A Primer on Managed Care: Multiple Chronic Conditions

it remains a silent epidemic, and malnutrition care approaches have not typically been included in most prevention and wellness, patient safety, care transitions, and population health strategies. Nationwide, there is a growing recogni- tion that poor health is largely attributable to social determinants of health (Marmot, 2005), which often are considered to exist outside of the health system’s span of influence. Thus, as healthcare entities employ population health strategies to better manage the health and asso- ciated healthcare costs for older patients, they It is imperative to screen for malnutrition and to address the social determinants of health. will likely be looking to CBOs to screen for and address the broad range of social determinants of health that contribute to malnutrition risk. CBOs’ role in combating malnutrition CBOs are uniquely positioned to advance malnu- trition care for community-dwelling older adults because CBOs are well-established in their com- munities and provide a wide array of programs and services that support older adults in their homes, wherein they manage their health on a day-to-day basis. Existing programs and ser- vices can be modified and leveraged to screen for and address the social risks contributing to and exacerbating malnutrition. For example, validated malnutrition and screening tools for the social determinants of health can be inte- grated into program assessments, care transition programs, and disease prevention and health promotion programs. Malnutrition standards of care, best prac- tices, and validated screening and diagnostic tools are available, and CBOs can systematically adopt them in a community setting and incor- porate them into existing program assessments. The Malnutrition Quality Collaborative’s (2017) National Blueprint: Achieving Quality Malnutri-

tion Care for Older Adults provides a list of vali- dated screening and assessment tools, including the Birmingham Nutrition Risk, Malnutrition Screening Tool, Malnutrition Universal Screen- ing Tool, Mini Nutritional Assessment, Nutri- tion Risk Classification, Nutritional Risk Index, National Risk Screening 2002, and the Short Nutritional Assessment Questionnaire. In addition, Seniors in the Community: Risk Evaluation for Eating and Nutrition, Version II (SCREEN-II) is a validated tool developed spe- cifically for community settings (Keller, Goy, and Kane, 2005). These screening tools can detect some risk indicators for malnutrition, including recent weight loss, poor intake of nutrients and- or poor appetite, plus body weight measures (e.g., self-report, calf circumference). Also, CBOs can add questions into program assessments to identify social determinants of health that contribute to malnutrition, such as those concerning lack of housing and trans- portation, food insecurity, social isolation, and poverty. The Social Interventions Research & Evaluation Network team created a comparison guide of the most widely used social determi- nants of health screening tools (Cartier, Fich- tenberg, and Gottlieb, 2018); the guide describes each tool and includes information about its intended population or setting, and the social risks each tool addresses. Effective population health management and value-based reimbursement success hinge on reducing healthcare costs and, according to the 2013 Health Care Cost and Utilization Project data, treating malnourished patients costs nearly twice as much as their well-nourished peers (Fingar et al., 2016). Consequently, proactively screening for malnutrition and addressing the social determinants of health are no longer lux­ uries, but an imperative.

The Population Health Management Imperative

Effective care transitions are key not only to improving outcomes and preventing avoidable

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