Parenter Enteral Nutr 2014 Feb38(2)186-95 doi 1011770148607113512154 Epub 2013 Nov 18 Weiss AJ Fingar KR Barrett ML et al Characteristics of Hospital Stays Involving Malnutrition 2013 Statistical Brief 210 2016 Sep In Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet] Rockville (MD) Agency for Healthcare Research and Quality (US) 2006 Feb- Available from httpswwwncbinlmnihgovbooksNBK396064
Admission and Discharge Characteristics of Discharged Patients With and
Without a Diagnosis of Malnutrition United States
Mark R Corkins et al JPEN J Parenter Enteral Nutr 201338186-195
44
95
126
269
0
5
10
15
20
25
30
Length of stay (in days) Total Costs (mean $) x1000
Malnutrition Effects
Not malnourished Malnourished
Malnutrition Prevalence
bull Malnutrition is under recognized in the hospital setting in the United States bull 33-54 estimated to be malnourished in the hospital bull Yet only 32 of patients are diagnosed in the hospital
bull Therefore opportunities exist for patient care and financial reimbursement
bull In 2015 physicians at Methodist Medical Center were diagnosing 3-4 of hospital patients with malnutrition
Corkins MR Malnutrition diagnoses in hospitalized patients United States 2010 JPEN J Parenter Enteral Nutr 2014 Feb38(2)186-95 doi 1011770148607113512154 Epub 2013 Nov 18
Malnutrition is costly
bull The annual burden of disease-associated malnutrition across the 8 diseases was $1567 billion in 2014 ($508 per US resident)
bull Why are hospital cost nearly tripled among malnourished patients Infections wounds staff timeattention MD
timeattention specialists increased ICU days increased vent days PTOTST needs length of stay medications readmissionshellip Corkins MR Malnutrition diagnoses in hospitalized patients United States 2010 JPEN J Parenter Enteral Nutr 2014 Feb38(2)186-95 doi 1011770148607113512154 Epub 2013 Nov 18 Economic burden of community-based disease-associated malnutrition in the United States Snider JT JPEN J Parenter Enteral Nutr 2014 Nov38(2 Suppl)77S-85S doi 1011770148607114550000 Epub 2014 Sep 23
Benefits of recognizing and diagnosing
Malnutrition
bull Improved patient care bull Nutritional interventions (earlier) bull Patient specific nutrition plan of care bull Follow-up and support by dietitians
bull Adjusted hospital measures bull Geometric mean length of stay (GMLOS) bull Risk of mortality (ROM) bull Severity of Illness (SOI)
bull Significant Improved reimbursement
Lung ca w lobectomy Lung ca w lobectomy Lung ca w lobectomy
$9000 $12300 ($3300 increase)
$16300 ($7300)
DRG DRG with CC (Moderate PCMMalnutrition)
DRG with MCC (Severe PCMMalnutrition)
GMLOS 30 SOI 1 ROM 1
GMLOS 51 SOI 2 ROM 2
GMLOS 104 SOI 3 ROM 2
DRG ndash Diagnostic Related Groups CC ndash Complication or Comorbidity MCC ndash Major Complication or
Comorbidity
Each DRG also has an assigned expected length of stay (GMLOS) [OE ratio] severity of illness
(SOI) [how sick are our patients] and risk of mortality (ROM) [mortality index]
Example of a Diagnosis Impact
Diagnosing Malnutrition
can be Challenging
bull Old markers are not reliable bull BMI ndash malnutrition can be present in all BMIs bull PAB Albumin ndash influenced by inflammation
and hydration bull Malnutrition criteria Re-defined in 2012
bull 2 of these 6 must be present for a diagnosis bull Weight loss bull Inadequate Energy Intake bull Loss of Muscle Mass bull Loss of Subcutaneous Fat bull Loss of Fluid Accumulation bull Diminished Functional Capacity
bull 4 of the above criteria requires a physical exam Consensus Statement of the Academy of Nutrition and DieteticsAmerican Society for Parenteral and Enteral Nutrition Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition) White Jane V et al Journal of the Academy of Nutrition and Dietetics Volume 112 Issue 5 730 - 738
Registered Dietitians
The Hospitalrsquos Nutrition Experts
bull Trained to feed support and recognize nutrition problems bull Nutrition undergraduate science degree many have
graduate degrees bull 1200-hour internship with 42 competencies bull Licensed by the state bull Many RDs have advanced certifications bull Nutrition Experts but are they Malnutrition experts
(They can behellip)
Methodist Medical Center
Malnutrition Initiative
bull Dietitians developed an Expertise on Malnutrition bull Nutrition-focused physical Exam (NFPE) essential to
comprehensive assess for Malnutrition bull Dietitian ldquobuy-inrdquo can be challenging
(We werenrsquot trained to ldquotouchrdquo patients) bull NFPE training available from the Academy of Nutrition and
Dietetics bull NFPE is new dietetic internship competency 2017
bull Only a physician can give a medical diagnosis bull Tool was developed to communicated the dietitianrsquos findings to the
physician physician makes an independent decision on diagnosis bull ldquoOut-side the boxrdquo screening (initiated Oct 2017)
bull RD-led comprehensive nutrition screening trial bull Required an additional FTE
bull Team approach bull nurses therapists case managers physicians administrators
bull Awareness effort
Methodist Medical Center
Malnutrition Initiative
Methodist Medical Center Malnutrition Initiative Results
300
700
1100
1500
1900
pe
rce
nta
ge o
f p
atie
nts
Methodist Medical Center
Percentage of In-patients Diagnosed with Malnutrition
Benchmark 19
Above includes only Medicare (excludes all per diem commercial payers managed care TennCare and self pay) only includes severe malnutrition (excludes non-severe mild) only includes severe Malnutrition as the only MCC (excludes patient with multiple MCCs) 2015 data yearly total extrapolated from Oct-Dec 2015 ndash since ICD10 codes Oct 2016 data Actual data 2017 data yearly total estimated from Jan-Aug 2017 data
Methodist Medical Center Malnutrition Initiative Results
$27589600
$65843900
$107414400
$0
$200000
$400000
$600000
$800000
$1000000
$1200000
2015 2016 2017
Incr
eas
e d
ue
to
Mal
nu
trit
ion
Dia
gno
ses
Methodist Medical Center Malnutrition Impact on Medicare Reimbursements
Conclusions
bull Missing Malnutrition is significant to hospitals bull Patient Care bull Financial
bull Dietitians need to be trained bull The NFPE is essential for a comprehensive malnutrition assessment
bull Dietitian duties and staffing is evolving bull A Paradigm Shift is occurring ndash focus changing from Joint Commission
requirements toward improved patient care bull Undertrained and Understaffed units will limit patient care and will
lead to missed reimbursement opportunities
Kathy J Irwin MS RD LDN CNSC
Clinical Nutrition Manager
Contracted by Morrison Healthcare
Phone 865-835-4118
email kathyirwiniammorrisoncom
Questions
Methodist Medical Center
bull 301 bed acute care hospital not-for-profit community hospital
bull Fourth largest employer in Oak Ridge
bull Approximately 1000 employees and 275 physicians
bull Average Daily census 140
bull ED Visits 45000+ annually
Malnutrition ndash Patient Care
bull The Skeleton in the Hospital Closet by Charles Butterworth MD 1974
bull The LeRoy Catastrophe by Michael M Meguid MD 2015
bull Definition of malnutrition bull Any nutritional imbalance bull Undernutrition typically with inadequate intake andor increased
requirements impaired absorption altered transport and altered nutrient utilization
bull Undernutrition historically is poorly described bull Difficult to ldquoseerdquo in patients
Consensus Statement of the Academy of Nutrition and DieteticsAmerican Society for Parenteral and Enteral Nutrition Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition) White Jane V et al Journal of the Academy of Nutrition and Dietetics Volume 112 Issue 5 730 - 738
Malnourished patients havehellip
bull 5x the likelihood of death bull Increased comorbidities bull 4x more likely to develop a pressure injury bull Depression of immune system bull Near 3x increase in length of hospital stay bull Near 3x increase in cost of hospital stay
Corkins MR Malnutrition diagnoses in hospitalized patients United States 2010 JPEN J Parenter Enteral Nutr 2014 Feb38(2)186-95 doi 1011770148607113512154 Epub 2013 Nov 18 Weiss AJ Fingar KR Barrett ML et al Characteristics of Hospital Stays Involving Malnutrition 2013 Statistical Brief 210 2016 Sep In Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet] Rockville (MD) Agency for Healthcare Research and Quality (US) 2006 Feb- Available from httpswwwncbinlmnihgovbooksNBK396064
Admission and Discharge Characteristics of Discharged Patients With and
Without a Diagnosis of Malnutrition United States
Mark R Corkins et al JPEN J Parenter Enteral Nutr 201338186-195
44
95
126
269
0
5
10
15
20
25
30
Length of stay (in days) Total Costs (mean $) x1000
Malnutrition Effects
Not malnourished Malnourished
Malnutrition Prevalence
