Facilitating recovery: Preparing patients to self-manage malnutrition after hospital discharge

Background: Malnutrition affects 20-45% of hospitalized adults in Canada and when left unresolved can significantly impact post-discharge recovery. The Canadian Malnutrition Task Force outlines pre-discharge actions by hospital dietitians to support patient self-management at home: Action 1: Recommend community resources; Action 2: Refer to community-based dietitians; and Action 3: Facilitate nutrition follow-up by primary care provider. This study aimed to identify barriers and enablers for these actions from the perspective of inpatient dietitians within one Canadian provincial health system serving ~ 4 million people.

 

Approach: An online survey with open-ended questions was designed with dietitian advisors and circulated to all inpatient dietitians via provincial nutrition services leadership for anonymous completion. Themes related to barriers and facilitators for recommended actions were identified using conventional content analysis. Optional follow-up interviews provided context for emerging themes. Dietitian advisors were engaged in interpretation and dissemination to inform system change.

 

Results: 57 geographically diverse dietitians completed the survey, working in inpatient-only (39%), inpatient plus community (56%) or inpatient plus administrative roles (5%).

 Responses indicated that Action 1 (Recommend) was common practice but faced barriers including narrow eligibility criteria for subsidized services; high cost and low availability of grocery or meal delivery; and lack of meal preparation support. Constantly changing community services created reticence to make recommendations.

Action 2 (Refer) was also part of usual practice, with barriers including long wait times for community-based dietitians; low confidence that high acuity patients would be prioritized; and uncertainty about “who and how” when referring to primary care dietitians. Low staffing of community-based and primary care dietitians was a clear contributor, while minimal feedback on patient outcomes after discharge caused doubt about whether pre-discharge actions were effective.

Action 3 (Facilitate) was rarely part of usual dietitian practice. The main barrier was physician-centric hospital-to-primary care communication, with little room for dietitians to communicate directly with primary care providers. Respondents emphasized that if the hospital physician did not prioritize nutrition, malnutrition would not be communicated to primary care; this was accompanied by doubt that patients would initiate nutrition care in the community. Finally, an overarching theme was the importance of interdisciplinary communication, collaboration and relationships when preparing patients to manage malnutrition.

 

Implications: Considering the prevalence of malnutrition in hospital, systemic and individual-level actions should be taken to support self-management of malnutrition after discharge. 1) System: Subsidize meal delivery, grocery delivery and in-home meal preparation for people with malnutrition. Individual: Providers of these services connect regularly with inpatient dietitians to support accurate recommendations. 2) System: Prioritize availability of dietitians in primary care and community.

 

 Individual: Community and primary care dietitians regularly clarify referral processes with inpatient dietitians and provide feedback about results of pre-discharge actions. 3) System: Re-imagine physician-centric processes to enable inpatient dietitians to communicate with primary care providers about nutrition concerns.

 

Individual: Primary care providers ask hospital physicians about nutritional therapy in hospital and screen regularly for malnutrition. Overall, communication and collaboration between multi-disciplinary hospital providers, community-based providers, patients and caregivers is essential to support nutritional recovery after hospital discharge.