Strategy to fight against malnutrition in chronic patients with complex health needs

Disease-related malnutrition (DRM) is a prevalent condition amongst older people as well as patients in all healthcare settings around the world. Chronic patients with complex health needs (CPCHN defined as those with complex chronic conditions that involve multiple health requirements, complex social support needs, or both) are especially vulnerable to malnutrition. Malnutrition is associated with increased morbidity, a higher hospital admission and readmission rate, increased needs for social resources and even a high mortality.

In Catalonia, CPCHN account for 3.5-5 % of the Catalan population (250,000 to 375,000 patients), and we have data pointing to a high prevalence of malnutrition in CPCHN admitted in hospitals for an acute episode (36 % malnourished, 47 % risk of malnutrition). Nevertheless, the prevalence of DRM in CPCHN in the community has been not sufficiently studied. In addition, health and social risk factors for malnutrition are unknown in these population.

Taking all these into account, it is necessary to establish an integrated and a collaborative health and social strategy for the screening and management of nutritional care, mainly from a community-based as well as a patient-centered approach.

The strategy to tackle against malnutrition in CPCHN is led by the Department of Health of Catalonia (PPAC, PIAISS), the Spanish Society of Parenteral and Enteral Nutrition (SENPE) and the Family and Community Nursing Association (AIFICC), with the support of the University of Vic. This strategy is based on a Decalogue of actions to fight against malnutrition previously identified by a consensus among experts from scientific societies, social services and public health, incorporating the vision of patients and caregivers.

Aims:

1. Highlight the DRM problem in CPCHN launching a prevalence study of DRM in the CPCHN selecting a representative sample of Catalonian society.

2. Establish an integrated and a collaborative intervention plan (nutritional and social) linked to the detection of malnutrition and/or social dysfunction.

Results and impact:

1. The prevalence study of DRM in the CPCHN is a prospective observational and multicenter randomized study that has been performed in a region of Catalonia, representative of the Catalan society (80 % urban, 20 % rural). The sample size calculated was 384 patients, a total of 404 patients have been participated. A very high prevalence of malnutrition and risk of malnutrition has been found (46.5 % risk, 5.9 % malnutrition) Living alone, polypharmacy and dysphagia were the most important social and health determinants that influence DRM and will allow us to focus strategies to improve patient care.

2. The integrated and collaborative intervention plan to tackle against DRM in CPCHN is based on a protocol that includes the clinical, nutritional and social risk screenings. With this aim, Primary Care teams (doctors and nurses) and Social Service professionals (Primary Care and community resources) are coordinated with the Nutritional Support Unit in the reference hospital in a collaborative manner. The first step has been to incorporate mandatory nutritional and social risk factors screenings in patients identified as CPCHN. A positive nutritional or social screening have been linked to comprehensive nutritional and social assessment plans that will allow diagnosing and encoding malnutrition and identifying patients at risk of social dysfunction. Diagnosis of DRM or social dysfunction is linked to an integrated intervention plan (nutritional and social), that includes case-conferences in the case of patients with complex needs.

Highlights: Prior to the development of the strategy for dealing with DRM in CPCHN, a low implementation of nutritional screening was detected. This fact was probably due to a low awareness of DRM, but also for lack of a feasible and efficient plan of approach, that must include not only the health aspects but also the social determinants that accompany the disease.

Contingencies: The implementation of this strategy is time-consuming, and requires an integrated health and social work.

Tutorials have been attached to the shared medical history of Catalonia to guide professionals in the application of the screenings.

Timeline: The prevalence study of DRM in the community has been finished at January 2016.

The mandatory screening and the validation of the nutritional and social intervention plan will be implemented during 2016.

Conclusion: The results of the prevalence study of DRM in CPCHN could be extrapolated to the rest of Catalonia, allowing us to manage effectively the health and social policies. It will also allow us to analyze the impact of different health care quality indicators linked to the strategy to approach to DRM. Nutritional and social community intervention can be cost-efficient, as demonstrated in the hospital setting, and probably will allow reducing unnecessary admissions, readmissions, complications, need for social resources and will help improve the quality of life in CPCHN. The impact of this strategy is based in detecting and treating in an integrated and collaborative manner DRM in CPCHN.