bull Malnutrition is under recognized in the hospital setting in the United States bull 33-54 estimated to be malnourished in the hospital bull Yet only 32 of patients are diagnosed in the hospital
bull Therefore opportunities exist for patient care and financial reimbursement
bull In 2015 physicians at Methodist Medical Center were diagnosing 3-4 of hospital patients with malnutrition
Corkins MR Malnutrition diagnoses in hospitalized patients United States 2010 JPEN J Parenter Enteral Nutr 2014 Feb38(2)186-95 doi 1011770148607113512154 Epub 2013 Nov 18
Malnutrition is costly
bull The annual burden of disease-associated malnutrition across the 8 diseases was $1567 billion in 2014 ($508 per US resident)
bull Why are hospital cost nearly tripled among malnourished patients Infections wounds staff timeattention MD
timeattention specialists increased ICU days increased vent days PTOTST needs length of stay medications readmissionshellip Corkins MR Malnutrition diagnoses in hospitalized patients United States 2010 JPEN J Parenter Enteral Nutr 2014 Feb38(2)186-95 doi 1011770148607113512154 Epub 2013 Nov 18 Economic burden of community-based disease-associated malnutrition in the United States Snider JT JPEN J Parenter Enteral Nutr 2014 Nov38(2 Suppl)77S-85S doi 1011770148607114550000 Epub 2014 Sep 23
Benefits of recognizing and diagnosing
Malnutrition
bull Improved patient care bull Nutritional interventions (earlier) bull Patient specific nutrition plan of care bull Follow-up and support by dietitians
bull Adjusted hospital measures bull Geometric mean length of stay (GMLOS) bull Risk of mortality (ROM) bull Severity of Illness (SOI)
bull Significant Improved reimbursement
Lung ca w lobectomy Lung ca w lobectomy Lung ca w lobectomy
$9000 $12300 ($3300 increase)
$16300 ($7300)
DRG DRG with CC (Moderate PCMMalnutrition)
DRG with MCC (Severe PCMMalnutrition)
GMLOS 30 SOI 1 ROM 1
GMLOS 51 SOI 2 ROM 2
GMLOS 104 SOI 3 ROM 2
DRG ndash Diagnostic Related Groups CC ndash Complication or Comorbidity MCC ndash Major Complication or
Comorbidity
Each DRG also has an assigned expected length of stay (GMLOS) [OE ratio] severity of illness
(SOI) [how sick are our patients] and risk of mortality (ROM) [mortality index]
Example of a Diagnosis Impact
Diagnosing Malnutrition
can be Challenging
bull Old markers are not reliable bull BMI ndash malnutrition can be present in all BMIs bull PAB Albumin ndash influenced by inflammation
and hydration bull Malnutrition criteria Re-defined in 2012
bull 2 of these 6 must be present for a diagnosis bull Weight loss bull Inadequate Energy Intake bull Loss of Muscle Mass bull Loss of Subcutaneous Fat bull Loss of Fluid Accumulation bull Diminished Functional Capacity
bull 4 of the above criteria requires a physical exam Consensus Statement of the Academy of Nutrition and DieteticsAmerican Society for Parenteral and Enteral Nutrition Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition) White Jane V et al Journal of the Academy of Nutrition and Dietetics Volume 112 Issue 5 730 - 738
Registered Dietitians
The Hospitalrsquos Nutrition Experts
bull Trained to feed support and recognize nutrition problems bull Nutrition undergraduate science degree many have
graduate degrees bull 1200-hour internship with 42 competencies bull Licensed by the state bull Many RDs have advanced certifications bull Nutrition Experts but are they Malnutrition experts
(They can behellip)
Methodist Medical Center
Malnutrition Initiative
bull Dietitians developed an Expertise on Malnutrition bull Nutrition-focused physical Exam (NFPE) essential to
comprehensive assess for Malnutrition bull Dietitian ldquobuy-inrdquo can be challenging
(We werenrsquot trained to ldquotouchrdquo patients) bull NFPE training available from the Academy of Nutrition and
Dietetics bull NFPE is new dietetic internship competency 2017
bull Only a physician can give a medical diagnosis bull Tool was developed to communicated the dietitianrsquos findings to the
physician physician makes an independent decision on diagnosis bull ldquoOut-side the boxrdquo screening (initiated Oct 2017)
bull RD-led comprehensive nutrition screening trial bull Required an additional FTE
bull Team approach bull nurses therapists case managers physicians administrators
bull Awareness effort
Methodist Medical Center
Malnutrition Initiative
Methodist Medical Center Malnutrition Initiative Results
300
700
1100
1500
1900
pe
rce
nta
ge o
f p
atie
nts
Methodist Medical Center
Percentage of In-patients Diagnosed with Malnutrition
Benchmark 19
Above includes only Medicare (excludes all per diem commercial payers managed care TennCare and self pay) only includes severe malnutrition (excludes non-severe mild) only includes severe Malnutrition as the only MCC (excludes patient with multiple MCCs) 2015 data yearly total extrapolated from Oct-Dec 2015 ndash since ICD10 codes Oct 2016 data Actual data 2017 data yearly total estimated from Jan-Aug 2017 data
Methodist Medical Center Malnutrition Initiative Results
$27589600
$65843900
$107414400
$0
$200000
$400000
$600000
$800000
$1000000
$1200000
2015 2016 2017
Incr
eas
e d
ue
to
Mal
nu
trit
ion
Dia
gno
ses
Methodist Medical Center Malnutrition Impact on Medicare Reimbursements
Conclusions
bull Missing Malnutrition is significant to hospitals bull Patient Care bull Financial
bull Dietitians need to be trained bull The NFPE is essential for a comprehensive malnutrition assessment
bull Dietitian duties and staffing is evolving bull A Paradigm Shift is occurring ndash focus changing from Joint Commission
requirements toward improved patient care bull Undertrained and Understaffed units will limit patient care and will
lead to missed reimbursement opportunities
Kathy J Irwin MS RD LDN CNSC
Clinical Nutrition Manager
Contracted by Morrison Healthcare
Phone 865-835-4118
email kathyirwiniammorrisoncom
Questions
Malnutrition ndash Patient Care
bull The Skeleton in the Hospital Closet by Charles Butterworth MD 1974
bull The LeRoy Catastrophe by Michael M Meguid MD 2015
bull Definition of malnutrition bull Any nutritional imbalance bull Undernutrition typically with inadequate intake andor increased
requirements impaired absorption altered transport and altered nutrient utilization
bull Undernutrition historically is poorly described bull Difficult to ldquoseerdquo in patients
Consensus Statement of the Academy of Nutrition and DieteticsAmerican Society for Parenteral and Enteral Nutrition Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition) White Jane V et al Journal of the Academy of Nutrition and Dietetics Volume 112 Issue 5 730 - 738
Malnourished patients havehellip
bull 5x the likelihood of death bull Increased comorbidities bull 4x more likely to develop a pressure injury bull Depression of immune system bull Near 3x increase in length of hospital stay bull Near 3x increase in cost of hospital stay
Corkins MR Malnutrition diagnoses in hospitalized patients United States 2010 JPEN J Parenter Enteral Nutr 2014 Feb38(2)186-95 doi 1011770148607113512154 Epub 2013 Nov 18 Weiss AJ Fingar KR Barrett ML et al Characteristics of Hospital Stays Involving Malnutrition 2013 Statistical Brief 210 2016 Sep In Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet] Rockville (MD) Agency for Healthcare Research and Quality (US) 2006 Feb- Available from httpswwwncbinlmnihgovbooksNBK396064
Admission and Discharge Characteristics of Discharged Patients With and
Without a Diagnosis of Malnutrition United States
Mark R Corkins et al JPEN J Parenter Enteral Nutr 201338186-195
44
95
126
269
0
5
10
15
20
25
30
Length of stay (in days) Total Costs (mean $) x1000
Malnutrition Effects
Not malnourished Malnourished
Malnutrition Prevalence
bull Malnutrition is under recognized in the hospital setting in the United States bull 33-54 estimated to be malnourished in the hospital bull Yet only 32 of patients are diagnosed in the hospital
bull Therefore opportunities exist for patient care and financial reimbursement
bull In 2015 physicians at Methodist Medical Center were diagnosing 3-4 of hospital patients with malnutrition
Corkins MR Malnutrition diagnoses in hospitalized patients United States 2010 JPEN J Parenter Enteral Nutr 2014 Feb38(2)186-95 doi 1011770148607113512154 Epub 2013 Nov 18
Malnutrition is costly
bull The annual burden of disease-associated malnutrition across the 8 diseases was $1567 billion in 2014 ($508 per US resident)
bull Why are hospital cost nearly tripled among malnourished patients Infections wounds staff timeattention MD
timeattention specialists increased ICU days increased vent days PTOTST needs length of stay medications readmissionshellip Corkins MR Malnutrition diagnoses in hospitalized patients United States 2010 JPEN J Parenter Enteral Nutr 2014 Feb38(2)186-95 doi 1011770148607113512154 Epub 2013 Nov 18 Economic burden of community-based disease-associated malnutrition in the United States Snider JT JPEN J Parenter Enteral Nutr 2014 Nov38(2 Suppl)77S-85S doi 1011770148607114550000 Epub 2014 Sep 23
