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Recommendations Summary

MiOA: Dietitian Effectiveness in the Community (2023)

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    MiOA: Dietitian Effectiveness in the Community

    Older adults living in the community and considered malnourished or at risk of malnutrition should receive nutrition interventions from a dietitian. Dietitian interventions are associated with weight maintenance or desired gain, and improved calorie and protein intake.

    Rating: Level 1(C)
    Imperative

    MiOA: Dietitian Effectiveness Post-Discharge

    Older adults discharged from acute care to the community and considered malnourished or at risk for malnutrition should receive nutrition interventions from a dietitian. Dietitian interventions are associated with increased calorie and protein intake, weight maintenance or desired gain, and improved nutrition status.

    Rating: Level 1(C)
    Imperative

    • Risks/Harms of Implementing This Recommendation

      Potential harms such as financial costs,  and the potential for anxiety related to nutrition therapy, may be associated with nutrition care provided by dietitians. Most adults 65 and older living in the United States are eligible to purchase Medicare Part B, though receiving this benefit requires the individual to initiate and pay for Part B benefits. Those without Medicare Part B would not have access to the Medicare benefit, so access to medical nutrition therapy (MNT) would be subject to individual health plan coverage or other options, such as private pay. MNT reimbursement may not cover the full cost of the service and the infrastructure needed to process claims. Costs may be incurred by certain organizations (e.g., Older Americans Act Nutrition Programs),  whereas other entities such as insurance providers may benefit from the cost-savings.

      Access to dietitian services is limited by the number of professionals and access limitations. Fostering increased numbers of dietitians, placed in community settings, and easily accessed, does imply costs. These costs would be anticipated to be less than the cost of continuing the reduced access/low numbers of dietitians. 

      Implementation of dietitian services for older adults living in the community may widen the health equity gap unless appropriate factors are considered. Many older adults experience health inequities related to nutrition and social determinants of health such as economic instability and access to quality healthcare.

    • Conditions of Application

      Dietitians should work within interdisciplinary teams to promote implementation of dietitian care. Protocols should include nutrition screening and referral to dietitians for individualized MNT. Incorporation of nutrition screening and referral to dietitians requires coordination of administrators, and organizational policies and procedures.   

      Acceptability

      There is limited research on the acceptability of MNT provided by dietitians by older adults. However, a systematic qualitative review was conducted exploring stakeholder experiences of dietetic service and care delivery. Stakeholders included patients, families, caregivers, consumers, dietitians, health professionals, educators, and support services. Authors indicated that stakeholders desired a personalized approach, access to dietetic services, and a relationship with the dietitian. 

      Table. Barriers and Facilitators for Implementation of Dietitian Interventions for Older Adults Living in the Community. 

      Barriers Facilitators/Strategies
      Lack of awareness of risk for malnutrition, and the poor outcomes associated with malnutrition. The prevalence of malnutrition is unknown nationally.
      • Widespread, regular malnutrition screenings of older adults in the community including primary care, social and meal programs, SNAP-ed workshops, etc.
      • Regular communication and collaboration with other healthcare providers.
      • Implement valid and reliable nutrition screening and assessment tools in all care settings to standardize definitions of malnutrition.
      • Establish care pathways and documentation of malnutrition in community settings, including approved billing codes.
      • Increasing funding resources and policies which require dietitian positions and referrals to dietitians in the community.
      • Partner with other professions and organizations to increase awareness of malnutrition in all care settings, including the community and long-term care.
      • Increased awareness of the Malnutrition in Quality Improvement Initiative (MQii). 
      Lack of priority for nutrition care for older adults.
      • Nutrition education through trusted professionals and organizations.
      • Active screening and appropriate referrals when positive malnutrition screens are identified. 
      • Nutrition/malnutrition training in healthcare professional curriculum.  
      State-based Aging, Health and Nutrition Plans often do not address malnutrition (Arensberg, 2022)
      • Consistent with the addition of malnutrition within the Older Americans Act, as amended in 2020, the Administration for Community Living instructions were issued in 2021 requiring State [Aging] Plans to include malnutrition a (KM_C364e-20180920105928 (acl.gov). 
      • State Public Health Departments and State Units on Aging. 
      • Area Agencies on Aging and local health departments. 
      • Federal and state agencies and policymakers.
      Lack of referral from healthcare practitioners to dietitians
      • Building relationships with physicians, social service programs such as senior satellite centers, collaboration with community hospitals. 
      • Establishing policies and funding which require referrals and facilitate data sharing. 
      • Malnutrition screening at annual senior wellness visits.
      Limited dietitians with appropriate training and knowledge to provide nutrition care for older adults living in the community 
      • Dietitians working in the community should consider Board Certification as a Specialist in Gerontological Nutrition. 
      • Older adult education within dietetic internship curriculum; inclusion of community-based malnutrition components in the Gerontologic Nutrition exam. 
      • Policies requiring the participation of dietitians (A Toolkit for Area Agencies on Aging). 
      • Incentives for dietitians to work in rural or underserved areas.
      Cost of Dietitian Intervention; Lack of Reimbursement of Services
      • Advocate for increased staffing and funding in community and long-term care programs.
      • Partner with established community programs to provide dietitian services to existing intervention plans.
      Patient Mobility / Transportation
      • Telehealth; Use of social service programs that facilitate transportation to appointments.
      • Dietitians providing services in an accessible location

    • Potential Costs Associated with Application

      Most adults 65 and older living in the United States are eligible to purchase Medicare Part B, though receiving this benefit requires the individual to initiate and pay for Part B benefits. Those without Medicare part B would not have access to the Medicare benefit, so access to MNT would be subject to individual health plan coverage or other options, such as private pay. MNT reimbursement may not cover the full cost of the service and the infrastructure needed to process claims. 

