Ensuring optimal nutrition during transitions from hospital to home remains a significant challenge for older adults, particularly those facing food insecurity and malnutrition. Nearly 76% of these patients experience gaps in nutritional care during these critical periods. Patients with food insecurity struggle to acquire the nutritious food necessary for recovery, especially when compounded by illness-related complications such as increased energy needs, decreased nutrient utilization, poor appetite or impaired ability to prepare and consume meals.
In many acute care settings, the primary strategy to address food insecurity and malnutrition post-discharge involves providing patients with handouts listing community resources. However, these methods are often ineffective, as patients frequently discard the handouts, encounter outdated contact information, face a frustrating "run-around" or have the responsibility of initiating contact. Health care providers also lack a closed-loop communication system, leaving them unaware of whether the patient successfully accessed the needed resources, further disrupting care continuity.
This situation highlights the urgent need for innovative solutions. There is a lack of interoperable electronic referral systems that could seamlessly bridge the gap between clinical care and community support. Implementing such systems would transform how information is shared, allowing community providers to proactively reach out to patients instead of leaving them to navigate complex care pathways on their own.
Recently published in Nutrition in Clinical Practice, this commentary showcases the CONNECT Study's innovative approach, piloting a Transition Care Model that connects patients facing food insecurity and malnutrition through a dietitian-led "Food Is Medicine" program. This intervention facilitates seamless data transfer from the clinical dietitian to the community dietitian using the HIPAA-compliant Academy of Nutrition and Dietetics Health Informatics Infrastructure (ANDHII).
By ensuring continuity of care and effectively connecting patients with food insecurity and malnutrition to community resources, these models can significantly improve health outcomes for this population and reduce hospital readmissions.
Join the Academy
Members of the Academy of Nutrition and Dietetics receive exciting benefits including complimentary continuing professional education opportunities, discounts on events and products in eatrightSTORE.org, invitations to exclusive members-only events and more!