Benefits of recognizing and diagnosing
Malnutrition
bull Improved patient care bull Nutritional interventions (earlier) bull Patient specific nutrition plan of care bull Follow-up and support by dietitians
bull Adjusted hospital measures bull Geometric mean length of stay (GMLOS) bull Risk of mortality (ROM) bull Severity of Illness (SOI)
bull Significant Improved reimbursement
Lung ca w lobectomy Lung ca w lobectomy Lung ca w lobectomy
$9000 $12300 ($3300 increase)
$16300 ($7300)
DRG DRG with CC (Moderate PCMMalnutrition)
DRG with MCC (Severe PCMMalnutrition)
GMLOS 30 SOI 1 ROM 1
GMLOS 51 SOI 2 ROM 2
GMLOS 104 SOI 3 ROM 2
DRG ndash Diagnostic Related Groups CC ndash Complication or Comorbidity MCC ndash Major Complication or
Comorbidity
Each DRG also has an assigned expected length of stay (GMLOS) [OE ratio] severity of illness
(SOI) [how sick are our patients] and risk of mortality (ROM) [mortality index]
Example of a Diagnosis Impact
Diagnosing Malnutrition
can be Challenging
bull Old markers are not reliable bull BMI ndash malnutrition can be present in all BMIs bull PAB Albumin ndash influenced by inflammation
and hydration bull Malnutrition criteria Re-defined in 2012
bull 2 of these 6 must be present for a diagnosis bull Weight loss bull Inadequate Energy Intake bull Loss of Muscle Mass bull Loss of Subcutaneous Fat bull Loss of Fluid Accumulation bull Diminished Functional Capacity
bull 4 of the above criteria requires a physical exam Consensus Statement of the Academy of Nutrition and DieteticsAmerican Society for Parenteral and Enteral Nutrition Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition) White Jane V et al Journal of the Academy of Nutrition and Dietetics Volume 112 Issue 5 730 - 738
Registered Dietitians
The Hospitalrsquos Nutrition Experts
bull Trained to feed support and recognize nutrition problems bull Nutrition undergraduate science degree many have
graduate degrees bull 1200-hour internship with 42 competencies bull Licensed by the state bull Many RDs have advanced certifications bull Nutrition Experts but are they Malnutrition experts
(They can behellip)
Methodist Medical Center
Malnutrition Initiative
bull Dietitians developed an Expertise on Malnutrition bull Nutrition-focused physical Exam (NFPE) essential to
comprehensive assess for Malnutrition bull Dietitian ldquobuy-inrdquo can be challenging
(We werenrsquot trained to ldquotouchrdquo patients) bull NFPE training available from the Academy of Nutrition and
Dietetics bull NFPE is new dietetic internship competency 2017
bull Only a physician can give a medical diagnosis bull Tool was developed to communicated the dietitianrsquos findings to the
physician physician makes an independent decision on diagnosis bull ldquoOut-side the boxrdquo screening (initiated Oct 2017)
bull RD-led comprehensive nutrition screening trial bull Required an additional FTE
bull Team approach bull nurses therapists case managers physicians administrators
bull Awareness effort
Methodist Medical Center
Malnutrition Initiative
Methodist Medical Center Malnutrition Initiative Results
300
700
1100
1500
1900
pe
rce
nta
ge o
f p
atie
nts
Methodist Medical Center
Percentage of In-patients Diagnosed with Malnutrition
Benchmark 19
Above includes only Medicare (excludes all per diem commercial payers managed care TennCare and self pay) only includes severe malnutrition (excludes non-severe mild) only includes severe Malnutrition as the only MCC (excludes patient with multiple MCCs) 2015 data yearly total extrapolated from Oct-Dec 2015 ndash since ICD10 codes Oct 2016 data Actual data 2017 data yearly total estimated from Jan-Aug 2017 data
Methodist Medical Center Malnutrition Initiative Results
$27589600
$65843900
$107414400
$0
$200000
$400000
$600000
$800000
$1000000
$1200000
2015 2016 2017
Incr
eas
e d
ue
to
Mal
nu
trit
ion
Dia
gno
ses
Methodist Medical Center Malnutrition Impact on Medicare Reimbursements
Conclusions
bull Missing Malnutrition is significant to hospitals bull Patient Care bull Financial
bull Dietitians need to be trained bull The NFPE is essential for a comprehensive malnutrition assessment
bull Dietitian duties and staffing is evolving bull A Paradigm Shift is occurring ndash focus changing from Joint Commission
requirements toward improved patient care bull Undertrained and Understaffed units will limit patient care and will
lead to missed reimbursement opportunities
Kathy J Irwin MS RD LDN CNSC
Clinical Nutrition Manager
Contracted by Morrison Healthcare
Phone 865-835-4118
email kathyirwiniammorrisoncom
Questions
Malnourished patients havehellip
bull 5x the likelihood of death bull Increased comorbidities bull 4x more likely to develop a pressure injury bull Depression of immune system bull Near 3x increase in length of hospital stay bull Near 3x increase in cost of hospital stay
Corkins MR Malnutrition diagnoses in hospitalized patients United States 2010 JPEN J Parenter Enteral Nutr 2014 Feb38(2)186-95 doi 1011770148607113512154 Epub 2013 Nov 18 Weiss AJ Fingar KR Barrett ML et al Characteristics of Hospital Stays Involving Malnutrition 2013 Statistical Brief 210 2016 Sep In Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet] Rockville (MD) Agency for Healthcare Research and Quality (US) 2006 Feb- Available from httpswwwncbinlmnihgovbooksNBK396064
Admission and Discharge Characteristics of Discharged Patients With and
Without a Diagnosis of Malnutrition United States
Mark R Corkins et al JPEN J Parenter Enteral Nutr 201338186-195
44
95
126
269
0
5
10
15
20
25
30
Length of stay (in days) Total Costs (mean $) x1000
Malnutrition Effects
Not malnourished Malnourished
Malnutrition Prevalence
bull Malnutrition is under recognized in the hospital setting in the United States bull 33-54 estimated to be malnourished in the hospital bull Yet only 32 of patients are diagnosed in the hospital
bull Therefore opportunities exist for patient care and financial reimbursement
bull In 2015 physicians at Methodist Medical Center were diagnosing 3-4 of hospital patients with malnutrition
Corkins MR Malnutrition diagnoses in hospitalized patients United States 2010 JPEN J Parenter Enteral Nutr 2014 Feb38(2)186-95 doi 1011770148607113512154 Epub 2013 Nov 18
Malnutrition is costly
bull The annual burden of disease-associated malnutrition across the 8 diseases was $1567 billion in 2014 ($508 per US resident)
bull Why are hospital cost nearly tripled among malnourished patients Infections wounds staff timeattention MD
timeattention specialists increased ICU days increased vent days PTOTST needs length of stay medications readmissionshellip Corkins MR Malnutrition diagnoses in hospitalized patients United States 2010 JPEN J Parenter Enteral Nutr 2014 Feb38(2)186-95 doi 1011770148607113512154 Epub 2013 Nov 18 Economic burden of community-based disease-associated malnutrition in the United States Snider JT JPEN J Parenter Enteral Nutr 2014 Nov38(2 Suppl)77S-85S doi 1011770148607114550000 Epub 2014 Sep 23
Benefits of recognizing and diagnosing
Malnutrition
bull Improved patient care bull Nutritional interventions (earlier) bull Patient specific nutrition plan of care bull Follow-up and support by dietitians
bull Adjusted hospital measures bull Geometric mean length of stay (GMLOS) bull Risk of mortality (ROM) bull Severity of Illness (SOI)
bull Significant Improved reimbursement
Lung ca w lobectomy Lung ca w lobectomy Lung ca w lobectomy
$9000 $12300 ($3300 increase)
$16300 ($7300)
DRG DRG with CC (Moderate PCMMalnutrition)
DRG with MCC (Severe PCMMalnutrition)
GMLOS 30 SOI 1 ROM 1
GMLOS 51 SOI 2 ROM 2
GMLOS 104 SOI 3 ROM 2
DRG ndash Diagnostic Related Groups CC ndash Complication or Comorbidity MCC ndash Major Complication or
Comorbidity
Each DRG also has an assigned expected length of stay (GMLOS) [OE ratio] severity of illness
(SOI) [how sick are our patients] and risk of mortality (ROM) [mortality index]
Example of a Diagnosis Impact
Diagnosing Malnutrition
can be Challenging
bull Old markers are not reliable bull BMI ndash malnutrition can be present in all BMIs bull PAB Albumin ndash influenced by inflammation
and hydration bull Malnutrition criteria Re-defined in 2012
bull 2 of these 6 must be present for a diagnosis bull Weight loss bull Inadequate Energy Intake bull Loss of Muscle Mass bull Loss of Subcutaneous Fat bull Loss of Fluid Accumulation bull Diminished Functional Capacity