      Access to dietitian services is limited by the number of professionals and access limitations. Fostering increased numbers of dietitians, placed in community settings, and easily accessed, does imply costs. These costs would be anticipated to be less than the cost of continuing the reduced access/low numbers of dietitians.

    • Recommendation Narrative

      Approximately 1 in 2 older adults in the community are at risk of malnutrition. Older adults living in the community may be at increased risk for malnutrition due to limited income, isolation, and depression. Age is a risk for chronic disease, and older adults are susceptible to disease related malnutrition. The consequences of older adult malnutrition are significant and impact the physical and mental health as well as quality of life of older adults; it also places a high burden on healthcare systems, family caregivers, and the community at large.

      The role of the dietitian is critical to prevention and treatment of malnutrition in older adults in all care settings. A dietitian is a credentialed healthcare professional who applies evidence-based information about nutrition and diet to contribute to the health and wellness of individuals, groups, and communities.

      Systematic reviews were conducted to evaluate the effect of dietitian interventions on older adults living in the community, and older adults discharged from acute care to the community. Nutrition interventions are planned action(s) designed to change nutrition behaviors, risk factors, environmental conditions, and to improve nutrition status.

      Eight studies were included in the systematic review that evaluated the effectiveness of dietitian interventions in older adults living in the community (Kim 2021, Locher et al. 2013, Reinders et al. 2022, Rydwik et al. 2008, Schlep et al. 2013, Nykanen et al. 2014, Endevelot et al. 2011, Kwon et al. 2015). Studies were published in Amsterdam (Schlip 2013) Canada (Payette 2002), Finland (Nykanen 2014), Israel (Endevelt 2011), Japan (Kwon 2015),  Korea (Kim 2021),  Netherlands (Reinders 2022), Sweden (Lammes 2012, Rydwik 2010) and the United States (Locher 2013). All study population were considered malnourished or at risk for malnutrition. Study durations ranged from 4 to 24 months. There were various platforms including in-home visits, telephone calls, and group instructions. Interventions provided by dietitians included individualized counseling in each of the included studies except for Kwon 2015 that provided education only.  A significant increase was found in calorie intake (Locher 2013, Rydwik 2008, Schlip 2013) protein intake (Ki 2021, Schlip 2013), and weight (low certainty) (Kim 2021, Rydwik 2008, Schlip 2013, Nykanen 2014). No significant effect was found on physical function (low certainty) (Rydwik 2010, Rydwik 2008, Schlip 2013, Endevelt 2011, Kwon 2015). Dietitian interventions may not be cost-effective according to quality-adjusted life years. However, study authors in one (Schlip 2013) of the two included studies Locher 2013, Schlip 2013) reported that the study was underpowered to evaluate cost-effectiveness, and limited intensity and duration may have limited cost-effectiveness (low certainty).

      Ten studies published within eight articles reported the effectiveness of dietitian intervention in older adults discharged from acute care to the community (Neelemaat et al. 2012, Feldblum et al. 2011, Neelemaat et al. 2011, Blondal et al. 2022, Beck et al. 2013, Beck et al. 2015, Andersson et al. 2017, Munk et al. 2021, Terp et al. 2018, Pedersen et al. 2016). Studies were published in Canada (Payette 2002),  Denmark (Beck 2013, Beck 2015, Terp 2018, Pedersen 2016),  Iceland (Blondal 2022), Israel (Feldblum 2011),  Netherlands (Neelemaat 2012, Neelemaat 2011, Neelemaat 2017),  Norway (Andersson 2017), and Scotland (Munk 2021). All included study populations were considered malnourished or at risk for malnutrition. The study duration ranged from 1 month to 6 months. Some studies began with dietitian intervention in the hospital and continued post-discharge. There were a variety of platforms, including telephone calls and home visits, or a combination of the two. Dietitian interventions included but were not limited to recommendations of oral nutrition supplements, individual counseling, and referral to programs such as Meals on Wheels. Dietitian interventions increased energy and protein intake (moderate certainty) (Neelemaat 2012, Feldblum 2011, Blondal 2022, Beck 2013, Beck 2015, Terp 2018) weight (moderate certainty) (Neelemaat 2012, Feldblum 2011, Neelemaat 2011, Blondal 2022, Beck 2013, Beck 2015) and nutrition status measured by valid nutrition assessment (low certainty) (Feldblum 2011, Pedersen 2015). There was limited evidence to evaluate cost-effectiveness (low certainty) (Neelemaat 2012) and no significant effect was found on physical function (low certainty) (Neelemaat 2012, Feldblum 2011, Beck 2013, Beck 2015, Terp 2018, Pedersen 2015) or mortality (moderate certainty) (Feldblum 2011, Neelemaat 2017, Soderstrom 2020, Beck 2013, Beck 2015, Munk 2021, Terp 2018).     

    • Recommendation Strength Rationale

      The evidence supporting the recommendations is based on Grades C (Low), D (Very Low), and B (Moderate). 

    • Minority Opinions

      None.