bull 4 of the above criteria requires a physical exam Consensus Statement of the Academy of Nutrition and DieteticsAmerican Society for Parenteral and Enteral Nutrition Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition) White Jane V et al Journal of the Academy of Nutrition and Dietetics Volume 112 Issue 5 730 - 738
Registered Dietitians
The Hospitalrsquos Nutrition Experts
bull Trained to feed support and recognize nutrition problems bull Nutrition undergraduate science degree many have
graduate degrees bull 1200-hour internship with 42 competencies bull Licensed by the state bull Many RDs have advanced certifications bull Nutrition Experts but are they Malnutrition experts
(They can behellip)
Methodist Medical Center
Malnutrition Initiative
bull Dietitians developed an Expertise on Malnutrition bull Nutrition-focused physical Exam (NFPE) essential to
comprehensive assess for Malnutrition bull Dietitian ldquobuy-inrdquo can be challenging
(We werenrsquot trained to ldquotouchrdquo patients) bull NFPE training available from the Academy of Nutrition and
Dietetics bull NFPE is new dietetic internship competency 2017
bull Only a physician can give a medical diagnosis bull Tool was developed to communicated the dietitianrsquos findings to the
physician physician makes an independent decision on diagnosis bull ldquoOut-side the boxrdquo screening (initiated Oct 2017)
bull RD-led comprehensive nutrition screening trial bull Required an additional FTE
bull Team approach bull nurses therapists case managers physicians administrators
bull Awareness effort
Methodist Medical Center
Malnutrition Initiative
Methodist Medical Center Malnutrition Initiative Results
300
700
1100
1500
1900
pe
rce
nta
ge o
f p
atie
nts
Methodist Medical Center
Percentage of In-patients Diagnosed with Malnutrition
Benchmark 19
Above includes only Medicare (excludes all per diem commercial payers managed care TennCare and self pay) only includes severe malnutrition (excludes non-severe mild) only includes severe Malnutrition as the only MCC (excludes patient with multiple MCCs) 2015 data yearly total extrapolated from Oct-Dec 2015 ndash since ICD10 codes Oct 2016 data Actual data 2017 data yearly total estimated from Jan-Aug 2017 data
Methodist Medical Center Malnutrition Initiative Results
$27589600
$65843900
$107414400
$0
$200000
$400000
$600000
$800000
$1000000
$1200000
2015 2016 2017
Incr
eas
e d
ue
to
Mal
nu
trit
ion
Dia
gno
ses
Methodist Medical Center Malnutrition Impact on Medicare Reimbursements
Conclusions
bull Missing Malnutrition is significant to hospitals bull Patient Care bull Financial
bull Dietitians need to be trained bull The NFPE is essential for a comprehensive malnutrition assessment
bull Dietitian duties and staffing is evolving bull A Paradigm Shift is occurring ndash focus changing from Joint Commission
requirements toward improved patient care bull Undertrained and Understaffed units will limit patient care and will
lead to missed reimbursement opportunities
Kathy J Irwin MS RD LDN CNSC
Clinical Nutrition Manager
Contracted by Morrison Healthcare
Phone 865-835-4118
email kathyirwiniammorrisoncom
Questions
Admission and Discharge Characteristics of Discharged Patients With and
Without a Diagnosis of Malnutrition United States
Mark R Corkins et al JPEN J Parenter Enteral Nutr 201338186-195
44
95
126
269
0
5
10
15
20
25
30
Length of stay (in days) Total Costs (mean $) x1000
Malnutrition Effects
Not malnourished Malnourished
Malnutrition Prevalence
bull Malnutrition is under recognized in the hospital setting in the United States bull 33-54 estimated to be malnourished in the hospital bull Yet only 32 of patients are diagnosed in the hospital
bull Therefore opportunities exist for patient care and financial reimbursement
bull In 2015 physicians at Methodist Medical Center were diagnosing 3-4 of hospital patients with malnutrition
Corkins MR Malnutrition diagnoses in hospitalized patients United States 2010 JPEN J Parenter Enteral Nutr 2014 Feb38(2)186-95 doi 1011770148607113512154 Epub 2013 Nov 18
Malnutrition is costly
bull The annual burden of disease-associated malnutrition across the 8 diseases was $1567 billion in 2014 ($508 per US resident)
bull Why are hospital cost nearly tripled among malnourished patients Infections wounds staff timeattention MD
timeattention specialists increased ICU days increased vent days PTOTST needs length of stay medications readmissionshellip Corkins MR Malnutrition diagnoses in hospitalized patients United States 2010 JPEN J Parenter Enteral Nutr 2014 Feb38(2)186-95 doi 1011770148607113512154 Epub 2013 Nov 18 Economic burden of community-based disease-associated malnutrition in the United States Snider JT JPEN J Parenter Enteral Nutr 2014 Nov38(2 Suppl)77S-85S doi 1011770148607114550000 Epub 2014 Sep 23
Benefits of recognizing and diagnosing
Malnutrition
bull Improved patient care bull Nutritional interventions (earlier) bull Patient specific nutrition plan of care bull Follow-up and support by dietitians
bull Adjusted hospital measures bull Geometric mean length of stay (GMLOS) bull Risk of mortality (ROM) bull Severity of Illness (SOI)
bull Significant Improved reimbursement
Lung ca w lobectomy Lung ca w lobectomy Lung ca w lobectomy
$9000 $12300 ($3300 increase)
$16300 ($7300)
DRG DRG with CC (Moderate PCMMalnutrition)
DRG with MCC (Severe PCMMalnutrition)
GMLOS 30 SOI 1 ROM 1
GMLOS 51 SOI 2 ROM 2
GMLOS 104 SOI 3 ROM 2
DRG ndash Diagnostic Related Groups CC ndash Complication or Comorbidity MCC ndash Major Complication or
Comorbidity
Each DRG also has an assigned expected length of stay (GMLOS) [OE ratio] severity of illness
(SOI) [how sick are our patients] and risk of mortality (ROM) [mortality index]
Example of a Diagnosis Impact
Diagnosing Malnutrition
can be Challenging
bull Old markers are not reliable bull BMI ndash malnutrition can be present in all BMIs bull PAB Albumin ndash influenced by inflammation
and hydration bull Malnutrition criteria Re-defined in 2012
bull 2 of these 6 must be present for a diagnosis bull Weight loss bull Inadequate Energy Intake bull Loss of Muscle Mass bull Loss of Subcutaneous Fat bull Loss of Fluid Accumulation bull Diminished Functional Capacity
bull 4 of the above criteria requires a physical exam Consensus Statement of the Academy of Nutrition and DieteticsAmerican Society for Parenteral and Enteral Nutrition Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition) White Jane V et al Journal of the Academy of Nutrition and Dietetics Volume 112 Issue 5 730 - 738
Registered Dietitians
The Hospitalrsquos Nutrition Experts
bull Trained to feed support and recognize nutrition problems bull Nutrition undergraduate science degree many have
graduate degrees bull 1200-hour internship with 42 competencies bull Licensed by the state bull Many RDs have advanced certifications bull Nutrition Experts but are they Malnutrition experts
(They can behellip)
Methodist Medical Center
Malnutrition Initiative
bull Dietitians developed an Expertise on Malnutrition bull Nutrition-focused physical Exam (NFPE) essential to
comprehensive assess for Malnutrition bull Dietitian ldquobuy-inrdquo can be challenging
(We werenrsquot trained to ldquotouchrdquo patients) bull NFPE training available from the Academy of Nutrition and
Dietetics bull NFPE is new dietetic internship competency 2017
bull Only a physician can give a medical diagnosis bull Tool was developed to communicated the dietitianrsquos findings to the
physician physician makes an independent decision on diagnosis bull ldquoOut-side the boxrdquo screening (initiated Oct 2017)
bull RD-led comprehensive nutrition screening trial bull Required an additional FTE
bull Team approach bull nurses therapists case managers physicians administrators
bull Awareness effort
Methodist Medical Center
Malnutrition Initiative
Methodist Medical Center Malnutrition Initiative Results
300
700
1100
1500
1900
pe
rce
nta
ge o
f p
atie
nts
Methodist Medical Center
Percentage of In-patients Diagnosed with Malnutrition
Benchmark 19
Above includes only Medicare (excludes all per diem commercial payers managed care TennCare and self pay) only includes severe malnutrition (excludes non-severe mild) only includes severe Malnutrition as the only MCC (excludes patient with multiple MCCs) 2015 data yearly total extrapolated from Oct-Dec 2015 ndash since ICD10 codes Oct 2016 data Actual data 2017 data yearly total estimated from Jan-Aug 2017 data
Methodist Medical Center Malnutrition Initiative Results
$27589600
$65843900
$107414400
$0
$200000
$400000
$600000
$800000
$1000000
$1200000
2015 2016 2017
Incr
eas
e d
ue
to
Mal
nu
trit
ion
Dia
gno
ses
Methodist Medical Center Malnutrition Impact on Medicare Reimbursements
Conclusions
bull Missing Malnutrition is significant to hospitals bull Patient Care bull Financial
bull Dietitians need to be trained bull The NFPE is essential for a comprehensive malnutrition assessment
bull Dietitian duties and staffing is evolving bull A Paradigm Shift is occurring ndash focus changing from Joint Commission
requirements toward improved patient care bull Undertrained and Understaffed units will limit patient care and will
lead to missed reimbursement opportunities
Kathy J Irwin MS RD LDN CNSC
Clinical Nutrition Manager
Contracted by Morrison Healthcare
Phone 865-835-4118
email kathyirwiniammorrisoncom
Questions
Malnutrition Prevalence
bull Malnutrition is under recognized in the hospital setting in the United States bull 33-54 estimated to be malnourished in the hospital bull Yet only 32 of patients are diagnosed in the hospital
bull Therefore opportunities exist for patient care and financial reimbursement
bull In 2015 physicians at Methodist Medical Center were diagnosing 3-4 of hospital patients with malnutrition
Corkins MR Malnutrition diagnoses in hospitalized patients United States 2010 JPEN J Parenter Enteral Nutr 2014 Feb38(2)186-95 doi 1011770148607113512154 Epub 2013 Nov 18
Malnutrition is costly
bull The annual burden of disease-associated malnutrition across the 8 diseases was $1567 billion in 2014 ($508 per US resident)
bull Why are hospital cost nearly tripled among malnourished patients Infections wounds staff timeattention MD
timeattention specialists increased ICU days increased vent days PTOTST needs length of stay medications readmissionshellip Corkins MR Malnutrition diagnoses in hospitalized patients United States 2010 JPEN J Parenter Enteral Nutr 2014 Feb38(2)186-95 doi 1011770148607113512154 Epub 2013 Nov 18 Economic burden of community-based disease-associated malnutrition in the United States Snider JT JPEN J Parenter Enteral Nutr 2014 Nov38(2 Suppl)77S-85S doi 1011770148607114550000 Epub 2014 Sep 23
Benefits of recognizing and diagnosing
Malnutrition
bull Improved patient care bull Nutritional interventions (earlier) bull Patient specific nutrition plan of care bull Follow-up and support by dietitians
bull Adjusted hospital measures bull Geometric mean length of stay (GMLOS) bull Risk of mortality (ROM) bull Severity of Illness (SOI)
bull Significant Improved reimbursement
Lung ca w lobectomy Lung ca w lobectomy Lung ca w lobectomy
$9000 $12300 ($3300 increase)
$16300 ($7300)
DRG DRG with CC (Moderate PCMMalnutrition)
DRG with MCC (Severe PCMMalnutrition)
GMLOS 30 SOI 1 ROM 1
GMLOS 51 SOI 2 ROM 2
GMLOS 104 SOI 3 ROM 2
DRG ndash Diagnostic Related Groups CC ndash Complication or Comorbidity MCC ndash Major Complication or
Comorbidity
Each DRG also has an assigned expected length of stay (GMLOS) [OE ratio] severity of illness
(SOI) [how sick are our patients] and risk of mortality (ROM) [mortality index]
Example of a Diagnosis Impact
Diagnosing Malnutrition
can be Challenging
bull Old markers are not reliable bull BMI ndash malnutrition can be present in all BMIs bull PAB Albumin ndash influenced by inflammation
and hydration bull Malnutrition criteria Re-defined in 2012
bull 2 of these 6 must be present for a diagnosis bull Weight loss bull Inadequate Energy Intake bull Loss of Muscle Mass bull Loss of Subcutaneous Fat bull Loss of Fluid Accumulation bull Diminished Functional Capacity
bull 4 of the above criteria requires a physical exam Consensus Statement of the Academy of Nutrition and DieteticsAmerican Society for Parenteral and Enteral Nutrition Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition) White Jane V et al Journal of the Academy of Nutrition and Dietetics Volume 112 Issue 5 730 - 738
Registered Dietitians
The Hospitalrsquos Nutrition Experts
bull Trained to feed support and recognize nutrition problems bull Nutrition undergraduate science degree many have
graduate degrees bull 1200-hour internship with 42 competencies bull Licensed by the state bull Many RDs have advanced certifications bull Nutrition Experts but are they Malnutrition experts
(They can behellip)
Methodist Medical Center
Malnutrition Initiative
bull Dietitians developed an Expertise on Malnutrition bull Nutrition-focused physical Exam (NFPE) essential to
comprehensive assess for Malnutrition bull Dietitian ldquobuy-inrdquo can be challenging
(We werenrsquot trained to ldquotouchrdquo patients) bull NFPE training available from the Academy of Nutrition and
Dietetics bull NFPE is new dietetic internship competency 2017
bull Only a physician can give a medical diagnosis bull Tool was developed to communicated the dietitianrsquos findings to the
physician physician makes an independent decision on diagnosis bull ldquoOut-side the boxrdquo screening (initiated Oct 2017)
bull RD-led comprehensive nutrition screening trial bull Required an additional FTE
bull Team approach bull nurses therapists case managers physicians administrators
bull Awareness effort
Methodist Medical Center
Malnutrition Initiative
Methodist Medical Center Malnutrition Initiative Results
300
700
1100
1500
1900
pe
rce
nta
ge o
f p
atie
nts
Methodist Medical Center
Percentage of In-patients Diagnosed with Malnutrition
Benchmark 19
Above includes only Medicare (excludes all per diem commercial payers managed care TennCare and self pay) only includes severe malnutrition (excludes non-severe mild) only includes severe Malnutrition as the only MCC (excludes patient with multiple MCCs) 2015 data yearly total extrapolated from Oct-Dec 2015 ndash since ICD10 codes Oct 2016 data Actual data 2017 data yearly total estimated from Jan-Aug 2017 data
Methodist Medical Center Malnutrition Initiative Results
$27589600
$65843900
$107414400
$0
$200000
$400000
$600000
$800000
$1000000
$1200000
2015 2016 2017
Incr
eas
e d
ue
to
Mal
nu
trit
ion
Dia
gno
ses
Methodist Medical Center Malnutrition Impact on Medicare Reimbursements
Conclusions
bull Missing Malnutrition is significant to hospitals bull Patient Care bull Financial
bull Dietitians need to be trained bull The NFPE is essential for a comprehensive malnutrition assessment
bull Dietitian duties and staffing is evolving bull A Paradigm Shift is occurring ndash focus changing from Joint Commission
requirements toward improved patient care bull Undertrained and Understaffed units will limit patient care and will
lead to missed reimbursement opportunities
Kathy J Irwin MS RD LDN CNSC
Clinical Nutrition Manager
Contracted by Morrison Healthcare
Phone 865-835-4118
email kathyirwiniammorrisoncom
Questions
Malnutrition is costly
bull The annual burden of disease-associated malnutrition across the 8 diseases was $1567 billion in 2014 ($508 per US resident)
bull Why are hospital cost nearly tripled among malnourished patients Infections wounds staff timeattention MD
timeattention specialists increased ICU days increased vent days PTOTST needs length of stay medications readmissionshellip Corkins MR Malnutrition diagnoses in hospitalized patients United States 2010 JPEN J Parenter Enteral Nutr 2014 Feb38(2)186-95 doi 1011770148607113512154 Epub 2013 Nov 18 Economic burden of community-based disease-associated malnutrition in the United States Snider JT JPEN J Parenter Enteral Nutr 2014 Nov38(2 Suppl)77S-85S doi 1011770148607114550000 Epub 2014 Sep 23
Benefits of recognizing and diagnosing
Malnutrition
bull Improved patient care bull Nutritional interventions (earlier) bull Patient specific nutrition plan of care bull Follow-up and support by dietitians
bull Adjusted hospital measures bull Geometric mean length of stay (GMLOS) bull Risk of mortality (ROM) bull Severity of Illness (SOI)
bull Significant Improved reimbursement
Lung ca w lobectomy Lung ca w lobectomy Lung ca w lobectomy
$9000 $12300 ($3300 increase)
$16300 ($7300)
DRG DRG with CC (Moderate PCMMalnutrition)
DRG with MCC (Severe PCMMalnutrition)
GMLOS 30 SOI 1 ROM 1
GMLOS 51 SOI 2 ROM 2
GMLOS 104 SOI 3 ROM 2
DRG ndash Diagnostic Related Groups CC ndash Complication or Comorbidity MCC ndash Major Complication or
Comorbidity
Each DRG also has an assigned expected length of stay (GMLOS) [OE ratio] severity of illness
(SOI) [how sick are our patients] and risk of mortality (ROM) [mortality index]
Example of a Diagnosis Impact
Diagnosing Malnutrition
can be Challenging
bull Old markers are not reliable bull BMI ndash malnutrition can be present in all BMIs bull PAB Albumin ndash influenced by inflammation
and hydration bull Malnutrition criteria Re-defined in 2012
bull 2 of these 6 must be present for a diagnosis bull Weight loss bull Inadequate Energy Intake bull Loss of Muscle Mass bull Loss of Subcutaneous Fat bull Loss of Fluid Accumulation bull Diminished Functional Capacity
bull 4 of the above criteria requires a physical exam Consensus Statement of the Academy of Nutrition and DieteticsAmerican Society for Parenteral and Enteral Nutrition Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition) White Jane V et al Journal of the Academy of Nutrition and Dietetics Volume 112 Issue 5 730 - 738
Registered Dietitians
The Hospitalrsquos Nutrition Experts
bull Trained to feed support and recognize nutrition problems bull Nutrition undergraduate science degree many have
graduate degrees bull 1200-hour internship with 42 competencies bull Licensed by the state bull Many RDs have advanced certifications bull Nutrition Experts but are they Malnutrition experts
(They can behellip)
Methodist Medical Center
Malnutrition Initiative
bull Dietitians developed an Expertise on Malnutrition bull Nutrition-focused physical Exam (NFPE) essential to
comprehensive assess for Malnutrition bull Dietitian ldquobuy-inrdquo can be challenging
(We werenrsquot trained to ldquotouchrdquo patients) bull NFPE training available from the Academy of Nutrition and
Dietetics bull NFPE is new dietetic internship competency 2017
bull Only a physician can give a medical diagnosis bull Tool was developed to communicated the dietitianrsquos findings to the
physician physician makes an independent decision on diagnosis bull ldquoOut-side the boxrdquo screening (initiated Oct 2017)
bull RD-led comprehensive nutrition screening trial bull Required an additional FTE
bull Team approach bull nurses therapists case managers physicians administrators
bull Awareness effort
Methodist Medical Center
Malnutrition Initiative
Methodist Medical Center Malnutrition Initiative Results
300
700
1100
1500
1900
pe
rce
nta
ge o
f p
atie
nts
Methodist Medical Center
Percentage of In-patients Diagnosed with Malnutrition
Benchmark 19
Above includes only Medicare (excludes all per diem commercial payers managed care TennCare and self pay) only includes severe malnutrition (excludes non-severe mild) only includes severe Malnutrition as the only MCC (excludes patient with multiple MCCs) 2015 data yearly total extrapolated from Oct-Dec 2015 ndash since ICD10 codes Oct 2016 data Actual data 2017 data yearly total estimated from Jan-Aug 2017 data
Methodist Medical Center Malnutrition Initiative Results
$27589600
$65843900
$107414400
$0
$200000
$400000
$600000
$800000
$1000000
$1200000
2015 2016 2017
Incr
eas
e d
ue
to
Mal
nu
trit
ion
Dia
gno
ses
Methodist Medical Center Malnutrition Impact on Medicare Reimbursements
Conclusions
bull Missing Malnutrition is significant to hospitals bull Patient Care bull Financial
bull Dietitians need to be trained bull The NFPE is essential for a comprehensive malnutrition assessment
bull Dietitian duties and staffing is evolving bull A Paradigm Shift is occurring ndash focus changing from Joint Commission
requirements toward improved patient care bull Undertrained and Understaffed units will limit patient care and will
lead to missed reimbursement opportunities
Kathy J Irwin MS RD LDN CNSC
Clinical Nutrition Manager
Contracted by Morrison Healthcare
Phone 865-835-4118
email kathyirwiniammorrisoncom
Questions
Benefits of recognizing and diagnosing
Malnutrition
bull Improved patient care bull Nutritional interventions (earlier) bull Patient specific nutrition plan of care bull Follow-up and support by dietitians
bull Adjusted hospital measures bull Geometric mean length of stay (GMLOS) bull Risk of mortality (ROM) bull Severity of Illness (SOI)
bull Significant Improved reimbursement
Lung ca w lobectomy Lung ca w lobectomy Lung ca w lobectomy
$9000 $12300 ($3300 increase)
$16300 ($7300)
DRG DRG with CC (Moderate PCMMalnutrition)
DRG with MCC (Severe PCMMalnutrition)
GMLOS 30 SOI 1 ROM 1
GMLOS 51 SOI 2 ROM 2
GMLOS 104 SOI 3 ROM 2
DRG ndash Diagnostic Related Groups CC ndash Complication or Comorbidity MCC ndash Major Complication or
Comorbidity
Each DRG also has an assigned expected length of stay (GMLOS) [OE ratio] severity of illness
(SOI) [how sick are our patients] and risk of mortality (ROM) [mortality index]
Example of a Diagnosis Impact
Diagnosing Malnutrition
can be Challenging
bull Old markers are not reliable bull BMI ndash malnutrition can be present in all BMIs bull PAB Albumin ndash influenced by inflammation
and hydration bull Malnutrition criteria Re-defined in 2012
bull 2 of these 6 must be present for a diagnosis bull Weight loss bull Inadequate Energy Intake bull Loss of Muscle Mass bull Loss of Subcutaneous Fat bull Loss of Fluid Accumulation bull Diminished Functional Capacity
bull 4 of the above criteria requires a physical exam Consensus Statement of the Academy of Nutrition and DieteticsAmerican Society for Parenteral and Enteral Nutrition Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition) White Jane V et al Journal of the Academy of Nutrition and Dietetics Volume 112 Issue 5 730 - 738
Registered Dietitians
The Hospitalrsquos Nutrition Experts
bull Trained to feed support and recognize nutrition problems bull Nutrition undergraduate science degree many have
graduate degrees bull 1200-hour internship with 42 competencies bull Licensed by the state bull Many RDs have advanced certifications bull Nutrition Experts but are they Malnutrition experts
(They can behellip)
Methodist Medical Center
Malnutrition Initiative
bull Dietitians developed an Expertise on Malnutrition bull Nutrition-focused physical Exam (NFPE) essential to
comprehensive assess for Malnutrition bull Dietitian ldquobuy-inrdquo can be challenging
(We werenrsquot trained to ldquotouchrdquo patients) bull NFPE training available from the Academy of Nutrition and
Dietetics bull NFPE is new dietetic internship competency 2017
bull Only a physician can give a medical diagnosis bull Tool was developed to communicated the dietitianrsquos findings to the
physician physician makes an independent decision on diagnosis bull ldquoOut-side the boxrdquo screening (initiated Oct 2017)
bull RD-led comprehensive nutrition screening trial bull Required an additional FTE
bull Team approach bull nurses therapists case managers physicians administrators
bull Awareness effort
Methodist Medical Center
Malnutrition Initiative
Methodist Medical Center Malnutrition Initiative Results
300
700
1100
1500
1900
pe
rce
nta
ge o
f p
atie
nts
Methodist Medical Center
Percentage of In-patients Diagnosed with Malnutrition
Benchmark 19
Above includes only Medicare (excludes all per diem commercial payers managed care TennCare and self pay) only includes severe malnutrition (excludes non-severe mild) only includes severe Malnutrition as the only MCC (excludes patient with multiple MCCs) 2015 data yearly total extrapolated from Oct-Dec 2015 ndash since ICD10 codes Oct 2016 data Actual data 2017 data yearly total estimated from Jan-Aug 2017 data
Methodist Medical Center Malnutrition Initiative Results
$27589600
$65843900
$107414400
$0
$200000
$400000
$600000
$800000
$1000000
$1200000
2015 2016 2017
Incr
eas
e d
ue
to
Mal
nu
trit
ion
Dia
gno
ses
Methodist Medical Center Malnutrition Impact on Medicare Reimbursements
Conclusions
bull Missing Malnutrition is significant to hospitals bull Patient Care bull Financial
bull Dietitians need to be trained bull The NFPE is essential for a comprehensive malnutrition assessment
bull Dietitian duties and staffing is evolving bull A Paradigm Shift is occurring ndash focus changing from Joint Commission
requirements toward improved patient care bull Undertrained and Understaffed units will limit patient care and will
lead to missed reimbursement opportunities
Kathy J Irwin MS RD LDN CNSC
Clinical Nutrition Manager
Contracted by Morrison Healthcare
Phone 865-835-4118
email kathyirwiniammorrisoncom
Questions
Lung ca w lobectomy Lung ca w lobectomy Lung ca w lobectomy
$9000 $12300 ($3300 increase)
$16300 ($7300)
DRG DRG with CC (Moderate PCMMalnutrition)
DRG with MCC (Severe PCMMalnutrition)
GMLOS 30 SOI 1 ROM 1
GMLOS 51 SOI 2 ROM 2
GMLOS 104 SOI 3 ROM 2
DRG ndash Diagnostic Related Groups CC ndash Complication or Comorbidity MCC ndash Major Complication or
Comorbidity
Each DRG also has an assigned expected length of stay (GMLOS) [OE ratio] severity of illness
(SOI) [how sick are our patients] and risk of mortality (ROM) [mortality index]
Example of a Diagnosis Impact
Diagnosing Malnutrition
can be Challenging
bull Old markers are not reliable bull BMI ndash malnutrition can be present in all BMIs bull PAB Albumin ndash influenced by inflammation
and hydration bull Malnutrition criteria Re-defined in 2012
bull 2 of these 6 must be present for a diagnosis bull Weight loss bull Inadequate Energy Intake bull Loss of Muscle Mass bull Loss of Subcutaneous Fat bull Loss of Fluid Accumulation bull Diminished Functional Capacity
bull 4 of the above criteria requires a physical exam Consensus Statement of the Academy of Nutrition and DieteticsAmerican Society for Parenteral and Enteral Nutrition Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition) White Jane V et al Journal of the Academy of Nutrition and Dietetics Volume 112 Issue 5 730 - 738
Registered Dietitians
The Hospitalrsquos Nutrition Experts
bull Trained to feed support and recognize nutrition problems bull Nutrition undergraduate science degree many have
graduate degrees bull 1200-hour internship with 42 competencies bull Licensed by the state bull Many RDs have advanced certifications bull Nutrition Experts but are they Malnutrition experts
(They can behellip)
Methodist Medical Center
Malnutrition Initiative
bull Dietitians developed an Expertise on Malnutrition bull Nutrition-focused physical Exam (NFPE) essential to
comprehensive assess for Malnutrition bull Dietitian ldquobuy-inrdquo can be challenging
(We werenrsquot trained to ldquotouchrdquo patients) bull NFPE training available from the Academy of Nutrition and
Dietetics bull NFPE is new dietetic internship competency 2017
bull Only a physician can give a medical diagnosis bull Tool was developed to communicated the dietitianrsquos findings to the
physician physician makes an independent decision on diagnosis bull ldquoOut-side the boxrdquo screening (initiated Oct 2017)
bull RD-led comprehensive nutrition screening trial bull Required an additional FTE
bull Team approach bull nurses therapists case managers physicians administrators
bull Awareness effort
Methodist Medical Center
Malnutrition Initiative
Methodist Medical Center Malnutrition Initiative Results
300
700
1100
1500
1900
pe
rce
nta
ge o
f p
atie
nts
Methodist Medical Center
Percentage of In-patients Diagnosed with Malnutrition
Benchmark 19
Above includes only Medicare (excludes all per diem commercial payers managed care TennCare and self pay) only includes severe malnutrition (excludes non-severe mild) only includes severe Malnutrition as the only MCC (excludes patient with multiple MCCs) 2015 data yearly total extrapolated from Oct-Dec 2015 ndash since ICD10 codes Oct 2016 data Actual data 2017 data yearly total estimated from Jan-Aug 2017 data
Methodist Medical Center Malnutrition Initiative Results
$27589600
$65843900
$107414400
$0
$200000
$400000
$600000
$800000
$1000000
$1200000
2015 2016 2017
Incr
eas
e d
ue
to
Mal
nu
trit
ion
Dia
gno
ses
Methodist Medical Center Malnutrition Impact on Medicare Reimbursements
Conclusions
bull Missing Malnutrition is significant to hospitals bull Patient Care bull Financial
bull Dietitians need to be trained bull The NFPE is essential for a comprehensive malnutrition assessment
bull Dietitian duties and staffing is evolving bull A Paradigm Shift is occurring ndash focus changing from Joint Commission
requirements toward improved patient care bull Undertrained and Understaffed units will limit patient care and will
lead to missed reimbursement opportunities
Kathy J Irwin MS RD LDN CNSC
Clinical Nutrition Manager
Contracted by Morrison Healthcare
Phone 865-835-4118
email kathyirwiniammorrisoncom
Questions
Diagnosing Malnutrition
can be Challenging
bull Old markers are not reliable bull BMI ndash malnutrition can be present in all BMIs bull PAB Albumin ndash influenced by inflammation
and hydration bull Malnutrition criteria Re-defined in 2012
bull 2 of these 6 must be present for a diagnosis bull Weight loss bull Inadequate Energy Intake bull Loss of Muscle Mass bull Loss of Subcutaneous Fat bull Loss of Fluid Accumulation bull Diminished Functional Capacity
bull 4 of the above criteria requires a physical exam Consensus Statement of the Academy of Nutrition and DieteticsAmerican Society for Parenteral and Enteral Nutrition Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition) White Jane V et al Journal of the Academy of Nutrition and Dietetics Volume 112 Issue 5 730 - 738
Registered Dietitians
The Hospitalrsquos Nutrition Experts
bull Trained to feed support and recognize nutrition problems bull Nutrition undergraduate science degree many have
graduate degrees bull 1200-hour internship with 42 competencies bull Licensed by the state bull Many RDs have advanced certifications bull Nutrition Experts but are they Malnutrition experts
(They can behellip)
Methodist Medical Center
Malnutrition Initiative
bull Dietitians developed an Expertise on Malnutrition bull Nutrition-focused physical Exam (NFPE) essential to
comprehensive assess for Malnutrition bull Dietitian ldquobuy-inrdquo can be challenging
(We werenrsquot trained to ldquotouchrdquo patients) bull NFPE training available from the Academy of Nutrition and
Dietetics bull NFPE is new dietetic internship competency 2017
bull Only a physician can give a medical diagnosis bull Tool was developed to communicated the dietitianrsquos findings to the
physician physician makes an independent decision on diagnosis bull ldquoOut-side the boxrdquo screening (initiated Oct 2017)
bull RD-led comprehensive nutrition screening trial bull Required an additional FTE
bull Team approach bull nurses therapists case managers physicians administrators
bull Awareness effort
Methodist Medical Center
Malnutrition Initiative
Methodist Medical Center Malnutrition Initiative Results
300
700
1100
1500
1900
pe
rce
nta
ge o
f p
atie
nts
Methodist Medical Center
Percentage of In-patients Diagnosed with Malnutrition
Benchmark 19
Above includes only Medicare (excludes all per diem commercial payers managed care TennCare and self pay) only includes severe malnutrition (excludes non-severe mild) only includes severe Malnutrition as the only MCC (excludes patient with multiple MCCs) 2015 data yearly total extrapolated from Oct-Dec 2015 ndash since ICD10 codes Oct 2016 data Actual data 2017 data yearly total estimated from Jan-Aug 2017 data
Methodist Medical Center Malnutrition Initiative Results
$27589600
$65843900
$107414400
$0
$200000
$400000
$600000
$800000
$1000000
$1200000
2015 2016 2017
Incr
eas
e d
ue
to
Mal
nu
trit
ion
Dia
gno
ses
Methodist Medical Center Malnutrition Impact on Medicare Reimbursements
Conclusions
bull Missing Malnutrition is significant to hospitals bull Patient Care bull Financial
bull Dietitians need to be trained bull The NFPE is essential for a comprehensive malnutrition assessment
bull Dietitian duties and staffing is evolving bull A Paradigm Shift is occurring ndash focus changing from Joint Commission
requirements toward improved patient care bull Undertrained and Understaffed units will limit patient care and will
lead to missed reimbursement opportunities
Kathy J Irwin MS RD LDN CNSC
Clinical Nutrition Manager
Contracted by Morrison Healthcare
Phone 865-835-4118
email kathyirwiniammorrisoncom
Questions
Registered Dietitians
The Hospitalrsquos Nutrition Experts
bull Trained to feed support and recognize nutrition problems bull Nutrition undergraduate science degree many have
graduate degrees bull 1200-hour internship with 42 competencies bull Licensed by the state bull Many RDs have advanced certifications bull Nutrition Experts but are they Malnutrition experts
(They can behellip)
Methodist Medical Center
Malnutrition Initiative
bull Dietitians developed an Expertise on Malnutrition bull Nutrition-focused physical Exam (NFPE) essential to
comprehensive assess for Malnutrition bull Dietitian ldquobuy-inrdquo can be challenging
(We werenrsquot trained to ldquotouchrdquo patients) bull NFPE training available from the Academy of Nutrition and
Dietetics bull NFPE is new dietetic internship competency 2017
bull Only a physician can give a medical diagnosis bull Tool was developed to communicated the dietitianrsquos findings to the
physician physician makes an independent decision on diagnosis bull ldquoOut-side the boxrdquo screening (initiated Oct 2017)
bull RD-led comprehensive nutrition screening trial bull Required an additional FTE
bull Team approach bull nurses therapists case managers physicians administrators
bull Awareness effort
Methodist Medical Center
Malnutrition Initiative
Methodist Medical Center Malnutrition Initiative Results
300
700
1100
1500
1900
pe
rce
nta
ge o
f p
atie
nts
Methodist Medical Center
Percentage of In-patients Diagnosed with Malnutrition
Benchmark 19
Above includes only Medicare (excludes all per diem commercial payers managed care TennCare and self pay) only includes severe malnutrition (excludes non-severe mild) only includes severe Malnutrition as the only MCC (excludes patient with multiple MCCs) 2015 data yearly total extrapolated from Oct-Dec 2015 ndash since ICD10 codes Oct 2016 data Actual data 2017 data yearly total estimated from Jan-Aug 2017 data
Methodist Medical Center Malnutrition Initiative Results
$27589600
$65843900
$107414400
$0
$200000
$400000
$600000
$800000
$1000000
$1200000
2015 2016 2017
Incr
eas
e d
ue
to
Mal
nu
trit
ion
Dia
gno
ses
Methodist Medical Center Malnutrition Impact on Medicare Reimbursements
Conclusions
bull Missing Malnutrition is significant to hospitals bull Patient Care bull Financial
bull Dietitians need to be trained bull The NFPE is essential for a comprehensive malnutrition assessment
bull Dietitian duties and staffing is evolving bull A Paradigm Shift is occurring ndash focus changing from Joint Commission
requirements toward improved patient care bull Undertrained and Understaffed units will limit patient care and will
lead to missed reimbursement opportunities
Kathy J Irwin MS RD LDN CNSC
Clinical Nutrition Manager
Contracted by Morrison Healthcare
Phone 865-835-4118
email kathyirwiniammorrisoncom
Questions
Methodist Medical Center
Malnutrition Initiative
bull Dietitians developed an Expertise on Malnutrition bull Nutrition-focused physical Exam (NFPE) essential to
comprehensive assess for Malnutrition bull Dietitian ldquobuy-inrdquo can be challenging
(We werenrsquot trained to ldquotouchrdquo patients) bull NFPE training available from the Academy of Nutrition and
Dietetics bull NFPE is new dietetic internship competency 2017
bull Only a physician can give a medical diagnosis bull Tool was developed to communicated the dietitianrsquos findings to the
physician physician makes an independent decision on diagnosis bull ldquoOut-side the boxrdquo screening (initiated Oct 2017)
bull RD-led comprehensive nutrition screening trial bull Required an additional FTE
bull Team approach bull nurses therapists case managers physicians administrators
bull Awareness effort
Methodist Medical Center
Malnutrition Initiative
Methodist Medical Center Malnutrition Initiative Results
300
700
1100
1500
1900
pe
rce
nta
ge o
f p
atie
nts
Methodist Medical Center
Percentage of In-patients Diagnosed with Malnutrition
Benchmark 19
Above includes only Medicare (excludes all per diem commercial payers managed care TennCare and self pay) only includes severe malnutrition (excludes non-severe mild) only includes severe Malnutrition as the only MCC (excludes patient with multiple MCCs) 2015 data yearly total extrapolated from Oct-Dec 2015 ndash since ICD10 codes Oct 2016 data Actual data 2017 data yearly total estimated from Jan-Aug 2017 data
Methodist Medical Center Malnutrition Initiative Results
$27589600
$65843900
$107414400
$0
$200000
$400000
$600000
$800000
$1000000
$1200000
2015 2016 2017
Incr
eas
e d
ue
to
Mal
nu
trit
ion
Dia
gno
ses
Methodist Medical Center Malnutrition Impact on Medicare Reimbursements
Conclusions
bull Missing Malnutrition is significant to hospitals bull Patient Care bull Financial
bull Dietitians need to be trained bull The NFPE is essential for a comprehensive malnutrition assessment
bull Dietitian duties and staffing is evolving bull A Paradigm Shift is occurring ndash focus changing from Joint Commission
requirements toward improved patient care bull Undertrained and Understaffed units will limit patient care and will
lead to missed reimbursement opportunities
Kathy J Irwin MS RD LDN CNSC
Clinical Nutrition Manager
Contracted by Morrison Healthcare
Phone 865-835-4118
email kathyirwiniammorrisoncom
Questions
bull Only a physician can give a medical diagnosis bull Tool was developed to communicated the dietitianrsquos findings to the
physician physician makes an independent decision on diagnosis bull ldquoOut-side the boxrdquo screening (initiated Oct 2017)
bull RD-led comprehensive nutrition screening trial bull Required an additional FTE
bull Team approach bull nurses therapists case managers physicians administrators
bull Awareness effort
Methodist Medical Center
Malnutrition Initiative
Methodist Medical Center Malnutrition Initiative Results
300
700
1100
1500
1900
pe
rce
nta
ge o
f p
atie
nts
Methodist Medical Center
Percentage of In-patients Diagnosed with Malnutrition
Benchmark 19
Above includes only Medicare (excludes all per diem commercial payers managed care TennCare and self pay) only includes severe malnutrition (excludes non-severe mild) only includes severe Malnutrition as the only MCC (excludes patient with multiple MCCs) 2015 data yearly total extrapolated from Oct-Dec 2015 ndash since ICD10 codes Oct 2016 data Actual data 2017 data yearly total estimated from Jan-Aug 2017 data
Methodist Medical Center Malnutrition Initiative Results
$27589600
$65843900
$107414400
$0
$200000
$400000
$600000
$800000
$1000000
$1200000
2015 2016 2017
Incr
eas
e d
ue
to
Mal
nu
trit
ion
Dia
gno
ses
Methodist Medical Center Malnutrition Impact on Medicare Reimbursements
Conclusions
bull Missing Malnutrition is significant to hospitals bull Patient Care bull Financial
bull Dietitians need to be trained bull The NFPE is essential for a comprehensive malnutrition assessment
bull Dietitian duties and staffing is evolving bull A Paradigm Shift is occurring ndash focus changing from Joint Commission
requirements toward improved patient care bull Undertrained and Understaffed units will limit patient care and will
lead to missed reimbursement opportunities
Kathy J Irwin MS RD LDN CNSC
Clinical Nutrition Manager
Contracted by Morrison Healthcare
Phone 865-835-4118
email kathyirwiniammorrisoncom
Questions
Methodist Medical Center Malnutrition Initiative Results
300
700
1100
1500
1900
pe
rce
nta
ge o
f p
atie
nts
Methodist Medical Center
Percentage of In-patients Diagnosed with Malnutrition
Benchmark 19
Above includes only Medicare (excludes all per diem commercial payers managed care TennCare and self pay) only includes severe malnutrition (excludes non-severe mild) only includes severe Malnutrition as the only MCC (excludes patient with multiple MCCs) 2015 data yearly total extrapolated from Oct-Dec 2015 ndash since ICD10 codes Oct 2016 data Actual data 2017 data yearly total estimated from Jan-Aug 2017 data
Methodist Medical Center Malnutrition Initiative Results
$27589600
$65843900
$107414400
$0
$200000
$400000
$600000
$800000
$1000000
$1200000
2015 2016 2017
Incr
eas
e d
ue
to
Mal
nu
trit
ion
Dia
gno
ses
Methodist Medical Center Malnutrition Impact on Medicare Reimbursements
Conclusions
bull Missing Malnutrition is significant to hospitals bull Patient Care bull Financial
bull Dietitians need to be trained bull The NFPE is essential for a comprehensive malnutrition assessment
bull Dietitian duties and staffing is evolving bull A Paradigm Shift is occurring ndash focus changing from Joint Commission
requirements toward improved patient care bull Undertrained and Understaffed units will limit patient care and will
lead to missed reimbursement opportunities
Kathy J Irwin MS RD LDN CNSC
Clinical Nutrition Manager
Contracted by Morrison Healthcare
Phone 865-835-4118
email kathyirwiniammorrisoncom
Questions
Above includes only Medicare (excludes all per diem commercial payers managed care TennCare and self pay) only includes severe malnutrition (excludes non-severe mild) only includes severe Malnutrition as the only MCC (excludes patient with multiple MCCs) 2015 data yearly total extrapolated from Oct-Dec 2015 ndash since ICD10 codes Oct 2016 data Actual data 2017 data yearly total estimated from Jan-Aug 2017 data
Methodist Medical Center Malnutrition Initiative Results
$27589600
$65843900
$107414400
$0
$200000
$400000
$600000
$800000
$1000000
$1200000
2015 2016 2017
Incr
eas
e d
ue
to
Mal
nu
trit
ion
Dia
gno
ses
Methodist Medical Center Malnutrition Impact on Medicare Reimbursements
Conclusions
bull Missing Malnutrition is significant to hospitals bull Patient Care bull Financial
bull Dietitians need to be trained bull The NFPE is essential for a comprehensive malnutrition assessment
bull Dietitian duties and staffing is evolving bull A Paradigm Shift is occurring ndash focus changing from Joint Commission
requirements toward improved patient care bull Undertrained and Understaffed units will limit patient care and will
lead to missed reimbursement opportunities
Kathy J Irwin MS RD LDN CNSC
Clinical Nutrition Manager
Contracted by Morrison Healthcare
Phone 865-835-4118
email kathyirwiniammorrisoncom
Questions
Conclusions
bull Missing Malnutrition is significant to hospitals bull Patient Care bull Financial
bull Dietitians need to be trained bull The NFPE is essential for a comprehensive malnutrition assessment
bull Dietitian duties and staffing is evolving bull A Paradigm Shift is occurring ndash focus changing from Joint Commission
requirements toward improved patient care bull Undertrained and Understaffed units will limit patient care and will
lead to missed reimbursement opportunities
Kathy J Irwin MS RD LDN CNSC
Clinical Nutrition Manager
Contracted by Morrison Healthcare
Phone 865-835-4118
email kathyirwiniammorrisoncom
Questions
Kathy J Irwin MS RD LDN CNSC
Clinical Nutrition Manager
Contracted by Morrison Healthcare
Phone 865-835-4118
email kathyirwiniammorrisoncom
Questions